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The Journal of Tuberculosis.

A Quarterly Magazine Devoted to the Prevention
and Treatment of Tuberculosis.

(Copyrighted.)

BDITBD BY
KAI(L VON RUCK and SILVIO VON RUCK.

VOLUME IV,
I902.

Ashevllie* North Carolina.
1902.

OMISSION.

Behring, Prof. E. von, The Production of Inamunity in Cattle through
'Jennerization," 407.

< <

INDEX.

Air, Open, Treatment of Consumptives, (£d.)> 313.

Air Passages, Tuberculous Infection through, 50.

Abrams, A. , Nutrition in Pulmonary Tuberculosis, 129.

Anaemia, Treatment of, (Supplement), 211.

Anderson. Willis S., Intratracheal Infections in Phthisis Pulmonalis, 217.

Appendix, Tuberculosis of, 406.

Aufrecht, Pulmonary Tuberculosis and Sanatoria, 162.

Barton, Joshua L., Intratracheal Medication in Diseases of Respiratory tract, 136.

Baumgarten, P., Immunity and Predisposition with Especial Reference to Tuber-
culosis, (Trans.;, 382.

Bleyer, J. Mount, Therapeutic Importance of Light in Tuberculosis, 105, 233,329.

Breath, Odor of, in Beginning Phthisis, 302.

Brooks, M. J., Differentiation and Diagnosis of Tuberculosis and Phthisis, 228.

Cattle, Communicability of Human Tuberculosis to, 52.

Childhood and Tuberculosis, (Orig.), 28.

Climate, Influence of , in Treat, of Pulmonary Tuberculosis, (Supplement), 319,
413.

Cobb, Carolus M., Relation of Scrofula to Tuberculosis, 224,

Cohen, S. Soils, System of Physiologic Therapeutics, Vol. Ill & IV, (Review) 201.

Comstock, A. J., Epidemic Influenza in Relation to Quarantine Against Tubercu-
losis, 222.

Cough and Expectoration, 189.

Cough -Spray and Dust of Dried Sputum in Spread of Phthisis, 45.

Coughing, Spread of Tuberculosis by, 48.

Culture Products in the Treatment of Tuberculosis, 140.

Denmark, Warfare Against Tuberculosis in, 293.

Diagnosis, Differential, of Tuberculosis and Phthisis, (Orig.), 228.

Diagnosis, Early, of Pulmonary Tuberculosis, Based upon Pathology of the
Disease, (Orig.), 256.

Diagnosis, Early, of Pulmonary Tuberculosis, 76.

Diagnosis, Early, of Pulmonary Tuberculosis, (Ed.), 203.

Diagnosis of Inherited Predisposition to Phthisis, 400.

Diagnosis of Tuberculosis of Lungs by Roentgen Rays, 77.

Dickey, W. A., What Should be the Attitude of the Profession toward the Public
and the Individual Suffering from Tuberculosis ? 19.

Diaphragm, Tuberculosis of, 308.

Diazo Reaction: Its Value as a Diagnostic Sign in Pulmonary Tuberculosis,
(Orig.), 366.

Diffusion of Tuberculosis, Methods of, 394.

Disinfection of Tuberculous Sputum, 64.

Dust and Spray, Penetration of Bacteria into Lungs thro' Inhalation of, 49.

Dust of Dried Sputum and Cough-Spray in Spread of Phthisis, 45.

Epididymis and Testicle, Treatment of Tuberculosis of, by. Ligature and Division
of Spermatic Cord. (Trans.), 32, 176.

Etiology of Inductive and Incipient Stages of Pul. Tuberculosis and Specific
Treat. Based Thereon. (Orig.), 372.

Exercise and Rest in Phthisio-Therapy, 303.

Expectoration and Cough, 189.

Experimental Pulmonary Phthisis, 57.

Feedinq^, Forced in Consumptives and Normal Individuals, 305.

Fever, Is the Slight Rise of Temperature in Consumptives, after Slight Bodily

Exertion, a True, 301.
Flick, Lawrence F., Are Meat and Milk a Source of Seed Supply for Human

Tuberculosis, 321.
Freudenthal, W., Operative Intervention in Laryngeal Tuberculosis, 124.
Gelatine, Subcutaneous Injection of. in Treatment of Hemoptysis, 306.
Haemorrhage, Treatment of, (Supplement), 88.
Hemoptysis, Subcutaneous Injection of Gelatine in Treatment of, 306.
Hemmeter, J. C, Diseases of the Intestines, (Rev.), 81, 309.
Home Treatment of Tuberculosis, (Orig.), 13.

Hueppe, Ferdinand, View-Points and Problems in Study |of Tuber., CTrans.), 271.
Ichthyol in Tuberculosis, (Orig.). 361.

Immunity and Predisposition with Especial Reference to Tuber., (Trans.), 382.
Infection, Droplet, Relation of. to Prophylaxis of Tuberculosis, (Ed.), 84.
Infection, Tuberculous, through Air Passages, 50.

Influenza, Epidemic in Relation to Quarantine Against Tuberculosis, (Orig.), 222.
International Medical Annual, (Rev.) 311.
Intratracheal Injection in Phthitis Pulmonalis, (Orig.), 217.
Intratracheal Medication in Diseases of Respiratory Tract, (Orig.), 136.
Italy, Warfare Against Tuberculosis in, 294.
Jacob, Paul, and Pannwitz, Enstehung und Bekaempf ung |der Lungentuberkulose,

(Rev.), 79.
Jacobson, William, Tuberculosis and Childhood, 28.
Joints, Tuberculosis of , History of Development of , (Trans.), 282.
Koenig, F., History of Development of Joint Tuberculosis, (Trans.). 282.
Larynx, Operative Intervention in Tuberculosis of, (Orig.), 124.
Lecithin in Tuberculosis, 78.
Lewis, H. E., Development of Tuberculosis in the Individual, with Remarks on

the Tubercle Bacillus and Allied Forms of Bacilli, 1.
Light— Therapeutic Importance of, in Tuberculosis, (Orig.), 105, 233, 329.
Mauclaire, Treatment of Tuberculosis of Testicle and Epididymis by Ligature and

Division of Spermatic Cord, 32, 176.
McLean, T. L., Etiology of Inductive and Incipient Stages of Pul. Tuberculosis

and Specific Treat. Based Thereon, 372.
McGahan, C. F., Treatment of Tuberculosis at Home, 13.
Meningitis, Tuberculous, Prognosis of, 404.
Meningitis, Tuberculous, Infantile Mortality from, 299.

Mortality, Infantile, from Tuberculous Meningitis and Tabes Mesenterica, 299.
Nurslings, Pulmonary Phthisis in, 300.
Nutrition in Pulmonary Tuberculosis, (Orig.), 129.
Open Air Treatment of Consumptives, (Ed.), 313.
Penis, New Form of Tuberculosis of, 74.
Penrose, C. A., Tuberculin from Bovine Tubercle Bacilli Contrasted with Tuber-

clin from Human Tubercle Bacilli, etc., 369.
Perry, A. W., Nutrition in Pulmonary Tuberculosis, 129.
Phthisis and Tuberculosis, Differential Diagosis of, (Orig.), 228.

- — — *-v«v

Phthisis, Experimental Pulmonary, 57.

Phthisis, Modes of Propagation of, etc., 62.

Phthisis, Prevention and Core of, 189.

Phthisis Pulmonalis, Intratracheal Injections in, (Orig.), 217.

Phthisis Pulmonary, in Nurslings, 300.

Phthisis, Recovery from, in Relation to Formation of Joints in Cartilage of First
Rib, 396.

Phthisis, Spread of by Cough- Spray and Dust of Dried Sputum, 45.

Pleurisy, Treatment of, (Supplement), 98.

Pneumonia Complicating Phthisis, Treatment of, (Supplement), 103.

Pneumothorax, Treatment of , (Supplement), 208.

Pottenger, F. M., Culture Products in the Treatment of Tuberculosis, 140.

Pottenger, F. M , Diagnosis of Incipient Pulmonary Tuberculosis Based upon
Pathology of the Disease, 256.

Predisposition and Immunity with Especial Reference to Tuber., (Trans.), 382.

Predisposition to Phthisis, Inherited, Diagnosis of, 400.

Prevention and Cure of Phthisis, 189.

Prevention of Tuberculosis, 71.

Prognosis of Tuberculous Meningitis, 404.

Prognostic Value of Diazo-Reaction in Pulmonary Tuberculosis, (Orig.), 366.

Propagation of Phthisis, Modes of, etc., 62.

Prophylaxis of Pulmonary Tuberculosis, 294. ^

Prophylaxis of Tuberculosis, 70.

Prophylaxis of Tuberculosis, Relation of Droplet-Infection to, (Ed.), 84.

Quarantine Against Tuberculosis, Epidemic Influenza in Relation to (Orig.), 222.

Registration of Tuberculosis, 67.

Respiratory Tract, Intratracheal Medication in Diseases of, (Orig.), 136.

Rest and Motion in Phthislo-Therapy, 303.

Roentgen Rajrs, Diagnosis of Tuberculosis of Lungs by, 77.

Sanitarium and Tuberculin Treat. , Reciprocal Relations of, 196.

Sanatoria and Pulmonary Tuberculosis, (Trans.), 162.

Sanatorium Treatment of Consumption, 199.

Scrofula, Relation of, to Tuberculosis, (Orig.), 224.

Simon, Chas. E., Text-Book of Physiological Chemistry, (Review), 200.

Spread of Tuberculosis, Statistics on, 291.

Sputum, Tuberculous, Disposal of, 64.

Steffen, Zur Path. Anatomie des Kindlichen, Alters (Rev.) 80.

Tabes Mesenterica, Infantile Mortality from, 299.

Temperature, Is the Slight Rise of, in Consumptives, after Slight Bodily Exertion,
a True Fever, 301.

Testicle and Epididymis, Treatment of Tuberculosis of, by Ligature and Divis-
ion of Spermatic Cord, (Trans.), 32, 176.

Thorax, Tuberculosis of Walls of, 308.

Trachea, Tuberculosis of, 73.

Treatment, Climatic, of Pulmonary Tuberculosis, (Supplement), 319, 413.

Treatment, Medicinal of Pulmonary Tuberculosis, (Supplement), 214, 316.

Treatment of Tuberculosis at Home (Orig.), 13.

Treatment of Tuberculosis, Culture Products in, 104.

Treatment, Open Air, of Consumptives, (Ed.), 313.

Treatment, Sanatorium, of Consumptives, 199.

Treatment, Specific, of Pul. Tuberculosis, Based on Etiology of Inductive and
Incipient Stages, (Orig.)i 372.

Treatment, Symptomatic of Tuberculosis, (Supplement), 88, 208, 316.

Treatment, Tuberculin, Reciprocal Relation to Sanitarium Treatment, 196.

Tubercle Bacillus, Influence of, in Pulmonary Tuberculosis, 54.

Tubercle Bacillus, Interpretation of Lesions Caused by, 398.

Tuberculin and Sanitarium Treatment, Reciprocal Relations of, 196.

Tuberculin Obtained from Bovine Tubercle Bacilli Contrasted with Tuberculin
Obtained from Human Tubercle Bacilli, etc., (Orig.), 369.

Tuberculosis and Phthisis, Differential Diagnosis of, (Orig.), 228.

Tuberculosis, Attitude of Profession toward the Public and the Individual Suffer-
ing, from, (Orig.), 19.

Tuberculosis, Culture Products in the Treatment of, 140.

Tuberculosis, Development of, in the Individual, with Remarks on the Tubercle
Bacillus and Allied Forms of Bacilli, (Orig.)» 1*

Tuberculosis, Human, Are Meat and Milk a Source of Seed Supply (Orig.), 321.

Tuberculosis of the Appendix, 406.

Tuberculosis of Diaphragm, 308.

Tuberculosis of Joints, History of Development of, (Trans.), 282.

Tuberculosis of Larynx, Operative Intervention in, (Orig.), 124.

Tuberculosis of Penis, New Form of, 74.

Tuberculosis of Testicle and Epididymis, Treat, of by Ligatu re and Division of
Spermatic Cord, (Trans.), 32, 176.

Tuberculosis of Thoracic Walls, 308.

Tuberculosis of Trachea, 73.

Tuberculosis of Uterine Appendages, 406.

Tuberculosis of Vagina, Grenesis of, 307.

Tuberculosis, Prophylaxis of, 70.

Tuberculosis, Pulmonary, and Sanatoria, (Trans.), 162.

Tuberculosis, Pulmonary, Climatic Treatment of, (Supplement), 319, 413.

Tuberculosis, Pulmonary, Early Diagnosis of, (Ed.), 203.

Tuberculosis, Pulmonary, Incipient, Diagnosis of. Based upon Pathology of the
Disease, (Orig.), 256.

Tubercolosis, Pulmonary, Medicinal Ireatment of, (Supplement), 214, 316.

Tuberculosis, Pulmonary, Nutrition in, (Orig.), 129.

Tuberculosis, Pulmonary, Prophylaxis of, 294.

Tuberculosis, Registration of , 67.

Tuberculosis, Spread of, by Coughing, 48.

Tuberculosis, Spread of. Statistics on, 291.

Tuberculosis, Study of, View-Points and Problems in, (Trans. )i 271.

Tuberculosis, Symptomatic Treatment of, fSupplement) , 88, 208, 316.

Tuberculosis, Therapeutic Importance of Light in, (Orig.), 105, 233, 329.

Tuberculosis, Varieties and Methods of Diffusion of, 394.

Upson, Chas. R., Prognostic Value of Diazo-Reaction in Pulmonary Tuber. 366.

Uterine Appendages, Tuberculosis of, 406.

Vaginal Tuberculosis, Genesis of, 307.

Warfare Against Tuberculosis in Denmark, 293.

Warfare Against Tuberculosis in Italy, 294.

Williams, John Hey, Ichthyol in Tuberculosis 361.

osS

Journal of Tuberculosis

VOL. IV JANUARY. 1902 No. 1

ORIGINAL CONTRIBUTIONS-

THE DEVELOPMENT OF TUBERCULOSIS IN THE INDIVIDUAL WITH

SOME REMARKS ON THE TUBERCXE BACILLUS AND

CERTAIN ALLIED FORMS OF BAOLU.*

BY H. EDWIN LEWIS, M. D., BURLINGTON, VT.

Philanthrophy properly concerns itself with the afflictions of the
multitude, but the humanitarianism of true medical science prescribes
that its usefulness should begin with a consideration of disease as it
afPects the unit of society — the individual.

The medical profession, owing its existence to the needs of indi-
vidual mankind, should therefore in the study of tuberculosis preface
all consideration of the disease by a due investigation of the factors and
changes involved in the development of tuberculous conditions in the
individual.

The pessimist in retrospection finds small results from the labors
of those great students who have devoted their lives and their fortunes
to the study of the disease. He is prone to claim that the slight lower-
ing of the death rate from tuberculosis during the last decade has
resulted solely from greater accuracy in diagnosis and a universal ten-
dency towards decrease of the general mortality rate.

But the optimist, God bless him! sees in the priceless labors of
Buehl, Villemin, Cohnheim, Klebs, Koch, Virchow, Eoux, Dieulafoy
and coimtless other toilers in the field of experimental medicine, great
promise for the future. From statistics and clinical observation he
recognizes the assailability of tuberculosis through hygienic and san-
itary measures, and from the post mortem table he is awakening to the

*Read in part at the Joint Meeting of the American Congress of Tubercu-
losis and the Medico-Legal Society, May 15 and 16, 1901.

significant fact that tubereiilons lesions are non-fatal in a fair majority
of instances. On cverv hand, therefore, lie sees abundant siirns to
foster the hope — ^yea, the confident expectation that sooner or later
the treatnjent of tuberculosis will be as specifically defined as that of
syphilis, diphtheria or malaria.

But thinking men, honest in every sense of the word, realize that
the facts essential to the ultimate conquest of tuberculosis lie behind
the phenomena which occur when the tubercle bacillus enters the
living organism — and perhaps before. More plainly expressed the
successful treatment and cure of tuberculous conditions must be based
on a more accurate knowledge of the infective agent and the develop-
ment and progress of its characteristic lesions in the human body.

For years the hereditary factor in the development of tuberculosis
has been held of great importance. But latter day investigation and
more intimate knowledge of cause and effect has modified the theory
of heredity to a marked degree. Today we know that direct trans-
mission of tuberculosis from parents to offspring is a rare occurrence
and never takes place except by infection during prenatal life through
the maternal blood supply to the foetus. This, then, is the only tenable
remnant of the theory of direct hereditary transmission of the disease.

We do recognize, however, the possibility of handing do^vn certain
stigmata of degeneration; not necessarily to the extent of physical
characteristics, like marked increase or decrease of the cephalic index
or changes in the helix of the ear, the teeth, the palatal vault, mental
conditions, etc., but in certain histologic depreciations in the vitality
and resistance of the cellular structures. Briefly stated, this theory,
which has ample verification in clinical experience, is that any disease
or degenerative change which vitiates the parental cellular elements
may give rise to degenerative tendencies in similar histologic structures
of the offspring, thus increasing susceptibility to any disease. The
lymphatic system probably shows the influence of hereditary vitiation
more often than any other body-tissue, and since the rise or fall of this
particular portion of the human organism has the greatest influence on
the develpment of tuberculosis, as I will endeavor to show later on, we
can readily understand how easy it has been in the past to superficially
consider pulmonary tuberculosis a hereditary disease.

Of 176 cases of tuberculous phthisis I have been able to collect
reliable data from, and whose family history 1 have been able to trace
back two generations, I have found tuberculosis or other respiratory
disease that might have been tuberculous in only 71 parents or grand-
^larents of 42 cases.

The following table of diseases that either caused death or prom-
inently occurred in the parents or grandparents of the above 176 cases
of pulmonary tuberculosis is interesting :

Tuberculous phthisis or other disease that

might have been tuberculous 71

Epilepsy 16

Apoplexy 46

Bright's disease 39

Cancer or malignant growths 60

Heart disease 148

Insanity 28

Chronic alcoholism 84

Diabetes 14

Syphilis 11

Miscellaneous diseases of chronic character. . . 157
Negative history of chronic ailment 382

Total parents and grandparents 1056

From the foregoing it woidd seem fairly evident that the heredi-
tary role of pulmonary tuberculosis is hardly so important a factor in
\he development of the disease as has been claimed in the past. It
would also seem to have no more causative bearing on the production
of a fertile soil than many other chronic ailments tending to histolog-
ic vitiation.

Another premise that should modify statistics of heredity is the
fact that the offspring of tuberculous parents are much more exposed
to infection from the intimacy of family relations, hence acquirement
of the disease in many seemingly hereditary cases must be attributed,
not to hereditary, but to direct infection.

The discovery of the specific germ of tuberculosis in 1882 cleared
up many mooted points in regard to the disease. The infectiousness
of tuberculous material had long been recognized but the exact agent
was unknown. Koch's discovery settled the matter once and for all, and
medical science profited wonderfully as a consequence of the marked
impetus given the study of bacteriology.

The recognition of a definite causative agent, more or less constant
in its results, stimulated further research of tuberculous phenomena,
and with the advent of more accurate information manv old theories
were proven fallacious. The doctrine of heredity sank back to an unim-
portant place, and close clinical observers awoke to the fact that while
tubercle bacilli were the cause of tuberculosis certain other factors

modified their pathogenic action. In other words certain conditions
of the human organism must be favorable to the growth and perpet-
uation of the tubercle bacillus or the disease is not produced — ^that is,
the soil must be adapted to the seed. It seems to me that study of this
question will bring us very close to the correct solution of all the varied
problems presented by the development or non-development of tubercu-
lous lesions.

But first we must study the seed. What factors or conditions
increase or decrease virulence of tubercle bacilli ? The answer to this
question is as yet unknown, but there is abundant proof to indicate
that tubercle bacilli do show variation in pathogenic intensity. Thus
bacilli from manifest disease in the cow, the horse or in man are
markedly different in their degree of virulence as shown by the expe-
ments of Theobald Smith.^ Likewise tubercle bacilli from different
lesions in the hiunan body also show decided pathogenic variation.
The experiments of Arloing and Lingard conclusively indicate this
fact, for they have demonstrated that tuberculous material from lesions
in the lungs killed guinea pigs and rabbits much quicker than that
taken from caseous glands or other parts of the body.

Every observer of clinical phenomena recognizes variations in the
progress and duration of tuberculous processes in general, but more
particularly of those occurring in the lung. Such variations may, it is
true, result from special susceptibility of the infected tissue in many
instances, but in many others there are abundant signs to point to a
varying degree of virulence of the infective material. One class of
cases may begin abruptly in individuals comparatively robust and give
rise to all the symptoms of an acute pneumonic process, constituting
the well-known '^galloping consumption," or "phthisis florida," which
frequently proves fatal in four to eight weekg. In still another class
of cases composed of individuals recognized as physically weak, the
tuberctdous condition may .be so insidious in onset and with a pro-
dromal stage so protracted that the distinct lesions of the disease cannot
be defined until far advanced. Periods of seeming resolution and
recovery may occur and yet the patient finally succumb years after the
initial onset of the disease. As I have previously said, the natural
deduction from these two types of the same disease is that they owe
their varience to different degrees of susceptibility of the individual.
In a measure this may be true in every case. Certainly we cannot con-
trovert such a deduction for we have no means of guaging vital resist-
ance. But I have been able to demonstrate that infective material

^Journal of Boston Society of Med. Science, 1900, iv., 95.

from widely different types of pulmonary tuberculosis does show
marked variation in virulence for the lower animals. My experiments,
while not so complete nor so skillfully conducted as might have been
I)08sible in a well equipped laboratory, were in part as follows :

One group of five guinea pigs and four rabbits, after aseptic
preparation, were inoculated with sputum from two cases of rapidly
fatal acute pneumonic phthisis ; and a second group with sputum from
two chronic cases, both of over one year's duration, but with slight
invasion of the lung substance. Of the first group, the guinea pigs all
showed extensive lesions in five to fourteen davs, and all but one died
inside of eight weeks. All of the rabbits also showed comparatively
rapid extension of the tuberculous infection, but the results in the
second group were quite different. In the same number of animals
the extension of the disease from the inoculated area was delayed two
or three times as long, and only one of the guinea pigs died within
three months. Of the second group of rabbits only two gave any reac-
tion to the inoculations whatsoever.

The quantity of tubercle bacilli in the specimens of sputum used
did not enter into the result, for the comparative number of bacilli,
judged from seven or eight microscopic slides, was greater in one of
the chronic cases than in both of the acute and rapidly fatal ones. The
Vermont state bacteriologist confirmed this fact, reporting for the
same specimens of sputum that the nimiber of bacilli in both of the
acute and in one of the chronic cases was "moderate" while in the
other chronic case the bacilli were "numerous."

Again, it is my belief that the tubercle bacilli found in late stages
of pxdmonary tuberculosis are more virulent than those found at the
onset. To adequately prove this the necessary experiments will have
to extend over long periods, and though I have several such under
investigation, I have not as yet been able to accumulate sufficient evi-
dence to prove my belief. However, during the progress of my
experiments, I have obtained one or two striking results.

A little over two and one-half years ago I inoculated three rabbits
with sputiun from a case of early but positive pulmonary tuberculosis.
The tubercle bacilli were easily demonstrable in the sputum. All of
the rabbits showed characteristic lymphatic enlargement after several
weeks, but when killed and examined three months later only one gave
indications of advanced pulmonary tuberculosis or of general involve-
ment. The case from whom the sputum used was obtained drifted out
of my sight and I did not see him again for one year and nine months,
when he again applied to me for treatment. His disease had been

progressive and he was evidently in the last stages. Both lungs were
extensively involved, as was the larynx. Expectoration was profuse^
but did not contain relatively any more bacilli than the sputum
obtained at the first examination. I inoculated several rabbits and was
astonished at the reaction produced. The point of inoculation in all
of the rabbits in from four to twelve days showed marked evidence
of suppuration and extension to the lymphatics. In two of the rabbits
a zone of extensive ulceration occurred around the inoculated point.
All of the animals were profoundly affected in contradistinction to those
inoculated with the same man's sputum one year and nine months
before. Indeed, the rabbits first experimented \\dth were apparently
not affected at all, for the lesion of inoculation healed in a few days
and never amounted to more than a slight nodule that could be felt
under the skin. Suppuration never took place.

I came to the conclusion that the second group of rabbits was
suffering from a mixed or additional pyogenic infection, and considered
that this nullified the experiment in so far as determining the relative
virulence of bacilli in different stages of the disease was concerned.
On the thirty-ninth day one of the rabbits died. Autopsy showed very
evident tuberculous lesions in the lungs, kidneys, liver and mesenteric
glands. I killed the other rabbits on the forty-fourth day, and they
too gave gross evidence of tuberculous disease of glands, lungs, kidneys
and other organs.

The fact, then, that of the first group of rabbits none should die,
and only one after three months time give evidence of microscopic
lesions, while of the second group one should die, and all show within
two months such marked progress of the disease, certainly seems sig-
nificant. Of course, I realize that this single experiment will not jus-
,tify any hard and fast conclusions, but no one can deny that it is
suggestive. Some reason must have existed to hasten or increase the
pathogenic action of the tubercle bacilli from the last specimen of
sputum. Whether it was the presence of the mixed infection or not
I am not prepared to say. I am inclined to believe so, however, since
certain experiments with the lower animals have demonstrated that
some germs that alone are comparatively non-pathogenic to individual
animals, become decidedly so when combined with certain others. For
instance Roger found that when animals immune to malignant oedema
were simultaneously injected with one to two c.c. of a culture of the
bacillus prodigiosus and a culture of malignant oedema, they would
speedily contract the disease. Giarre also found that adult guinea
pigs, which ordinarily resist infection with the pneumococcus, succumb

readily to septicemia when pneumococci are combined with diphtheria^
bacilli.

Some observers, notably Sata and Ophuls*, have been studying
the presence of other bacteria in pulmonary tuberculosis, and their
research and investigations point to the importance of mixed infection
in producing the pathologic conditions and symptoms considered charac-
teristic of the disease. It would seem that pulmonary tuberculosis is a
pure tuberculosis only in the beginning, that advance of the disease is
coincident with the establishment of a new factor which in itself is
largely responsible for the destructive process, or else greatly augments
the action of the tubercle bacilli.

Out of the twenty-seven cases of markedly progressive pulmonary
tuberculosis whose sputum I have examined very carefully during the
last three months, there was pronoimced mixed infection in all but
three cases. Streptococci were most evident in fourteen cases,
staphylococci in four and pneumococci in six. The disease seemed to
be most active in those cases of mixed streptococcic infection and was
evidenced by high fever ranging over 102 degrees F., more profuse
sweating and general exaggeration of the symptoms characteristic of
profound toxaemia. In three cases of streptococcic infection I have
been able to produce a decided remission of the fever and other
toxaemic symptoms and to establish improvement, temporary at least,
by the injection of 20 c. c. of anti-streptococcic serum. More extended
study is needed on this subject, but from my own clinical and micro-
scopic observations I am convinced that the .fatal character and
progress of pulmonary tuberculosis is invariably hastened, and may
possibly be largely due to the presence of a secondary or mixed infection.

Another phase of the study of tubercle bacilli and their action is
the investigation of certain pseudo-tuberculous conditions. Flexner^
has described a pathologic condition characterized by a caseous pneu-
monia and a nodular condition of the peritoneum which he has called
pseudo-tuberculosis-hominis-streptothrica. A streptothrix which was
found in the lesions was very diflFerent from ordinary forms of tubercle
bacilli or streptothrix. The fact that small branched forms of tubercle
bacilli are occasionally found in tuberculous lesions resembling the
actinomyces, to which the above streptothrix probably belongs, may
show that these pseudo-forms of tuberculosis bear some relation to the
real disease after all. The recent discovery of several acid-proof
bacilli closely resembling the bacilli of tuberculosis in morphology and

^American Journal of Medical Sciences, 1900, cxx., 56.
'Journal of Experimental Medicine, 1898.

tinctorial peculiarity raises new conjecture concerning the pathogenic
relation of these bacilli to the potent germ of tuberculosis. Just how
strong parasitic tendencies these similar appearing bacilli possess is
unknown^ and such investigation ojQFers an interesting and highly
important field of study. New and startling facts are sure to be dem-
onstrated, and the widespread existence of tuberculosis will be more
readily accounted for when they are properly classified and recognized.

MoUer^ has recently described a grass bacillus which he found
in bam dust. This germ forms rods in fluid media, and in its mor-
phologic aspect closely resembles the tubercle bacillus. It is patho-
genic to guinea pigs, the lesions being almost microscopically identical
with those of true tuberculosis. Histologically the process also
closely resembles tuberculosis. It is an interesting fact that MoUer
while studying this grass bacillus was taken ill with a sore throat, and
in certain masses which he expectorated was able to demonstrate this
germ. Marzinowsky in studying the bacterial contents of the tonsillar
crypts found an acid-proof bacillus that greatly resembles the tubercle
bacillus. It was fairly frequent in the follicles of the tonsils as he
demonstrated it in five out of twelve cases. The bacillus is polymor-
phous and stains by the Gram, Ziehl-Gabbet methods. Marzinowsky
found a similar bacillus in the sputum of a patient with bronchitis, and
comparison of cultures showed it to be identicjal with the one found
in the tonsils. Another bacillus that has been found in the sputum
of patients with pulmonary gangrene, and described by Fraenkel,
Cappenheim and Babinowitsch, is very similar to the tubercle bacillus,
although more constantly clubbed at one end and a trifle longer. It
has all of the morphologic and staining peculiarities of the tubercle
bacillus.

In the sputum of a case of acute bronchitis occurring in a robust
dairyman I found, in addition to streptococci, a number of fairly long
bacilli some of which were branched two or three times. Some
appeared broken like a chain. These bacilli were acid-proof and
alcohol-proof and stained well by the Ziehl-Gabbet method. Rabbits
inoculated with this sputum showed suppuration at the point of inocu-
lation and a lymphatic enlargement in three weeks. In shortly over
a month in some caseous material taken from the peritoneal glands of
these rabbits I was able to find the same bacillus, but in interwoven
clumps. Those bacilli that were separated from these clumps were
smaller and resembled tubercle bacilli closely, with the exception of
being considerably thicker. The patient gave a history of having been

'Centralbl. f. Bakt., Abth. I., 1899, XXV., 369-373.

loading hay for several days and having caught cold on the third day
*of this particular work. He had no chill but commenced to cough
'quite severely. He did not stop work but complained bitterly of pro-
:f use perspiration^ although it was in midwinter. At the time of my
first seeing him his temperature was 99.6 degrees ; pulse 80 ; cough
Tery severe, and with much purulent expectoration. His underclothing
^as fairly soaked with perspiration. Physical examination, aside from
the moist bubbling rales over the larger bronchial tubes typical of bron-
«chitis, was negative. Under suitable treatment he made a good
recovery and in four weeks was entirely well. He informed me and
I was able to verify the fact that two other men working with him in
loading hay were taken sick just as he was, and at the same time. I
-am inclined to believe that this was a case where a grass or hay bacillus
was present, and in some degree actually pathogenic.

It can readily be seen how easily these allied organisms might be
mistaken for potent tubercle bacilli, under certain conditions, and it
is extremely probable that this very thing has been done many times in
the past. Then again, may it not be possible for these closely similar
bacilli, but more particularly for this so-called grass bacillus, to acquire
the identical pathogenic properties of real tubercle bacilli by continued
passage thi*ough cattle or susceptible human beings just as it has been
-demonstrated that the virulence of weakly potent tubercle bacilli is
increased in intensity by passing through a series of highly susceptible
4inimal8 like the guinea pig ?

Now the question arises, from all the varied mass of evidence
resulting from investigation of the tubercle bacillus and its allied
^orms, what deduction can be drawn?

Just this : From clinical and laboratory study there are substan-
tial grounds for the belief that the tubercle bacillus is evolutionary in
•character, which evolution is evidenced by certain variations and
.^adations in a morphology and virulence modified by the chemic or
biochemic conditions of different environments.

This brings us to a consideration of the soil or those conditions
within the human body which favor development of tubercle bacilli
-and their characteristic lesions. From Hippocrates down medical men
have recognized a predisposition to tuberculosis in certain individuals.
In the main this predisposition has been considered a lowering of vital
resistance, a weakness of the defensive forces opposed to the attack
•of bacterial hordes. This so-called vital resistance is an unknown quan-
tity, and the real nature of immunity and susceptibility is at best only
-conjectural. Until the solution of these mysteries is wrested from the

fastness of the human body the cure of tuberculosis will remain just a^
chimerical as it has always been. Back to the ultimate cell we must
go and carefully study those phenomena^ chemic or histologic^ which
either arrest or permit the march of the bacterial executioner, if we
would find the truths we seek.

A careful study of the Ijinphatic system of the human body
points to the fact that this portion of the animal organism has an
important bearing on the development of tuberculosis. As early a&
1695 Silvlus recognized a weakness of the lymphatic vessels in scrof-
ulous conditions, and later observers confirmed his views. More
recently Fox attributed a disposition to tuberculosis to certain anatomic
and physiologic defects of the lymphatics, while Virchow has laid the
cause of scrofula to a weakness or imperfection in the arrangement
of individual lymphatic systems.

Histologic investigation teaches us that the lymph "glands" or
more properly the lymph nodes act as filters of all foreign material
that gains entrance to the body. Whether this property of attracting
and storing up, as it were, foreign microscopic bodies is a phase of
chemotaxis or simply a mechanical phenomenon, no one can say, but
the fact remains.

Experiments on animals and numerous clinical facts prove con-
clusively that the first brunt of an invading infection is borne by the
Ivmphatic tissue. And still further clinical observation, susbtantiated
by post mortem examinations, demonstrates that the lymphatics suc-
cessfully overcome and resist tuberculous infection in a fair proportion
of cases.

Considerable discussion has arisen in regard to the exact nature
of the protective forces resident in the lymphatic tissue. Defensive
proteid substances called alexins have been shown to normally exist
in the blood, their presence conferring certain forms of immunity.
It is probable, therefore, that like substances are present, or produced
when needed, in the cells of the lymph nodes. It may be a fact of
direct importance furthermore, that physiologically the lymphatic sys-
tem has an important influence on the chemic phenomena which we
are pleased to call the process of nutrition or tissue metabolism.

It should be remembered that every cell of the body is having its
own struggle for existence, a struggle which consists of assimilating
nutritive material, of transforming the same into complex tissue
elements necessary for a maintenance of cell identity and the produc-
tion of cell energy, and of getting rid of superfluous end-products
tinnecessary for these functions. Any time during the life of a cell

or an aggregation of cells the metabolic equilibrium may be destroyed
from several causes: — by variation in the supply or quality of the
nutritive pabula, by mechanical injury, or by toxic influence. The
result is a cell metamorphosis or cyto-degeneration, and through result-
ing inability of the cell to throw off chemic substances inimical to the
preservation of its original identity and existence, the degeneration
continues and finally ends in necrobiosis.

Now it may be properly asked what relation does cyto-degenera-
tion bear to the development of tuberculosis ? A rational deduction is-
just this : If substances analogous to the alexins of the blood, or other
factors in the lymphatic system whose function is to arrest or destroy
the influence of tubercle bacilli, are insufiicient for this purpose, then
the germs gain entrance to the circulation in a potent form and are
scattered throughout the body. Should cyto-degenerative changes be
general and extensive the tubercle bacilli will find many locations pre-
senting favorable conditions for their growth and destructive influence.
A disease, therefore, of which acute miliary tuberculosis presents a
typical picture, is the result.

But if the cyto-degenerative areas are few and small, no matter
how many bacilli gain entrance to the system, the conditions will be
unfavorable for the development and destructive influence of all but
a small number, and the tuberculous process will be limited, just aa
it is seen to be in the insignificant tuberculous nodules found in many
lungs on post mortem examinations.

It should not be understood that all physical weakness or degen-
eration induces tuberculosis. Conditions of marked vitiation or
depravity of the bodily structures may exist quite generally through-
out the body and yet tuberculosis never occur, even when external
conditions are extremely favorable to infection. If this was not so,
nearly every injury or disintegration of tissue would become tubercu-
lous at the point of solution. But we know from clinical investigation
and experiments on animals that the point where tuberculous infection
enters the organism rarely shows progressive tuberculous lesions. The
typical tuberculous process usually becomes evident in some organ
more or less remote from the atrium of infection.

The more frequent occurrence of tuberculosis of the lung would
seem to militate against the theory that cellular degeneration does not
induce tuberculous disease, for it has been pretty thoroughly demon-
strated that tubercle bacilli enter the body more frequently by inhala-
tion than otherwise. But under normal conditions the anatomic
arrangement of the air pasages, their irregularities, and the moisture

of the lining membranes thoroughly arrests foreign particles and dari'
fies the inspired air before it reaches the air vesicles. Furthermore,
foreign material which does reach the bronchial tubes is rapidly carried
to the nearest lymph tissue, the bronchial "glands/^ and there left, as
is shown by the post mortem appearance of the bronchial "glands" of
those whose work requires the constant inhalation of air laden with
soot or coal dust.

There is also ample proof that tubercle bacilli do infect the bron-
chial and other lymph nodes without extension to the lung tissue, but
there is nothing to show that tuberculous lesions of the lung are not
preceded by glandular infection. It is not strange that the lungs
flht>uld most frequently present definite tuberculous lesions. When the
other factors that prevent the systemic ingress of active tubercle bacilli
are removed, the nature of the respiratory process, the extreme and
constant tax that is placed on the cellular structure of the lung by
atmospheric variation, and the trophic and circulatory changes it is
subjected to by internal conditions, make cyto-degeneration of the lung j

more common than of any other part of the body.

In conclusion let me emphasize this fact: The development of i

tuberculosis in the individual is the result of a coincidence of not '

one but of several conditions. Those conditions are, first : A potent
tuberculous infection depending for its potency on a certain degree of
virulence. Second: A certain negative chemic or histologic condition
of the lymph nodes, resulting from hereditary tendencies or from cir-
cumstances of environment, which fails to arrest or inhibit the growth
and systemic ingress of potent tubercle bacilli. And third: A retro-
grade metamorphosis of structural cells in some part of the body, (more i
particularly in the lung), from trophic, traumatic or toxic influence
which favors the local growth of the invading germ.

It can be readily understood that the first two conditions are rela-
tive, that is a particularly large amount or a specially virulent tubercu-
lous infection might overcome resistant conditions of the lymphatic sys-
tem that ordinarily would be effective against a less virulent or smaller
amount of infective material. And conversely a weakened lymphatic
system might prove vulnerable to what under ordinary conditions
would be non-potent tuberculous material. In other words the success
of tubercle bacilli in making a systemic ingress depends upon bacter-
ial power, toxic or vegetative, which is numerically or through special
potency greater than the forces, chemic or histologic, of the lymph
nodes which tend to resist or prevent such ingress.

In leaving my subject I realize that there is much in the fore-

going which may be open to question and difficult of proof. But as
contradiction or affirmation of any statement requires new facts or
more accurate presentation of old ones^ my humble deductions may
prove of some slight value after all.

THE TREATMENT OF TUBERCULOSIS AT HOME**

BY CHARLES F. MCGAHAN, M. D.^ AIKEN, S. C.

Mr. President and Gentlemen :

I have the pleasure of bringing before you today the considera-
tion of a topic that is agitating the whole civilized world. Only six
weeks ago a congress was held in London on this one disease. It was
as largely attended by physicians from all parts of the globe as are
the international congresses on general medicine. So important was
the subject considered and so anxious was our profession for the report
of its deliberations, that our most progressive journals arranged to
receive the great Koch article by cable, and it was published on this
side of the Atlantic the same week it was delivered in London.

We all agree that better results are attained by the treatment of
patients in sanatoria, and at resorts where there are provisions made
for out door amusements, but it is only the minority and lucky few
who are fortimate enough to be able to avail themselves of these means.
The overwhelming majority must be treated at home. I do not mean
in the country a few miles from where these patients have dwelt, but
in their actual homes. As it Avill be many years before the state gov-
ernments, backed by the philanthropic public, will have adequate
accommodations in the different sanatoria for these unfortunates, the
first point for us to consider is the care we can give them without such
advantages.

OPEN AIB TBBATMBIVT.

Fresh air being of the greatest importance, we should consider
the location and ventilation of the apartment, but if there is a balcony
to the house we had better place the patient's bed upon it and have a
suitable awning made for shelter; if the house should be a tenement
without a balcony the best thing to do is to fix up the roof so that
we can there place a bed and thus locate our patient out of doors.
Should the house be situated in one of our smaller towns, with a small
yard or grounds around it, we can build what the Germans call a "Lie-

*Read before the 27 th Annual Meeting of the Mississippi Valley Medi-
cal Association.

genhalle" for the patient to stay in, or we can put him in a tent. The
"Liegenhalle" is to be preferred because one side is entirely open,
revolves upon cog wheels, and can be turned to keep out the rain and
strong winds, while the patient is protected and remains practically
out of doors. In selecting a tent I prefer a circular one with a large
opening in the top which ^dll allow the foul air to escape, the fresh
air entering at the bottom. Should it be more convenient for us to get
the square or army tent, it \^'ill be necessary to have a large flap made
in the rear part of the tent, two feet wide by two feet six inches long,
directly opposite the entrance, which, by leaving the flaps at the
entrance and the ventilator open, ^ill secure an excellent current of
air. I prefer the tent placed upon a platform about two feet from the
ground, so as to allow a circulation of air imder it. The patient must
be kept warm by proper clothing and in very cold weather, if necessary,
hot water bottles can be put into the bed. There should be no carpet
upon the floor, nor draperies in the apartments occupied by phthisical
patients. The furnishings may be as comfortable as the purse can
aflford and as luxurious as hygiene will permit.

CABS OF MEMBEBS OF FAMILY AND FRIENDS OF PATIENT.

It is in protecting the other members of the family from the dis-
-ease that the general practitioner has the opportunity of doing the
most good. He must recognize the disease early, and now that most
of our states have founded bacteriological laboratories for free exam-
ination of sputa, it is the duty of the practitioner to send the sputum,
in every case in which there is the least shadow of suspicion, to one
of the laboratories for a report. Upon tubercle bacilli being found,
it seems almost useless for me to say that the patient must be provided
with a bed in which he can sleep alone and, if possible, he should be
the sole occupant of the room, not only for his own benefit, but also for
the protection of the other members of the family. If my attention
had not been called to this point a short time ago, when I saw two
young girls occupying the same room and bed, one being in the last
tjtage of phthisis, the other seemingly well, it would be superfluous at
this period of our knowledge of the etiology of the disease to touch
upon this subject.

The habit of kissing which is so often resorted to by members of
the family and the invalid is also dangerous and should be prohibited.

CASE OF SPUTA, HANDKEBCHIEFS AND CLOTHES OF PATIENT.

It is well for the patient to have an antiseptic solution with which
to rinse out his mouth several times a day. Xot that I expect to thus
kill the bacilli, but because therewith anv bacilli mav be removed that

may have lodged against the teeth or the sides of the mouth. The
greatest attention should be paid to the care of the sputa which should
be received in one of the sputa-cups, of which there are a great variety
un the market. I prefer the paper cups that can be burned, to the
l.K)cket sputa-flasks which have to be sterilized each day after use. The
pocket sputa-flasks may be very good for patients in sanatoria, as they
are there taken charge of and thoroughly sterilized by competent per-
sons, but with patients at home, I generally find that they will not,
and often caimot sterilize them ; so I much prefer their using the paper
<;u8pidor8 instead. When taking exercise away from home, such as
walking or driving, I advise expectorating into cheese cloth which,
after use, is put into an oil-silk bag ; the latter on returning home and
after its contents are burned, should be thoroughly mped out with an
antiseptic solution. I prefer the use of cheese cloth to a handkerchief
because, being cheap, it can be burned. Of course in institutions all
linen can be thoroughly sterilized before it is washed, but at private
homes my experience is that the difficulties of doing this thoroughly
are so great that patients and their families become careless ; therefore,
I think it best to destroy by fire everj'thing possible that comes in
contact with the patient's expectoration.

VENTILATION OF APABTMENTS.

Under "Open Air Treatment" I laid particular stress upon the
ventilation of the apartments in which the patient lives, and I wish
now to call your attention to only an additional point or two : Do not
l>e afraid of the night air. Insist upon having the room as thoroughly
ventilated by night as in the day ; and in winter, by all means have an
open fire. With a stove it is abnost impossible to control the heat.

Several years ago, in the White Mountains, I had under my care
during the summer a poor girl suffering from phthisis. Some philan-
thropic people raised a sum of money to send her south. The amount
was not sufficient to procure other than poor accommodations, and as
her home was a New England farm-house, with every room heated by
stoves, I advised her to use the money in building for herself a good
airy room with a large wood-fire-place. She did so, and I was much
pleased, upon my return the next summer, to find that she had greatly
improved. She continued to gain and has been well now for some six
years.

NOUBISHMENT.

Equally as important as ventilation, is the proper feeding of the
patient. Some years ago, when frequent feeding was considered most
important it was the custom to give food every few hours, while a few

years later it was thought best to give the patient only three meals a
day, and nothing between times. My own experience has been that we-
cannot follow any set role and that each case must be studied sep-
arately. What we should aim at, is, to give our patients as much nour-
ishment as they can assimilate. I think it is well to give some hot drink,,
on awakening in the morning before the patient gets out of bed, such,
as a glass of hot milk, cocoa or beef tea. I prefer a glass of milk and
vichy; it is, however, not of enough importance, but that we can leave-
the choice to the palate of the patient. There are two advantages to-
be gained by the patient's taking warm nourishment upon awakening.
First, it loosens the mucus and enables it to be raised more easily;
second, it strengthens the patient, so that he experiences less fatigue
from dressing. If the patient's digestion permits, it is wise to give-
him three meals a day and also some light food between the meals and
upon going to bed. But if there is the slightest sign of distress of the
stomach we must take care of and rest the digestive organs, adapting
the quantity and quality of food to their present capacity. In regard
to the kinds of food I much prefer those that are prepared fresh in
one's own kitchen, to manufactured ones, although as to the latter I do-
not wish to be misunderstood, as I appreciate fully the value of many
of the laboratory products with which you are all undoubtedly familiar ;
and I have seen a great deal of good accomplished by them. I am,
however, partial to milk in its natural condition or, if necessary, with
lime, barley or vichy water. I try to have a patient take from a quart
and a half to two quarts a day. I consider eggs next in importance
to milk and advise my patients to take at least four a day ; it is imma*
terial whether they take them boiled, poached, or in sherry, but I do*
not approve of them fried nor do I allow any fried food. Hoast beef,
beef steak, mutton, lamb, turkey or chicken, with vegetables should
be given with enough variety to tempt the appetite. Plain pudding
or fruit may be allowed for dessert, but the eating of pastry should be
discouraged. I do not agree with the German physicians who advocate-
the use of wine or beer with the midday or evening meal. On the con-
trary, I consider that the patient is better without them, and I allow
whiskey only when from some cause, the patient becomes exceptionally^
fatigued, or needs a stimulant. I do not think its regular use is pro-
ductive of good results.

BEST ANB EXEBCI6E.

I now come to the last one of the trinity — air, nourishment and
rest. We have already considered the first two, and I deem rest of
equal importance with them. While there is fever it is necessary to

keep the patient in a reclining position. For this purpose I find the
wicker reclining or steamer chair most comfortable. But should the
' patient not be able to afford this luxury, a couple of armchairs will
answer the purpose very well — one to sit in, and the other tilted to
hold the feet. After the fever ceases, exercise should be encouraged^
particularly puch as will expand the chest. The breathing tube which
admits of pidmonary gymnastics is then of especial value. I find, how-
ever, that most patients are apt to overdo, hence we must prescribe
not only the kind of exercise but just how much should be taken, as
a great deal of harm comes from over fatigue. We should always
warn patients to guard against getting tired; walking is the safest
mode, but horseback riding, golf, and bicycling are all good forms of
exercise but only for selected cases, and then in moderation.

KEDICATION.

We have no specific drugs for this disease. If one has followed
the literature of the past twenty years, and has seen the numerous
drugs and methods of treatment that have been advocated by excellent
minds, and endorsed and lauded by the leading men of the time in the
profession only to be abandoned for new ones it will convince any one
that the routine use of drugs is of little value. Tonics and medicines
that build up the general system have their uses, and as symptoms
present themselves of sufficient importance for treatment, we are
called upon to prescribe. Of the numerous tonics I have had most
excellent results from iron, strychnine and arsenic. I consider malt
and cod liver oil as foods, and have found few patients who could not
take the combination when mixed in suitable proportions. Dyspepsia
should be treated by controlling the diet, and, if needed, by the use
of drugs. The different forms of dyspepsia which occur in phthisical
patients are so varied that it would be impossible, in an article of this
sise, to do more than say that each form must be treated according to
the symptoms presented.

Cough needs no treatment unless it is so bad as to disturb the
rest of the patient at night. In such cases we are obliged to use one of
the preparations of opium, and it devolves upon us to select the one
which is least apt to disturb the patient's stomach. Codein and heroin
have, in my hands, served the best purposes. All cough mixtures are
an abomination and only disorder the digestion. When the general
health improves and the limgs heal the cough will cease, and not till
then.

WHEN CAN WE CONSIDEB A PATIENT OUBED?

It is very important that we recognize a condition when the

patient is to all intents and purposes cured and able to mingle with
his fellow men, without danger of infecting them. When the patient
has had no fever for six months and his cough has ceased and when, *
upon repeated bacteriological examinations, we fail to find tubercle
bacilli, I think we can safely consider the patient cured. In this con-
nection, it is also important that we should educate the public so that
it may know when there is no danger of contagion from contact with
recovered patients.

The following case which came under my care will illustrate this
point : A patient who had been under treatment for six months had
improved so much that he had gained twenty pounds in weight. He
bad been without fever, cough or expectoration for two months and
the chest had quite cleared up. What little expectoration could be
secured I examined repeatedly for tubercle bacilli, and failed to find
them. He returned north, and was pronounced cured by his physician
who is one of the best known specialists in the East. In spite of all
this his employer would not allow him to return, but preferred to pay
his board at a summer resort, rather than to have him around his stable.

THE AFTER CASE OF A PATIEIVT WHO HAS ONOE HAD TUBEBOULOSIB.

It is necessary that he should always live in good airy apartments,
and have plenty of fresh air, both day and night. He should endeavor
to obtain an occupation that will keep him out of doors. His nutrition
should always be kept up to a high point, for he has demonstrated by
his first attack, that he has the suitable soil which is liable to reinfec-
tion. He therefore finds that whenever he allows his general health
to become impaired the greatest strain is placed upon the weakest part,
and this part will first give way ; hence, it is imperative that a patient
once having had pulmonary phthisis should always take care of him-
:self and should be very watchful for any sign of failing health..

Dr. Beverly Robinson, in the St. Louis Courier-Journal, has
mounded the key note of the after care of pulmonary patients, when he
says, ^'Legislation should make it imperative that the tenements, work-
shops and apartments of the poor should be so constructed that the
occupants will get plenty of sunshine and fresh air." Take a con-
sumptive, who has been cured, and send him back to live and work in
a dark and ill ventilated apartment, and he will soon fall victim a
second time to the white plague.

WHAT SHOULD BE THE ATTITUDE OF THE MEDICAL PROFESSION

TOWARD THE PUBUC AND THE INDIVIDUAL

SUFFERING FROM TUBERCULOSIS.*

BY WILLIAM A. DICKEY, A. M., M. D., TOLEDO, OHIO, PROFESSOR OF THE PRINCI-
PLES AND PRACTICE OF MEDICINE AND CLINICAL MEDiaNE, TOLEDO
MEDICAL COLLEGE. AITENDING PHYSICIAN AT ST.
VINCENT'S HOSPITAL. MEMBER AMER-
ICAN MEDICAL ASSO-
CIATION, ETC.

The discovery of the tubercle bacillus by Koch in 1882 caused
renewed interest in the investigation and discussion of tuberculosis.
The discovery of the cause led to the hope and belief that ultimately
a cure for the disease would be found, as well as a more accurate knowl-
edge of the means by which it is spread. Knowing how it is dissemi-
nated, its prevention would follow as a natural sequence when every
avenue was safely guarded.

This is not only a medical subject of great significance, but an
economic one as well, involving as it does a great saving of life and
therefore of increased productive force to the State and individual. It
becomes, then, one of vital importance because of its wide range of
application. Much has already been learned that will be of practical
and lasting benefit. On the contrary, many opinions and beliefs that
are now held and freely expressed, will, doubtless, as time goes by
prove to be erroneous and as a consequence be greatly modified or
entirely cast aside. Almost from the earliest history of medicine there
have been those who held to the opinion that in some way, and under
certain conditions, tuberculosis was communicable. Few, I take it,
will dispute that fact today. But the manner in which it is spread is
not so plain. The sputum during the late period of the disease con-
tains the bacilli in large numbers. The breath does not contain the
germs and is, therefore, devoid of danger. The disease is not com-
municable from person to person after the manner of diptheria, scarlet-
fever, and small-pox, but the bacilli in some way, find ingress to the
body where in a suitable soil they grow and multiply. A vulnerable
oonstitntion brought about from any cause whatever, environment,
and hereditary predisposition are important factors.

I am inclined to think that ^'hereditary predisposition'' is a factor
of more potency than we are willing to admit. In the August 24th

*Read before the Mississippi Valley Medical Association, at Put-in-Bay,
Sept. i2th, 13th and 14th, 1901.

number of the Medical Kecord, an editorial^ based upon an address bj
Dr. Edmund E. Wilson to the graduates of the Yale Medical School,
on "The Higher Claims of Minute Research in Biology and Medicine,"
gives an abstract which, to my mind, is significant. In speaking of
the phenomena of cell division, Dr. Wilson, says : "The fertilized egg
receives the neuclear matter in exactly equal quantity from both the
parents, in the form of rod-like bodies known as chromosomes, that are
identical in number, form and size in both male and female. Our
researches on cell-division are converging with ever increasing prob-
ability to the conclusion that the paternal and maternal materials con-
tained in the chromosomes are, or at least may be, equally distributed
by division to all the cells of the body whatever be their structures or
functions. In other words, every cell may thus receive neuclear mate-
rial from both parents and thus bear within itself the germs of the
hereditary predisposition of both."

By a majority possibly, of those competent to speak with
authority, it is believed that the disease per se is so seldom inherited
as to play a minor role in its continuance. It must be admitted, how-
ever, that in a surprisingly large proportion of cases, 50 per cent,
according to some statistics, a history of the disease can be found in
the forebears or some one or more of the immediate family. The
spread of the malady in these families is explained by domiciliary con-
tact and the inhalation of the germs. In a great many of these
instances this will not hold good, because it is constantly cropping out
in those widely separated and who had not seen each other in years.

We frequently speak of the inheritance of insanity, syphilis and
diseases of a kindred character and why not of tuberculosis ? Of the
possibility of such inheritance there is no doubt; its frequency is the
only point in dispute.

The present commonly accepted theory is that the sputum is the
main source of contagion ; being spit upon the ground, becoming dry,
the bacilli are carried by currents of air and inhaled by the predisposed
individual, and thus the disease is inaugurated. That this is dangerous
to the public no one will deny ; that every possible means at the com-
mand of the commonwealth and municipality should be employed to
put an end to expectorating on the sidewalks and in public places and
conveyances, all will admit ; that a wider range of distribution is thus
constantly maintained and the danger to the susceptible person accen-
tuated, is conceded; but is it proven that this is the principal source
of danger as is so stoutly insisted upon by a majority, possibly, of
those who write upon the subject ? And are we not in danger of pro-

ducing a needless feeling of alarm, and in many cases actual hardship,
among people by insisting too strongly upon the great peril attached
to it ? I am aware that the lungs being the primary seat of the lesion,
is considered proof of inhalation of the poison : if this is true, the larynx
and tonsillar tissues ought to be the initial seat more frequently than
they are, when as a matter of' fact primary tuberculosis of the larynx
is a very rare thing. Objections may be had to this on the ground
that lodgement of the bacilli in the tonsils and pharynx is difficult
because of the well nigh constant motion in swallowing. This is no
greater for children than adults. Moreover the tonsils are considered
the atrium for the germs of other diseases that occur very frequently,
viz. : rheumatism and La Grippe. It is well known that sunlight will
destroy germs with marvellous rapidity — some of course sooner than
others. It has been shown that the diffused solar rays entirely destroy
the virulence of tubercle bacilli in from five to seven days and that the
direct rays will do so sometimes in a few minutes, or at most in a few
hours. Kansom has shown by experiment upon the lower animals that
the germs are innocuous in from two to fourteen days after exposure
to light, but by exposure in the dark only, they retained to some degree
their inf ectiveness for a much longer period. They are less infective
when exposed to currents of air than when they are not. "Light and
currents of air destroy them quickly." These experiments were often
repeated and each time gave the same result. Even when the bacilU
are injected into the most susceptible of all animals — the guinea-pig —
for purposes of experiment the slightest deviation of temperature,
either of the culture media or atmosphere, renders the result negative.
Sudden atmospheric changes lessen in a great degree the vitality of
the germ. In this zone the regular changes of the seasons, to say
nothing of the sudden and numerous barometric oscillations inhibit in
a large measure their power to produce the disease. May not the non-
pathogenic germs in the air weaken, or in many instances entirely
destroy the virulence of the pathogenic ones ?

Dennison in an article in a recent issue of the New York Medi-
cal Journal says the destructive influence of sunlight upon the tuber-
cle bacillus is now generally conceded.

Moreover, when the individual is so far advanced with the dis-
ease that the sputum contains the bacilli in large numbers we have
mixed infection. The various cocci are present in innumerable quan-
'tity, grow rapidly, and by their saphrophitic action cause almost
immediate decomposition — analytical processes — of the sputum, thus
rendering it an unsuitable medium for the tuberculous germs. To

have the bacilli resifitant; they must be raised on suitable media and
at proper temperature, and sudden freezing and thawing will inhibit
their growth and render them in a measure non-virulent. These germs
having weight are found in greatest numbers near the ground; con-
sequently children would b^ more liable to become infected than grown
persons. There is neither histologic nor- physiologic difference between
the mucous and adenoid tissue of children and adults, unless it should
be in the fact that in the latter the glandular tissue is more active
and the lymph spaces larger. In this event the germs ought the more
quickly to be taken up and find lodgment, and thus produce changes in
the yoimg, very quickly and easily discernible in a body so impres-
sionable, and not lie dormant, as it is claimed, until late in life.

However, it is not impossible for the germs to remain inactive in
the gland tissue of children and at some favorable time in after life
the disease make its appearance as a consequence of an early infec-
tion rather than of a late one. Steffen has recently published the
results of 260 autopsies on children in which he finds that more than
25 per cent, of them died of tuberculosis.

Children are much more vulnerable to all forms of disease, hence
if the dust-laden air is so dangerous, more children ought to take the
disease than those of mature years. This we are told is not true,
because the greater number of deaths occur between the ages of 17
and 35. Again we would logically conclude that in those health
resorts that have for years been visited by consumptives the increase
in the number of tuberculous individuals among the permanent resi-
dent population would be very marked, because they have been allowed
to expectorate hither and yon as pleased their own sweet will. In
a letter received some years ago from Dr. Pari von Buck of Asheville,
"N, C, (and I am sure no one will question Dr. von Buck's qualifica-
tions to speak upon a question of so much importance) concerning this
point, he says : ^^There is no apparent increase of tuberculous disease
in the permanent resident population of this resort; on the contrary,
tuberculosis is practically unknown amongst those who have resided
here for several generations, and those who did not resort to this local-
ity on account of already present tuberculosis." The same can be
said of other resorts of a similar character both cis and trans Atlantic.
In the oft quoted Brompton Hospital for Consumptives in England,
there is not a well authenticated case of an individual contracting the
disease within its walls; if so it has escaped my attention. The same
may be said of Falkenstein, Germany.

Gardiner of Colorado Springs, an acute observer, has studied the

subject very carefully and. finds that the number of cases originating,
in the city is very small and that, too^ in spite of the fact that the
"Springs" have been the resort of consumptives for twenty years,.
Fluegge denies that the bacillus-laden dust is the dangerous factor int
infection. He has only been able to produce the disease when some-
lesion of the respiratory tract existed. It is his opinion that the dan-
ger of infection by the dry sputum is improbable.

Do not misinterpret my meaning and assume that I think there is
no dagger from the dried sputum ; far from it. However, there is, to
my mind, an exaggerated feeling of alarm in certain quarters caused
by intemperate statements from the profession and much inconvenience
and in many cases actual and needless suffering is occasioned. As an
illustration I need but point out to you the action of some of our west-
em states in passing laws prohibiting consumptives from coming within
their borders, hotels and boarding houses refusing them even temporary
shelter. For this inflamed popular sentiment the profession is to
blame.

A few years ago Dr. Baker, Secretary of the Michigan State
Board of Health, issued a circular in which he stated that three thous-
and cases of tuberculosis occurred annually in that state from con-
tagion alone. By what process of reasoning this distinguished phy-
sician arrives at such a conclusion I am unable to teU. But why this
number? If three thousand, there must have been a time when there
were less, and a priori there would be a time when there would be
infinitely more, being incremental in character. If this unfortunate
state of affairs were true, Michigan would be ere this, the land of the
"great white plague'' instead of the splendid commonwealth that it
is ; and what would be true of that state would be true of all others.

The greatest source of danger from the expectoration of tubercu-
lous individuals comes from the overcrowded tenement districts of our
larger cities, where sunlight and currents of air are well nigh unknown.
Here the environment for the continuance of the disease is ideal. The
habits of the people are vicious in the extreme. Their constitutions,
undermined by excesses of all kinds, particularly alcoholic, with lack
of good, nutritious food, as weU as raiment, and pure air, make them
easy victims of this dread malady. Being ignorant of the danger
arising from the sputum, its destruction ia not thought of ; indeed not
considered necessary and absolutely no care is taken. Moreover, from
conditions beyond their control the sick and the well must occupy the
same sleeping room, often the same bed. This it is conceded by all
is exceedingly dangerous under the most favorable circumstances and

should not be done, but in the tenement districts and among the very
poor elsewhere the danger is infinitely increased. These, coupled with
repeated intermarriages give a gloomy outlook for this people unless
the most rigid sanitary measures are carried out. This as is well
known is being done in some cities, but by no means in all to the
extent it should be. It is here our best energies should be put forth,
and well directed efforts continued. If the State could provide homes
for these unfortunate poor, in some healthful locality, far removed
from the great centers of population, it would confer a lasting benefit
upon the public and the individual, by limiting the spread of the disease
end curing a certain per cent, of cases, thus restoring them to family
and friends and making them a productive force to the State. In
cases of this kind "we are our brother's keeper." He is human like
ourselves and is entitled not only to our sympathy but to our protec-
tion. It is his misfortune, certainly not always his fault if he is so
sorely afflicted. That tuberculosis in its incipiency is curable can no
longer be doubted. Unfortunately many of these cases are not seen
until the disease has made such inroads as to make it well nigh impos-
sible to do anything ; or if seen early a proper diagnosis is not made.
In Koch's now much discussed paper, read before the Congress
of Tuberculosis in London, he denies the identity of human and bovine
tuberculosis and doubts the transmissibility of the latter to man, thus
discrediting the necessity of the precautions that have been taken in the
destruction of tuberculous cattle. This is no new theory and certainly
is not original with Koch. In August, 1899, Professor Adami read a
paper before the Canadian Medical Association in which he calls atten-
tion to the lack of evidence to prove the hypothesis of the transmission
of animal tuberclosis to man. He says that when human tubercle
bacilli are injected into animals the tendency is to become localized and
lead to transient effects. In the same year Dr. Theobald Smith of
Massachusetts said, "I have found in a set of tubercle bacilli, that is,
isolated human sputum, and in the disease in cattle* that there were cer-
tain differences that could be easily recognized by laboratory methods,"
find that thus far in his work he had not found human and bovine
tubercle bacilli to be identical. He adds, however, that the strength of
his position depends largely upon the number of cases examined, and
unless my memory is much at fault he took a similar position the year
before, that is in 1898, in a paper read before the Association of Amer-
ican Physicians in Washington City. Others have written along sim-
ilar lines. As to the bacilli in the milk of tuberculous cows, it is pretty
generally agreed that in those having well marked tuberculosis, the

milk is very apt to contain the bacilli and should not be used unless
sterilized. The per cent, of frequence varies with the observer. Thus
ObermuUer found the germs in 61 per cent, of the samples of milk
sold in Berlin, while Petri found them in only 14 per cent. Intestinal
tuberculosis in children has been offered as proof, not only of the
milk origin of the disease, but as well of the identity of human and
bovine tuberculosis. Primary intestinal tuberculosis is a very rare
thing ; indeed, its existence is denied by clinicians of wide experience.
Still, of London, says the commonest channel of infection of tubercu-
losis in children is through the lungs ; when the mesenteric glands are
involved it is the intestines ; the latter is less common in infancy than in
later childhood. From this he argues that milk is not the usual source
of the disease in infancy. From the foregoing it is very evident that
until it is definitely determined that bovine tuberculosis is not trans-
missible to man, that neither the meat nor milk of a tuberculous ani-
mal should be used in an uncooked state, and that in well marked
cases the cow should be killed, and paid for out of the public treasury.
It is an unjust hardship to expect the unfortunate owner of a tubercu-
lous cow, not to be recompensed for the destroyed animal, even though
the destruction be for the public good. The interests of the State and
individual are identical; they should be reciprocal.

No teacher should be allowed in the public schools who is suffering
from tuberculosis. During the constant, and many times well nigh
immediate contact with the pupil the act of coughing projects to a
•considerable distance innumerable bacilli, which being inhaled by the
susceptible child, either as a result of inherited predisposition or low^
•ered vital resistance from any cause, may easily induce the disease.
To say that ventilation in our public schools is sadly deficient, is express-
ing it mildly. The atmosphere is rebreathed and breathed again until
each child suffers from a semi auto-intoxication. If to an atmosphere
of this kind you add the germs of a disease of this character, and the
child in the condition I have indicated, it needs no philosopher to
tell "vdiat the result will be. The parents and children have a right
to demand that every safeguard be thrown around the latter while
pursidng their studies. Larger and more numerous playgrounds should
"be provided and more time allowed for recreation. Simple devices
for muscular development should be supplied and the necessity for
their use should be pointed out to the children; more especially to
those with a hereditary predisposition. Particularly is this true in
the densely populated portions of our larger cities.

What then should be the attitude of the profession toward the
public and the individual suffering from tuberculosis t

In the political parlance of the day it should be a campaign of
education. The profession having a thorough and comprehensive
knowledge of the different sources of danger, the public and the indi-
vidual should be told of them, and the best means of avoiding them.
As I have said before, the interests of all being identical, they should
be reciprocal; the physician pointing out the way, the individual,
singly and collectively, contributing to "the end in view" by complying
with the rules laid down by the profession. "Pro bono publico" should
be the motta

Whether this would mean the compulsory notification of all caseft
of pulmonary tuberculosis is a debatable question ; or rather I should
say what action should be taken after notification had been given t*
Not belonging to the same class of diseases as scarlet fever and diph-
theria, the placarding of houses and apartments, with isolation of the
individual would be useless, and no doubt would meet with the most
determined resistance. If, simply to furnish information as to the
destruction of sputimi, and hygienic matters generally, it would occa-
sion no offence and would, no doubt, be received with greatest kind-
ness. All this, however, could be done by the conscientious family
doctor without notification.

The State and municipality should enact such laws as will make
it an offense punishable with a fine for an individual suffering with
well marked tuberculosis of the lungs to spit upon the sidewalk or any
place where the people congregate. It should be the duty of the
police to see that these laws were enforced. Every consumptive when
away from home should provide him or herself with Japanese napkins
or bits of cheese-cloth — both inexpensive — ^in which the sputum can
be collected (and that, too, without any offense to the most fastidious)
and then burned. Paper spit-boxes are an unpleasant sight and should
be reserved for the home, where they can be used. The room or
apartments in which a consumptive has lived for any considerable
length of time should have all belongings removed, renovated and
subjected to sunlight and currents of air, and the paper removed from
the walls and burned and the walls thoroughly cleansed before new
paper is put on in its stead. The floor should be thoroughly scrubbed
with hot water. All windows should be removed. The most rigid
supervision of the dairy and all dairy products should be made by one
competent for the work and not because of his ability as a ward-caucua
manipulator, and until it shall be determined by ii\numerable experi-

ments carried through series of years that bovine tuberculosis is not
communicable from animals to man, if a tuberculous cow is found she
should be taken from the herd and the milk not allowed for domestic
purposes, and this, too, even though the udder show no tuberculous
lesions. If decidedly tuberculous, the animal should be killed and
the carcass destroyed by fire. "So butter should be made from a dis*
eased animal, no matter how slight the lesion. The importance of this
precaution is apparent from some experiments made by the Imperial
Health Office at Berlin, where 250 guinea-pigs were inoculated by
peritoneal injections with ^H^utter bacilli,'^ cultivated from butter made
from the milk of tuberculous cows, with positive result^s in all of them.
The public press can aid the profession greatly by printing articles from
time to time from a reliable source, pointing out the necessity for more
rigid sanitary laws (including the complete destruction of the sputum
of the consumptive) and the great benefit to be derived from a strict
compliance with them.

In our large cities public baths should be instituted where the
deserving poor can free of charge take a bath at least twice a week.
There is nothing that will so fortify and strengthen the debilitated as
a cool or cold plimge. However desirable this may be as a health-
giving measure, it will be a long time until it will be done. Mean-
while let the profession urge upon the people in the tenement house
districts, and upon all who do not practice it, the benefits to be derived
from frequent bathing. An elaborate outfit is not necessary ; a bucket
with two gallons of clean water in it, and a sponge or towel is all that
is essential, unless you care to add to this some good soap. Bathing
not only strengthens nerve and muscle but aids in nutrition and the
public must be made to comprehend the fact that nutrition is the
fortress against bacterial invasion ; that the individual weakened from
any cause is more liable to take the disease than one who is not ; that the
debilitated individual offers the least resistance, hence the best soil for
the germ to grow easily and rapidly.

28
TUBERCULO^ AND CraLDHOOD-A RESUME.*

BY WILLIAM JACOBSOHN, B. S., M. D., NEW YORK.

PORMBRLY ATTBNDING PRYSICIAK AND INSTRUCTOR, DISSASBS OF CHILDRBN,

DBMII^T DISPENSARY AND INFANTS* HOSPITAX, CITY OP N8W YORK,

MEMBER MBDICAI. SOCIETY OF THE COUNTY OF NEW YORK, ETC.

That tuberculosis is a communicable disease, that its morbid
processes are caused by the bacillus tuberculosis, that its lesions are
distributed generally or limited locally, and that these morbid processes
produce characteristic effects, each student of pathology and bac-
teriology knows.

However, in children, the early recognition of this disease, its
peculiar manifestations, its relations to other affections, the preventive
measures for its control, are of vast importance to each of us ; for the
"Child is father of the man ;'' and whatever knowledge is disseminated
for the good of the child will certainly make the man stronger, and
better able to cope with the struggles of existence.

The human cells are the defenders against the incoming agents
of destruction. Heredity is our inheritance of these cells; if these
cells are sufficiently powerful, that is, if our heredity is excellent,
we shall conquer these enemies; if not, they will overpower us. In
infancy and childhood, cellular activity is very much pronounced, for
there is a constant rapid growth and development, and when it is neces-
sary to combat disease, a still further exertion will be required of the
cells, and the task to be overcome will be proportionate to the relative
hereditary strength. In spite of this hereditary strength, when pre-
vious exertions have too far lowered the vitality of the cells, disease
will be victorious; and on the contrary when deficiency of hereditary
strength is early recognized, by fortifying cellular resistance, and
avoiding cellular irritability, disease can be prevented.

How then, does this want of cellular resistance, of vital energy,
of immunity, or of hereditary power manifest itself as tuberculosis,
so that the disease can be early recognized ? Although, today, we have
at our command more precise scientific methods and instruments, and
the aid of bacteriology, we must mainly rely upon clinical diagnosis of
this disease in children. The sputum of children is often not expec-
torated, and commonly swallowed, and the absence of bacilli in the
tuberculous, inflammatory products is not rare. The injection of
tuberculin, as a means of diagnosis in children is not devoid of the
danger of the further spread of the disease.

*Rcad before the American Congress of Tuberculosis; May i6th, 1901.

Bemembering the seats selected for the development of tubercu-
losis, viz., the tissues of the skin, subcutaneous tissue, mucous, serous,
and synovial membranes, piamater, the glands, bones, and the lungs,
liver, spleen, kidneys and testes, we can associate these seats with the
following diseases; scrofulous (so-called), subcutaneous, and tubercu-
lous abscessses, glandular tuberculosis, osseous tuberculosis, synovitis,
meningitis, general tuberculosis, and tuberculosis of the different
organs.

As is well known, glandular eiilargement occurs in other infec-
tions and we must be able to differentiate between tuberculosis and
them.

That glands are infected at first, is proven by having found bacilli
in glands, and not in the lungs in pulmonary tuberculosis. Glandular
enlargement is commonly found in children and i3 the forerunner of
more serious future trouble, when left without treatment. The origin
of the bacillary infection which ends in the miliary form, and in men-
ingitis, has been traced to caseous tracheal and bronchial glands; if
these glands become large, their presence can be recognized by dull-
ness on percussion between the scapulae ; these glands may so enlarge
as to extend up in the neck along the sides of the trachea. Bearing
in mind the frequency of the occurrence of such glands, and the pres-
ence of spasm, often mistaken as spasmodic asthma, or some laryngeal
disease, the diagnosis can be made.

Glandular tuberculosis, often called scrofula, although occurring
at any age is very common in the young. The glands become enlarged,
tender and often undergo suppuration; those of the neck, of the
axilla, of the groin, or of the mesenteries becoming involved. Often
these glands become smaller, and undergo calcareous change; the
tubercle bacilli are retained, and at some later time in life when the
individual is run down, set up a general or pulmonary tuberculosis.
Associated with these glandular enlargements, we often find inflam-
mation of bones or joints, and ulcerations of skin and mucous mem-
branes. The child is anaemic, slowly emaciating, and having a hectic
fever. If we suspect lung tuberculosis associated, and examine the
chest, we are often surprised at so little involvement; there may be
a few crackling rales, chiefly below the nipples, and in the scapular
region. In young children it is very important to examine the lower
lobe of the lung, for here it is common to find a cavity, although in
adults we seek it in the upper lobe. In tuberculous disease of the
mesenteric glands there is wasting of the child, enlargement of the
abdomen, pain, griping after ingestion of food, diarrhoea, and pyrexia.

On palpation around the umbilicus^ by pressing backward toward the
spine, and by carefully manipulating the abdominal wall the glands
rre detected; the bowels should have been previously evacuated. In
longer standing cases, when the peritoneum is involved, adhesions be-
tween the intestinal coils, and between the latter and the abdominal
wall take place ; these coils of matted intestines can then be detected.
Ulceration of the intestines and localized abscess often follow. The
severity of the diarrhoea is dependent upon the extent of the ulceration
of the intestine.

Where evidence of glandular tuberculosis is present and the child
is wasting away, losing appetite, becoming paler, cross, fretful, its
sleep being disturbed, hands held clenched, you may expect tubercu-
lous meningitis, often described under head of acute hydrocephalus.
Following these preliminary signs, the child's pulse becomes rapid and
it shows it has pain in the head by putting hand on head and crying
out at the slightest noise or light. Then follows projectile-like vomit-
ing, pupils become contracted and irregular and abdomen is retracted.

These symptoms last three or four days or a week with an irreg-
ular fever of an intermittent type. Then come the stages of the
disease that are marked by dilated pupils, slow pulse, cessation of cry-
ing, hemiplegia, stupor, irregular pulse and respiration, and coma.

Tuberculosis of the skin has been mentioned above, and we shall
briefly dispose of it because rarely present in children. Sometimes
there occurs in so-called scrofulous children ulceration of the skin at
its junction with the mucous membranes, for example at the lips, and at
ihe vulva. Kecently, I have seen such a case, the diagnosis of which
was properly made by laboratory examination. Frequently onycho-
tiosis is of tuberculous origin. Injuries to the skin are often followed
by involvement of glands through the lymphatic circulation. Iritis
tuberculosa, occurring mostly in children, is rare. The diagnosis is
determined by the chronicity of the affection, the characteristic appear-
ance of the iris and by its resistance to all ordinary treatment for iritis.

Proceeding to the mucous membranes, it is to be expected that
the presence of enlarged tonsils, adenoids, nasal or other obstructions
to proper respiration will cause tuberculosis. In these structures,
proper soil is found for the lodgment of the bacilli as well as other
pathogenic germs and the latter are thus carried through the system.
Middle-ear disease is also caused by the presence of these obstructions,
and in a similar manner the resulting mastoid disease is often tuber-
culous. The importance of removing said growths cannot be over-
estimated. It is wrong to wait until the child "overgrows them" for

meanwhile the chest capacity becomes less and less^ giving rise to the
sunken and pigeon chest, which owing to the lack of tidal air, affords
proper soil for the development of pulmonary tuberculosis.

Familiar to both physician and surgeon are synovial and osseous
tuberculosis. Ostitis of foot, caries of phalanges, of fingers, ribs, ster-
num, mastoid, and nasal bones, and dactylitis are met conmionly.
Chronic tuberculous abscesses, originating from lower dorsal and lum-
bar spine, psoas abscess, hip, knee, elbow and wrist disease are to be
mentioned in this connection.

Cold abscesses, in the form of small subcutaneous abscesses are
often present in infants a few months old. First, they appear as
small nodules, the size of a small pea or less, situated on the limbs or
trunk. They are mostly chronic in their course, either remaining
stationary, slowly suppurating or becoming larger. Eventually the
skin assumes a reddish purple color, becomes thinner imtil at last there
escapes thin pusoften mixed with blood. When examined, bacilli will
often be found in the discharge.

Of the organs, therQ is hardly one that may not be affected with
tuberculosis. If the kidneys, liver, spleen, suprarenal bodies, larynx,
testicles are involved, it is usually secondary to general tuberculosis
or pulmonary tuberculosis. No attempt will be made to describe the
affections separately of these organs, as these descriptions may be ob-
tained elsewhere.

How to combat tuberculosis is now engaging the attention of the
medical world. In introducing this subject, I stated the importance of
the role which cellular activity plays in children. At the beginning
phase of life the cell should be strengthened. The feeding of the
infant and child must be properly done, in order to furnish the proper
growth and development for the cell. Waste must be properly elimi-
nated by properly dressing, by attentions to the skin, by properly bath-
ing, and by attention to the other excretatory organs.

Kegular daily bathing with cool water acts as one of the best
stimulants to cellular activity.

Exercise in children is too often neglected at the expense of men-
tal attainments. Children should sleep in well ventilated rooms.
Overcrowding, such as is permitted in the greater cities in tenements,
is criminal.

Philanthropists can find no better field for usefulness than build-
ing large model tenements with spacious courts, the roofs of such tene-
ments to be turned into gardens in summer, and enclosed glass sun-

parlors in winter, for playgrounds for the children. If such were-
done^ a large percentage of lung diseases would disappear.

Weakly infants and children would by these means greatly
strengthen their cellular resistance to all germs.

In addition, proper medication and direction by the family phy*
sician, as well as the isolation of already diseased children in sanatoria
and rural colonies, would terminate this dreaded affection.

ORIGINAL TRANSLATIONS.

THE TREATMENT OF TUBERCULOSIS OF THE EPIIXDYMIS AND TES-
TICLE BY UGATURE AND DIVISION OF
THE SPERMATIC CORD.*

BY DR. MAUCLAIRE OF PARIS.
PRELIMINARY CONSIDERATIONS AS TO PATHOGENY AND TREATMENT.

Tuberculosis of the epididymis and testicle is treated by sorae
authorities by early castration, and by others by conservative pro-
cedures. In our opinion, all the possibilities of the lattter have not
yet been exhausted. If there be such a thing as a localized tubercu-
losis, it is surely seen when this disease attacks the testicle.

In place of removing this organ and its chief excretory duct, the
epididymis, could we not ligate either the vas deferens, the nutrient
artery of the testicle, or the veins and lymphatics (for the latter ves-
bols should contain the internal secretion of the gland); or finally
could we not ligate all these various structures — in other words the
totality of the spermatic cord — at the same time ? These various liga-
tures we have either already performed, or we intend to practice them,
in order to induce atrophy, not only of the testicle but of the epi-
didymis as well, when the latter has become infected by tuberculosis.

Pathogeny : — ^In order to appreciate thoroughly the possibilities of
this operation, it is necessary to take into consideration first the actual
state of our knowledge of the pathogeny of tuberculosis of the
epydidymis and testicle. According to some authorities, Reclus for
example, genital tuberculosis begins in the epididymis. Other writers
like Guyon and Lancereaux believe that the infection originates in the
prostate and seminal vesicles, and iavades the epididymis by extension
from the latter structures. Finally a long series of observers look

*Translated for the Journal of Tuberculosis.

upon genital tuberculosis as a disease which begins in the kidney and
descends to the peripheral organs by succession of continuity, viz. : the
bladder, prostate, seminal vesicles, vas deferens, epididymis and tes-
ticle.* The possibility of infection through the urethra by sexual
intercourse has been conceded by various authorities; but cannot be
demonstrated by animal experiment.

Haematogenous infection of the genital apparatus is not a matter
of doubt, because we know that Koch's bacillus exists in the blood of
the tuberculous subject, albeit in very small numbers.* A noteworthy
fact is the grafting of a tuberculous process upon epididymitis of gon-
orrhoea! origin. Does not this suggest the localization of a general
condition? Is not the same consequence seen in adenitis? We have
often seen in the Ricord Hospital the transformation of venereal
adenitis — inguinal and crural — ^into tuberculous adenitis. Our master,
Humbert, often drew our attention to this particular. The same law
doubtless holds good for the transformation of gonorrhoeal orchitis in
the tuberculous.

The role of the lymphatics in the pathogeny of infection of the
epididymis is difficult to determine. We must simply keep in mind
the fact that the lymphatic system is the chief route, not only for the
propagation of, but for the subsequent destruction of the bacillus.
Some hold with Malassez that the path of infection of the epididymis
and testicles is found in the intercanalicular lymphatic spaces ; others
Math Gaule, believe that propagation occurs along the canalicular
epithelium of the seminiferous tubes ; still others regard the ordinary
blood vessels as the route of invasion. New researches are required
to shed light on these points of pathogeny.

The frequency with which one epididymis becomes infected when
the other has been removed for tuberculous disease, prompts inquiry
as to how such a form of recurrence is brought about. Infection must
either occur through the prostate, or else both epididymes must have
been infected from a common focus seated about the prostato-vesicular
region. Both these possibilities could occur simultaneously. However
this form of propagation takes place, it is necessary to protect tho
second testicle by ligating its own cord.

We shall not consider in this connection the epididymo-orchitic
tuberculosis of childhood. Here we know that peritoneal infection is
common; also that the haematogenous route is more likely to be a
factor in the child than in the adult. We know, further, that in the
child the testicle is attacked more commonly than the epididymis.
Chronic tuberculosis is more benign than in the adult, it terminates

more readily in suppuration^ and is more likely to end in resolution,
livithout relapse or generalization. It is the same, in fact, in the child
^8 is joint tuberculosis — often merely an external and local malady.

TBEATMBirr.

1. Castration : — ^This operation has always been performed, for it
was long believed that a tuberculous testicle was a form of cancer, or
that it would become cancerous in time. Abandoned as a result of the
teachings of Laennec, it again came into vogue with modem antisepsis.
Since 1892 it has again lost groimd and is in a fair way of extinction,
save in cases with numerous fistulae and profuse suppuration.

Castration, whether early or deferred, is not as radical a procedure
as has been believed, for it is always done too late. It rarely happens
that a- patient will submit to this operation when he suffers from noth-
ing more than a few nodules of the head or tail of the epididymis. As
a rule he consents to operation only in primarily hypertrophic forms
<or when suppuration is profuse.

The doctrine that castration does away with the internal secretion
of the testicle, I hold to be pure theory. How could a testicle thus
diseased secrete anything of benefit to the organism? The excretory
passage is obliterated, and infectious elements proceed from the
tuberculous focus into the lymphatics and veins to contaminate the
organism at large. As for the internal secretion it would likely be
compromised as soon as the epididymis becomes nodular and the tes-
ticle filled with tuberculous granules. While spermatogenesis may be
preserved at the outset it would rapidly become altered.'

If during the operation of castration the vas deferens is not
'excised to the point where it empties into the seminal vesicle a bacil-
lary fistula is apt to result. Again, if the castration result without
local sequelae, we may still within a short time observe the infection
•of the other testicle, as if the latter had transpired through the vasa
deferentia, seminal vesicles and prostate. Such an outlook is most
^discouraging to both patient and physician, and thus it is natural that
castration has at present but few partisans. Bardenheuer has had
28 relapses in 38 cases, and other authors have had a similar experience.
I have seen one relapse follow complete ablation of the vas deferens.

Finally castration is no more able than conservative operations
to afford uniform relief in cases of prostatic and vesicular lesions, save
in cases of intense suppuration of the epididymis. As Longuet states,*
castration is not a radical operation, for it may be followed by relapse
in the stump, in the prostate and seminal vesicles, in the bladder, in
the opposite testicle, in the bones and in the lung !

It is doubtless well in castration to save some portion of the tes-
ticle, however small. Dupuytren states that in his day many castrated
individuals committed suicide or died of vexation ; and many authors,
including Malgaigne, Fualds, Pilcher and Pujol have mentioned the
psychical disturbances which follow castration. Quite recently Vouil-
lac has published a thesis on testicular prothesis (Paris, 1899).

2. Simple Eoccision of all the Tvberculoua Tissues: — This is an
old operation, dating back to the time of Astley Cooper and Curling.
At the present day an exploratory incision with extirpation of the
tissue found diseased is recommended by Lejars,*^ Koenig,® Poncet,^
Delbet* and other distinguished surgical authorities. If the incision
does not expose any diseased tissue, the albuginea is sutured. Becently
Poncet and Delore^ have insisted that lesions of the testicle and albu-
ginea may be latent and that they may therefore pass unperceived
during the preliminary orchidectomy.

8. Epididymectamy: — ^In 1880 Bardenheuer performed thq first
systematic total extirpation of the epididymis; his initiative was fol-
lowed by a number of prominent operators including Duplay, Humbert,
l/cjars, etc., etc.

Total epididymectomy is based on the fact that the testicle proper
is often healthy. This is not the rule — ^far from it, as we shall see
later. The operation consists in resection of the epididymis, with
preservation of the testicle intact. If the vas deferens is involved,
funiculectomy is also practiced. Duplay asserts that this piethod is
applicable to certain cases only, in which the testicle is implicated. In
this form of intervention the whole epididymis is extirpated, although
it may contain but one or two small foci of disease.

Atrophy of the testicle does not follow total epididymectomy to
any notable extent. In one case we observed a change in the dimen-
sions of the corresponding testicle, with compensatory hypertrophy of
its fellow of the opposite side, six months having elapsed since the
operation.

4. Methodical Excision of the TvberculoiLS Nodules in the Epi-
didymis: — This operation, practised by Malgaigne, Jobert and other
older surgeons ia at present advocated by Duplay.^^ The technique
consists simply in searching the whole of the epididymis and testis for
tuberculous foci which are extirpated wherever found. Sometimes
nothing is left of the testicle but an indurated lump, but this suffices
for the moral gratification of the patient. The use of the curette
belongs here and Quenu's*^ operation consists of an exploratory incision
with extirpation of the caseous foci and contiguous indurated tissues

by means of the sharp spoon. The wound is then cauterized with chlo-
ride of zincy and either unites by first intention or is tamponned with
iodoform-gauze.

5. Cauterization with the Hot Iron : — ^Tbis operation was origin-
ally described by Velpeau in 1851; but it was found that fistula
readily resulted from this form of intervention. Yemeuil used the
cautery with such effect that his operation might be described as a
"castration by fire.'' This operator even believed that the cautery
produced the regression of prostatic lesions in 80 per cent of cases.
Curettage may be combined with cauterization.

In regard to interstitial injections^ the results have not been bril-
liant. Cures are stated to have followed the injection of camphorated
naphthol, chloride of zinc, etc.

Simple medical treatment is of no avail — a mere avowal of our
helplessness.

Involution of the tuberculous lesions has been observed after aU
the conservative methods of treatment, just as after castration. Is
it not therefore wise to attempt to procure the atrophy of the tubercu-
lous epididymis by ligature or division ?

GENERAL CONSIDERATIONS UPON THE RESULTS OF SECTION AND LIGATURE.

As we intend to describe a new conservative method based upon
ligature and section^ undertaken with the intention of producing atro-
phy, to be followed by auto-grafting of the isolated organ, let ub
briefly review the results of these procedures in general. We regard
such a study in physiology as absolutely indispensable, for it will show
us how to proceed when ligation is to be applied to the testicle and
epididymis.

We shall consider the results of ligation or section upon: — 1.
Healthy organs. 2. Organs, the seat of neoplasms. 3. Infected
organs. 4. The testicle in all possible relations.

1. General Historical Sketch of Physiological Ligature: — ^liga-
ture and section h^ve been practiced upon the excretory ducts, vessels
and nerves of liealthy organs since Saunders tied the ductus communia
choledocbiid in 1*^7 5. Cooper, Curling and others ligated and divided
the vfls deferens in the first half of the 19th century and Claude T^er-
nard tied the pancreatic duct in 1850. In 1867 Obolensky divided the
spermatic nerves as well as the vas deferens. Several experimenters
tied the hepatic artery in 1876 and four years later Amozan and Vail-
lard ligated the ducts of the parotid.

In 1805 Alessandri performed individual ligature of each of the

afferent and efferent vessels of the testicle and of the nerves of the
laiter; fortj* experiments were reported. His work has been con-
tinued bv others. In the same year Kanf mann showed that the pan-
creas and liver undergo atrophy if their nerve supply is cut off ; while
in 1898 Alessandri demonstrated that atrophy of the kidney occurred
whether its artery or its vein was ligated.

2. History of Ligation in Connection with Organs the Seat of
Tumors: — Harvey himself in 1651 ligated the spermatic arteries for
elephantiasis of the scrotum and testicle and for tumors involving
the latter, with favorable results. Broca therefore terms him the father
of this method in surgery. Lange in 1707 suggested the wisdom of
imitating those veterinary surgeons who divide the arteries in strumous
tumors. Early in the 19th century ligation of arteries for tumors was
practiced by several surgeons including Maunoir, who tied the spermatio
arteries for "sarcocele" in 1815. The various recorded facts in regard
to ligation, etc., have become too numerous for repetition in this con-
nection; suffice it to say that ligature of the cord, vasectomy, etc., to
produce atrophy of the prostate became legitimate surgical procedures
about 1895. Bier had previously sought to cure hypertrophy of the
prostate by tying the hypogastric arteries (1891.)

8. History of Ligation^ etc,^ for Infected Organs : — ^In 1862 Skey
tied the spermatic cord in a case of tuberculosis of the testicle, because
he feared the result of castration in a cachectic subject.

Bier, by his well-known method of venous compression has caused
the disappearance of "white swellings" ; this compression is of course
equivalent to temporary ligature.

In 1897 Tuffier compressed the pedicle of a suppurating kidney
with retention-forceps, and the affected organ was eliminated through
the wound.

The work of Skey, Bier and Tuffier leads up to the method advo-
cated by the author.

ATROPHY OF GLANDS BY LIGATION OR DIVISION OF THE EXCRETORY CANAL.

There is enough evidence on record to show that, as a general
proposition, ligation of the excretory duct of a gland will produce
atrophy of that organ. For example, Arnozan and Vaillard have
shown that ligature of Steno's duct will bring about sclerosis and
atrophy of the parotid.

If we apply this principle to the testicle we should consider the
effects of all possible forms of obliteration, whether teratological,
pathological or physiological; and we must consider the results of

such obliteration upon both the internal and the eztemal secretion of
the testicle.

a. Teratology teaches us that the vas deferens may be absent,
although atrophy of the testicle and epididymis does not coexist. In
Brugnone's case the spermatic passages were obliterated from the mid*
die of the epididymis to the bladder; nevertheless the remainder of
the epididymis and the testicle had not undergone atrophy and were
found to contain spermatozoids.

In Gosselin's patient the funicular portion of the cord together
with the inguinal portion (about 10 cm. altogether) was absent. The
testicle, however, had undergone no alteration in size or appearance,
and also contained spermatozoids.

b. Physiological ligature and 'division of the deferent canal has
frequently been practiced. Brissaud, writing in 1880, states that
these procedures do not cause cirrhosis and atrophy of the testicle.
The corpus Highmori appears to protect this organ in some way from
the inflammatory alterations which lead up to cirrhosis. The epi-
didymis undergoes inflammatory change, and if the experiment animal
is left with the females, spermatogenesis occurs in an exaggerated
fashion, with subsequent return of the testicle to the embryonid state.
But when the animal is isolated, ligature of the vas deferens is followed
by no changes in the testicle.

The restdts of other experimenters in this sphere have been con-
flicting and quite recently the subject has been investigated anew. In
1895 Alessandri^^ decided that ligature of the vas deferens would
eventually produce atrophy of the epididymis and testicle. There is,
at first an increase in the amount of connective tissue, but a process
of sclerosis eventually leads to the disappearance of the canaliculi. In
the epididymis, the first permanent alteration consists in a loss of the
cilia, the epithelium assuming the simple type.

c. Pathology teaches us that the vas deferens may be obliterated
as a result of any of the forms of orchitis, yet this obliteration is not
necessarily followed by atrophy of the epididymis and testicle. Bar-
denheuer and Englisch have each noted the fact that extirpation of the
vas deferens and epididymis (for tuberculosis) is not followed by
atrophy of the testicle, while GriflSths has observed a slight atrophy
under these circumstances. Generally speaking the eflFects of path-
ological obstruction of the vas deferens have been conflicting.

ATROPHY OF THE ORGANS AS A RESULT OF ARREST OF THE ARTERIAL^

CIRCULATION.

1. Oeneralities : — Arterial ligation has been practiced in both
healthy and diseased conditions (tumors). Curling saw atrophy of
the testicle follow ligation of the spermatic artery; while Wardrop
reported two cases in which atrophy of this organ followed the obliter-
ation of the arteries incidental to the presence of aortic aneurism^
Miflet** showed by numerous experiments upon the dog that ligation
or embolism of the spermatic artery gave rise to haemorrhagic infarc-
tions of the testicle which were followed in turn by a sclerotic atrophy*
Arrest of the circulation of the spermatic and deferent arteries induces
atrophy of the epididymis.

From numerous published accounts of the results of ligation or
division of the spermatic arteries, it is evident that great disparity
exists^ some authors reporting no atrophy whatever, others partial
atrophy, complete atrophy and gangrene respectively. There is, how-
ever, plenty of evidence that such ligation does produce atrophy on a
great many occasions.

There are a few recorded cases in which ligation of the spermatic
artery for some disease of the testicle has caused atrophy of the latter
organ. The author's experience will be detailed later on.

ATROPHY OF THE TESTICLE AND EPIDIDYMIS AS A RESULT OF ARREST OF THE

VENOUS aRCULATION.

Here, as elsewhere, the published reports are conflicting. It 18
certain that the obliteration of the spermatic veins incidental to the
operation for varicocele is practically without effect upon the testide,
although a few authors claim that a slight atrophy of the organ results.
Phlebitis of these veins has caused profound alteration in the testicles,
but here a condition of septic infection of the latter is to be inferred.
The author's experience is to be found farther on.

ATROPHY OF THE TESTICLE BY SIMULTANEOUS ARREST OF BOTH THE ARTERIAL

AND VENOUS CIRCULATIONS.

Curling, Pott and others have noted the occurrence of the fact
that simple compression of the vessels of the cord by a hernia has
determined an atrophy of the testicle. Similar compression by the
dilated veins in varicocele may have the same effect. Numerous
experiments have shown that division or ligation of all the vessels of
the cord at once may cause simple atrophy or necrosis. In 1895
Alessandri claimed that this resiUt was inevitable. If the deferent

urtery were left intact^ atrophy still took place, although more slowlj.
The process of atrophy was preceded by coagulation-necrosis.

If in the operation of obliteration of the veins for varicocele the
spermatic artery is accidentally severed or is tied, atrophy of the tes-
ticle is of frequent occurrence. Tillaux claims that if the funicular
and deferent arteries are left intact the nutrition of the testicle is main-
tained.

In 1897, Albarran and Motz** resected portions of all the vessels
and nerves in the cord, with the exception of the deferent artery and
its veins. The vas deferens was left intact. In two such experiments
upon dogs the testicles were found completely atrophied at the end
of three months. It must be borne in mind that in these experiments
the nerve was severed.

ATROPHY OF THE TESTICLE AFTER LIGATURE AND DIVISION OF THE NERVES.

We know that various lesions of the cerebrum, cerebellum and
laeduUa have provoked atrophy of the testicles, although the rationale
of this sequence has been much discussed. Division or resection of
the spermatic nerves also determines an atrophy of the testicle. Cer-
tain observers, however, have encountered an atrophy of the prostate,
but no change in the testicle, after this experiment. Alessandri found
that excision of a portion of the nerves brought about necrosis of the
testicular epithelium.

The author's experiments will be detailed later.

ATROPHY OF THE TESTICLE AFTER LIGATURE OR SECTION OF ALL THE VESSELS

AND NERVES OF THE CORD.

Total ligature of the cord has been known to produce gangrene
of the testicle in the dog. In a human prostatic subject, total section
of tlie cord was followed by a diminution in size of the testicle by
one-half. Generally speaking, the results in this class of experiment
or surgical intervention have been contradictory.

THE author's RESULTS IN TOTAL DIVISION OF THE CORD IN TUBERCULOSIS

OF THE TESTICLE AND EPIDIDYMIS.

It is probable that when aseptically performed, the result of
this intervention is always an atrophy, never a necrosis of the testicle.
An incidental eflFect of this division of the cord is the protection of the
opposite testicle from tuberculous infection, while lesions of the pros-
tate and seminal vesicles may be thereby influenced towards resolution.

Technique: a. Resection or simple section between two ligatures: —
We first make an inguino-scrotal incision for the purpose of exposing

the cord. Two strong catgut ligatures are then placed upon the latter.
The superior ligature is placed against the external orifice of the
inguinal canal, the cord being lightly drawn outward. After division
of the cord between the ligatures the cut ends are cauterized with the
thennocautery. The wound is cleansed with sublimate and the lips of
the cutaneous wound sutured, as a rule without drainage.

In a few of our earlier cases we resected about 2 cm. of the cord,
the inferior ligature being placed very low. This technique was aban-
doned, because several arterial twigs were destroyed which would have
been of service in the consecutive grafting of the testicle.

General or local (cocaine) anaesthesia was employed in the
author's cases. The subcutaneous ligature was found to be prac-
ticable, but this resource was not used lest the continuity of the vas
deferens should be reestablished — a result which has been recorded in
the cases of the common bile-duct and pancreatic duct.

b. Section between two ligatures^ combined either with curettagcy or
open incision, or the use of the thermocautery.

In addition to the section of the cord the author has several times
practiced curettage of the tuberculous focus in both suppurative and
non-suppurative cases and M-ith or without fistula. When a scrotal
fistula was present, it was curetted in its continuity, or the entire epi-
didymis was scraped, while the testicle was drawn out through the
inguino-scrotal incision, originally made for ligation and division of
the cord. Since simple division will not quickly produce atrophy of the
suppurating and fistulous gland it was thought best to resort to curet-
tage of the diseased foci at the same time. The presence of small foci
of tubercles in the tail of the epididymis, unrecognizable by palpation,
often explains why ligature alone is insufficient to produce atrophy
promptly. These small, latent, cold abscesses have been encountered
by us vsdth greater frequency than authorities admit. However that
may be, we always cauterize them well, after we have dravm the tes-
ticle out of the wound to protect the latter from the pus. The field
of operation is then carefully wiped dry, and thus ascepticized, the
testicle is replaced in the scrotum, provided a scrotal fistula does not
coexist. This method of procedure is not followed by scrotal suppura-
tion.

When, however, a scrotal fistula is already present, the act of
opening the scrotum for the purpose of cauterizing the epididymis,
is comlnned with incision and "marsupialization" of the fistulous tract,
and gauze-drainage is made by the latter. Under these circumstances
suppuration is abimdant after the operation, and some necrotic frag-

ments are expelled. A fibro-glandular mass is left in the scrotum
after resolution has occurred, which gives satisfaction to the patient
and surgeon, although it may produce scarcely any secretion, external
or internal.

It is especially in cases of massive and hypertrophic tuberculous
lesions of the epididymis that we have done centripetal cauterization
over the entire organ with the fine point of the thermocautery, the
entire mass having been drawn outward through the inguino-scrotal
incision. This procedure should not, however, be carried too far.

We have made trial of the method of exposure of the tvbercvloue
lesions. Everyone is aware, of course, that by this empirical resource,
tuberculous peritonitis has been cured, this result taking place only in
ascitic cases — about one-sixth of the patients recovering. We have
laid bare the tuberculous foci in the epididymis by an incision made
either above and corresponding to the nodules in the head of the organ^
or below and corresponding to the tuberculous foci in the tail. If the
whole structure was affected the incision made, was of the longitudinal
and external lateral type, designed in such a manner as to avoid
exposing the testicle, which might lead to a fungus of the latter OTg^lu
In one case in which we involuntarily exposed the testicle, a fungua
was doubtless prevented by suturing the albuginea. In another casCi
wishing to prolong the exposure of the tuberculous foci to the air, we
did not suture the albuginea. The wound dressing was insufficient to
retain the testicle and epididymis in the scrotum and elimination of
the gland resulted.

In a patient with suspected tuberculosis of the epididymis, we
operated despite the coexistence of pulmonary lesions, by simple
epididymotomy, antero-posterior section. Atrophy of the gland and
epididymis set in very rapidly, and one month later these structures
were reduced in size to the volume of a small nut. How does the
testicle exist after separation from its cord? Whence come the new
nutrient vessels ? The testicle persists and is nourished because of the
adhesions which it forms with its envelopes. Its blood supply comes
henceforth from branches of the external pudic alone. Of these
branches some proceed as far as the fibrous tunic, there to anastomose
with the visceral terminals of the spermatic and deferent arteries;
while others irrigate the organ to a very slight degree through its infe-
rior ligament. Finally, branches of the cremasteric artery anastomose
v;ith the funicular branches of the spermatic. If the cremaster has
not been too much torn, there is still an arterial route which can form
anastomoses in case of complete division of the vessels and nerves of

the cord. In our more recent operations we have ruptured the cord
longitudinally for a short extent, whereupon its vessels prolapse and
are ligated by themselves, the remainder of the cord being left intact.

Finally the scrotal ligament which is half fibrous and half mus*
cular and extends from the posterior pole of the testicle to the scrotum,
(it is really a vestage of the gubemaculum testes) contains some anas-
tomotic vessels (Charpy)^^. These may assist in forming a compensa-
tory collateral circulation, thereby favoring the grafting of the testicle
in cases in which the cord has been completely severed.

Immediate results of complete division of the cord. When we are
dealing with a case of non-suppurating tuberculosis, a slight degree
of swelling and tenderness is noted on the day following the operation.
We have occasionally seen the temperature rise as high as 38^ C-
But fever is an inconstant phenomenon and the conditions under which
it occurs are as yet undetermined. It is possible that the chloroform
eauses an exacerbation of the pulmonary lesions which may coexist in
these cases.

In our more fortunate cases, atrophy of the testicle is in evidence
as early as the fifteenth day and persists during the succeeding interval.
The normal tenderness to pressure disappears completely at the very
outset.

In cases of tuberculosis accompanied by small, cold abscesses —
fistula being as yet undeveloped — the results are the same if the focus
has been well cauterized and asepticized.

In cases of suppurating and fistulous tuberculosis the results are
less brilliant. The post operative swelling persists for a longer period,
the testicle becomes painless to pressure, the fistula persists for a long
time and repeated use of the curette may be required. Eventually,
however, the epididymis and testicle undergo atrophy. The most dis-
couraging feature in these suppurative cases is the abundance of the
pus and the chronicity of the affection whenever it has been necessary
to resort to multiple cauterization.

The fibrous residue which remains after resolution has occurred
is satisfactory to the patient and is a good substitute for the artificial
testicles employed after castration.^®

Does the persistence of the fistula indicate a prolonged necrobiosis
of the epididymis, such as is seen in the spleen after ligation of its ves-
sels ? In any case we thought best not to excise the fistulous tracts, hop-
ing to conserve as much as possible of the genital mass.

An attempt should have been made to ascertain if Koch's bacilli
were present in force in the fistulous pus after division of the cord.

The most successful of our cases is that in which we ligated the
cord on both sides with the exception of the vas deferens, deferent
artery and the small veins which accompany the latter. On the left
side there was no fistula ; and after ligation we proceeded to cauterize
the bacillary nodules, one of which was suppurating. The entire mass
was replaced within the scrotum. By the eighth day the testicle and
epididymis had diminished in size by one third ; and by the end of the
third week, by one*half. At a later period two small purulent foci
were eliminated. On the right side the testicle was fistulous and sup-
purating. After ligation, I applied the curette and the fine point of
the thermocautery. The mass formed by the testicle and epididymis
rapidly diminished in volume, and the fistula closed completely by the
twenty-fifth day.

The only accidents seen by us in these cases consisted of haemato-
mata of considerable size which suppurated. Was this an operative
shortcoming, due to insufiicient haemostasis, when the cord was sep-
arated from its envelopes? The pulmonary lesions which coexisted,
and which were suppurative in character, may have readily protiuced
suppuration of these baematomata. As these patients have micro-
organisms in their blood, the cause of suppuration may have originated
within. It is thus that Vanverts explains those suppurations of the
spleen after ligature of its vascular pedicle. However this may be,
the frequency with which these haematomata occur, together with the
frequent occurrence of suppuration of the wound when an abscess of
the testicle is present, has influenced us in our more recent cases to
drain the wound high up.

Hyperthermia has been noted after the operation, even in one
case with aseptic evolution. In the only histological examination
which we made in a patient wlio died of pulmonary tuberculosis, M.
Delamare ascertained that the seminiferous tubes were normal in num-
ber and dimensions, while their epithelium was intact. There .was no
hypertrophy of the interlobular connective tissue.

The advantages of our method of isolating the testicle are very
great, if, as Villard believes, one-half of the patients with genital
tuberculosis have their lungs intact. From the same point of view it
would be interesting to know what proportion of patients with tes-
ticular tuberculosis have tubercles in the prostate or seminal vesicles.

Be that as it may, the tuberculous testicle, thus isolated and
grafted, is no longer a menace of infection to the organism at large.
It also seems to us that this isolation has favored, in certain cases, the
spontaneous cure of the vesicular and prostatic lesions. It probably

also averts recurrence of the disease in the opposite testicle, which,
however, as a matter of precaution should have its vas deferens ligated.
As for the genital functions they are amply preserved, as shown
by the testimony of our patients.

[to bk OOirOLTTBia).]

REVIEW OF CURRENT LITERATURE.

OTJ THE SPREAD OF PHTHISIS BY COUGH-SPRAY AND THE DUST OF

DRIED SPUTUM.

Heymann, Zeitschrift fiir Hygiene und Infectionshrankheiten^
1901^ Bd. XXXVniy ^o. 1, speaks of the increasing interest in the
subject of infective spray. Koeniger made especially thorough
researches in human beings with cultures of the bacillus prodigiosus,
placed in the mouth, the effect upon the spray by the most diverse
forms of speech having been studied. The maximimi projection of the
spray was caused by the articulation of the consonants p^ /, h and t.
Laschtschenko also studied the degree of diffusion of the droplets by
speaking, coughing, and sneezing. In one instance it required but two
minutes for an entire room to become infected from the spray of a
single individual.

Even after speech in a low voice tho walls of the room showed
evidence of contamination, not only in front of the experiment-indi-
vidual, but behind and at the sides as well. Kocniger has also studied
the duration of the suspension of these infected droplets in the air.
He found that the air was free from them after one or at most two
hours. When instead of the prodigiosus a larger germ was chosen
(the bacillus mycoides) the precipitation occurred much more rapidly.
These results differ from those obtained by Fliigge with artificial spray
which remained suspended for five hours. This difference may be
due to various causes, such as the actual degree of moisture of the air,
the possibly different behavior of water and saliva under the same
circumstances, the manner in which the spray is produced and the size
of the microorganisms. That this latter element exerts considerable
influence we know from the results of the work of Buchner, Megele and
Rapp in 1899.

Eoeinger, who found that natural spray was projected to such
great distances, has been corroborated upon this point by the recent

work of Kirstein and Hutchison; the former traced the culture
beyond the confines of the room, and practically through the entire
building in which the experiments were perf ormed, even to a distance
of 600 meters.

None of the experimenters along this line have made use of the
tubercle bacillus. The authority of Comet places the danger of
infected spray far beneath that of infected dust, for this authority
regards the line of experiment pursued with artificial sprays as highly
unrealistic. This point of view doubtless represents the opinion of the
majority, for we nowhere find much account made of infected spray
under the head of prophylaxis.

Minor experiments have been made with tuberculous spray upon
objects placed near the mouth of a patient while the latter spoke or
coughed, and prophylactic suggestions have been advanced, based upon
the character of the findings; but as just now stated the broadcast
diffusion of the tuberculous spray has thus far never been studied.

Comet's deductions from the infectiousness of dried sputum, the
latter being admitted, cannot be regarded as proven any more than the
claim of the infectiousness of spray. His experiments are open to the
charge of exaggerating natural conditions. The present author has
therefore imdertaken new researches into the subject of the broadcast
difiPusion of the tubercle bacilli by both infected spray and infected
dust.

He first investigated the limits of diffusion of cough-spray in
a given room. It was first found that a consumptive \mder perfectly
natural conditions rarely projected his cough-spray for a greater dis-
tance than a meter. This being the case it is not difficult for a healthy
individual to keep out of the range of the spray. It was moreover
ascertained that a handkerchief held before the patient's face was
sufficient to reduce the maximum limit to 80 cm.

However this experiment only traces the tubercle bacillus for a
short interval, and the important question of the wanderings and ulti-
mate fate of the germ demand further research of a different charac-
ter. The question first to be answered is, ^^how long do the germs
remain fioating in the air." The table in the original article shows that
the interval varies from 15 minutes to 1^ hours.

The second question relates to the fate of the bacilli after the fall
to the fioor, and is easily answered. After the tiny particles of spray
hecome dry the microorganisms undoubtedly rise with the ordinary
dust and settle on the furniture. Another question therefore arises,
viz. — "what is their tenacity of life under these circumstances" ? To

secure material the author made use, in part, of an artificial spray. His
tabtdations show positive results in a fair number on the second and
third day and exceptionally as late as the 12th and 18th day. These
exceptional instances of survival occurred invariably in experiments
with darkened room.

Heymaim now made comparative series of researches with the
dust of dried sputum. He investigated the manner in which the dust
is produced, the interval during which it floats in the air and the
behavior of the dust under aspiration. He also investigated the air in
rooms occupied by consumptives under natural conditions, both in hospi-
tal and private dwellings. He is then in position to make a statement
as to the comparative risk of infection from spray and dust. He repeats
the maxim in this connection — '^seek the enemy where he oftenest
appears." As to the constancy of the production of infected spray by
the tuberculous, he admits that there are circumstances imder which
the danger of infection becomes minimized ; thus some patients do not
project infected spray during the warm summer months. Doubtless
there are periods in the life of any consimiptive in which his spray is
free from virulence. It has already been stated that the distance of
propulsion in coughing rarely exceeds a meter, but this space between
the infected and the healthy cannot be maintained in the relations of
private life such as those of mother and child, or even in the inter-
course of many workshops.

But when we come to the question of infected dust, the formation
of such a product is only an incident in the history of a consumptive. It
is possible in dirty private dwellings, but should not occur elsewhere.
When such dust is formed its heaviness causes most of it to sink
quickly to the floor, only a minimal quantity remaining suspended in
the air. Comet's experimentally generated dust is a gross exaggera-
tion of natural conditions.

Much more just is the criterion of testing the air of the suspected
room. It is undoubtedly true that under particular circumstances in
factories, shops, railway-cars, in fact wherever men assemble in
close quarters, that a fine dust, capable of floating in the air, may be
formed in sufficient quantity to infect the air of the compartment. But
«uch a state of afPairs could hardly occur in hospitals and private dwell-
ings.

THE SPREAD OF TUBERCULOSIS BY OOUGHING*

L. Napoleon Boston, Journal of the American Medical Association^
Sept. 14, 1901, has reported an interesting series of practical experi-
ments, undertaken by him in the Philadelphia Hospital with a view of
determining whether or not consumptives emitted a fine spray when
talking, laughing, clearing the throat or by their characteristic hack-
ing, which might in any way be dangerous to the health of their asso-
ciates. Fifty patients, in all of whom unquestionable evidence of
either pulmonary or laryngeal tu])erculosis existed and in whose Sputa
tubercle bacilli had been found, were employed in the investigation
of the question. The methods pursued by Boston were as follows : —
The spray was collected by means of a mask made of wire and arranged
to hold two microscopic slides directly in front of the nose and mouth,
at a point three inches distant from the lips. The patients were
instructed to wear the mask from one to one and a half hours at that
period of the day when apt to cough least. The mask was not worn
during the morning or evening because of the usual tendency to the
occurrence of paroxysmal coughing at these times of the day and the
patients were directed during paroxysms to remove the mask.

On microscopical examination of the fifty specimens obtained from
these 50 patients 38 were found to contain tubercle bacilli, from 4 to
6 bacilli being the smallest number found in any specimen, while many
of them presented fields in which tubercle bacilli were too numerous
to be counted. In addition to tubercle bacilli other bacteria were
observed, viz. — bacilli, clusters of cocci, and most constantly diplococci,
and streptococci. Small squamous epithelium, small epithelial cells
and leucocytes were also found.

By the use of the low power objective very fine droplets, invisible
to the naked eye, were located upon the slide and in these with the 1-12
oil emersion niunerous tubercle bacilli were frequently demonstrated.

From patients, the subjects of laryngitis, and from those who
talked loudly or frequently cleared their throats, the most spray was
emitted. In patients who were very weak, speaking only in a whisper
scarcely any spray collected on the slide and this seldom contained
tubercle bacilli

Men with heavy moustaches ejected no spray on the slide until
after the moustache was held from falling over the mouth.

Coughing with mouth open of course favored the production of
the spray.

The author suggests that infection of open wounds during surgi-
cal operations may occur by such ejection of spray in instances in

"vvhich thoee performing the operation or assisting, are the subjects of
either acute or chronic infection of the mouth, throat or respiratory
tract and in conclusion says — ^''The advisabiKty of all persons being
provided with a mask of gauze on entering the operation-room, to pre-
vent all possibility of their contaminating the air of the room, would
appear from a bacteriologic standpoint to be a rational procedure, yet
before this precaution can be urged, it too, must be tried by the surgeon
and shown to lessen the number of cases of infection for which at
present no ascribable cause is given/'

ON THE PENETRATION OF BACTERIA INTO THE LUNGS THROyCH

INHALATION OF SPRAY AND DUST.

Nenninger, ZeiUchrifi fur Hygiene und InfectionskrankheHen,
Bd. XXXVm, No. 1, 1901, has made numerous researches upon
ATiiTTiiilfl in this direction, the gist of which may be found in the abstract
of an article by Prof. Fluegge in this number. He has also considered
this subject in its relationship to mankind, naturally from a somewhat
different point of view; as experiments in the human species could
hardy be undertaken.

We know from autopsies that bacteria are able to penetrate into
the deeper bronchioles. Besides if the germs could enter the tiny
breathing tubes of a guinea pig, how much more readily could they
be received into the respiratory tract of a man, where the rapidity of
the air current is much greater.

We must bear in mind how large the munber is of men who are
forced by their occupation to breathe bacteria-laden air.

It is easily possible bv forced inspiration to cause the transfer of
bacteria from the mouths' of experiment-animals into the lungs, and
men should be exposed to the same liability.

It has been abundantly shown that the expiratory current is per-
meated with bacteria-laden droplets which are diffused through the
acts of speaking, coughing, etc. The inspiratory stream should like-
wise contain this infected spray. This stream should readily succeed
in bearing particles of fine spray from the mouth into the deepest pas-
sages. The nasal secretion, however, from its tenacity does not
readily lend itself to droplet-formation. But we must not forget that
at the onset of a coryza there is a period at which the discharge is
extremely thin and watery.

Droplet formation is thought to occur most naturally at the oral
portion of the throaty where the respiratory and digestive tracts meet ;
in general any portion of the upper passages in constant movement —
as in swallowing, speaking, coughing, sneezing, yawning, etc., is cal-
culated for droplet formation, because it is in such localities that
bridges and membranes of secretion form, which are broken up into
9pray by the out and incomJM^nnffr^^ Hence we must

include among these localiti^&e Vocal^oGml^^back of the tongue,
palatal arch, uvula and pop^or wall of the pnfRr^mz.

The germ contents of the)|ffi(ffth(^]|g^r^re a menace to the
lungs ; and conversely th^ij|^utum oi the tuD^mous, contaminating
the mouth, becomes a menaM £dr Jthoee who. live in dose relations with
the patient. ^^i ^n A ^^^ ,,0^

TUBERCULOUS INFECTION THROUGH THE AIR PASSAfiBS

Thomson, The Practitioner^ July, 1901, begins a paper on this
subject with the query, ^Svhy is the nose so seldom attacked by tuber-
cle V' Autopsies show that it participates with pulmonary tuberculosis
but once in 450 times.

Our knowledge of the hygienic importance of nasal respiration
has only been recognized for the past 15 years. The vibrissae act as
a sort of chevaux de frise in arresting the bacilli at the entrance into
the nose. The sticky mucus entangles those microorganisms which
succeed in passing the first obstacle. The ciliated epithelium is a
third antagonist, while finally phagocytosis destroys such invaders as
succeed in getting past the other hindrances. But even this is not all,
for during lachrymation a flow of tears enters the nasal chambers, and
the act of sneezing is also efficacious in ridding them of any foreign
particles which may chance to be present.

In the few recorded cases in which tubercle bacilli have been
reported as present in the nose, the material for culture was doubtless
taken from anterior nares. Mucus well within the nose is always prao-
tically sterile.

Recently Benshaw has introduced tuberculous sputum into the
nasal chambers of guinea pigs with the usual result that infection
appeared in situ.

A strange fact was the failure of the occurrence of secondary
deposits in the brain and thorax, the viscera alone having been impli-
cated.

The author has recently studied a case of primary tuberculosis of

the nose. He believes that it represents the first recorded case of this
localization ia Great Britain, but a number have been published since.
Dr. Steward having reported a series of six. The lesion takes the form
of a granuloma at the anteror portion of the septum.

To take up the subject of tuberculous infection in general, the
mode of propagation in a given case should be one of four, viz., acci-
dental inoculation, hereditary transmission, ingestion by way of the
alimentary tract and inhalation through the respiratory tract. ITatur-
ally from its title the author's paper must be limited to a consideration
of the last named cause.

That germs could ever be aspirated directly into the alveoli of
the lungs is contrary to all physiological teachings; there are far too
many barriers in the way, and even if these should be surmounted the
air-cells contain a considerable amount of still residual air. The torn
pleural cavity is naturally sterile, while expired air is likewise free
from germs. Hence when bacilli enter the upper passages we must
seek for some natural port of entry in which a foothold is obtainable.
The first locality to investigate is the tonsillar tissue, especially when
the seat of hypertrophy. An abundance of available statistics appears
to show that something like 5 per cent, or 6 per cent, of adenoids show
tuberculous infection. The very large surplus of negative results
cannot outweigh the significance of these negative findings.

In regard to the f aucial tonsils, they are more frequently infected
by tubercle than are the postnasal adenoids, the ratio being at least
two to one. Experiments have abundantly shown that insoluble color-
ing matters pass from the tonsils into the lymphatics and general
economy.

Primary infection of the larynx is most difficult to determine. It
is known to have occurred in extremely rare cases, and we also know
that in the great majority of cases the lungs must first be infected. The
api>roximate frequency of primary implication cannot, however, be
ascertained. The author quotes the saying of Jonathan Wright that
the 'bacillus must be baptised in the lungs and bom again before it
is able to overcome the resistance of the larynx.'' The act of swallow-
ing has a cleansing efiFect upon the larynx, for the cords are thereby
compressed together and mucus from the ventricles is forced to flush
them, BO to speak, toward the oesophagus.

Everything points to the "cross-roads" where the air and food
passages meet, as a source of danger from tubercle ; because just here
is seated the "tonsillar ring." In this connection should be mentioned
the frequency with which the middle ear is afiFected in tuberculosis.

52
THE COMMUNICABILITY OF HUMAN TUBERCULOSIS TO CATTLE.

Dr. Sheridan Delipine, Professor of Pathology in Owen's College,
Manchester, publishes an experiment upon four calves with the view
of the further elucidation of this question^ British Medical Joumaly
Oct. 26th9 1901. Believing that different degrees of virulency existed
in tubercle bacilli from human subjectSy the author obtained from dif-
ferent patients sputa which contained tubercle bacilli: 1st: — ^Long
slender forms showing typical mekchromatism ; 2nd:— Thick forms
staining ahnost uniformly; 3rd: — Short forms occurring in dtunps;
4th : — Short forms staining badly. These sputa were mixed, and the
calves were inoculated therewith — one directly into the lungs, one
under the skin, one intra-peritoneal, 5 c. c. of the sputum being injected
in each case ; another was fed 50 c. c. of the mixed sputa in a single
day.

The author refrained from the tuberculin test, fearing that po»*
sibly induced immunity from the tuberculin might jeopardize the
result, and preferred to depend upon the evidence of extension of the
disease from the locality of infection for his demonstration of success-
ful inoculation if this should actually take place.

The results were on the whole not as satisfactory as was hoped
for, because calf no. 1, injected into the lung, died on the sixth day
from other infection introduced with the sputum and proved on autopsy
to have been tuberculous before. Calf no. 2 suffered a like fate;
an enlarged and inflamed lymph ganglion, situated about 5 inches
from the point of infection, contained tubercle bacilli which proved
virulent in guinea pigs. The author, while rejecting the experiment,
thinks that this case might fairly be given as an instance of rapid
infection of lymph ganglia, supported by the result in the guinea
pigs.

The third calf which was fed 50 c. c of the mixed sputum showed
signs of illness 2 weeks later, had diarrhoea and died 26 days after
inoculation, and after having received a test dose of 10 mininifl of
tuberculin less than 8 hours before death. The post mortem examina-
tion showed semi-purulent peritonitis, enlargement and softening of
all the mesenteric glands, and of other lymph-ganglia connected with
the alimentary canal. No tubercle bacilli were discovered in the
lymph-ganglia. Inoculation was positive in one pig, which was inocu-
lated from the oesophageal gland, another died rapidly; two others
gave no external evidence of the disease.

The author concludes this case to be of considerable interest^

although the death was not caused by tuberculosis, but apparently by
the same bacillus which killed calves no. 1 and 2, and which was
the chief cause of the pathologic changes found in the lymphatic
ganglia connected with the intestines.

The state of these glands made it difficult to find tubercle bacilli,
but the fact that there was no evidence in any other part of tubercu-
losis, and one of the pigs died of tuberculosis due to the inoculation,
causes the author to attach a belief of strong probability that the
tuberculosis of these glands was caused by the ingestion of tuberculous
sputum.

The fourth calf was inoculated on Aug. 1, intra-peritoneal ; the
inoculation was followed by swelling of adjacent gland (4 inches dis-
tant) and irregular rises of temperature. On August 26, this animal
was tested with tuberculin, which test was followed by a rise of 1° F.
and the previously enlarged gland increased in size and became tender,
but afterward resumed its previous size.

On October 15, the temperature had become more regular and
another tuberculin test (15 minims) was applied. To this the calf
responded with a rise to 106.2° F. receding to 103.8 in 24 hours; three
days thereafter it was killed.

The post-mortem examination showed no typical tubercles in the
aforementioned enlarged gland; several cheesy, tuberculous masses
were found in the large omentum, numerous tubercles in the pelvic
peritoneum, miliary tubercles in the suspensory ligament of the liver.
in the parietal peritoneum behind, in the diaphragmatic above, in the
spleen; the parietal peritoneum in both iliac regions was thickened,
rough and covered with small fleshy tuberculous looking nodules, and
small polypoid masses (resembling yoimg grapes) ; the mesenteric and
retro-hepatic glands and 2 sacro-iliac ganglia were enlarged. A few
tubercles were present in the capsule of the liver, and in the peritoneal
covering of the spleen. Small fleshy tubercles were found in the
pleural cavity most abundant in the diaphragmatic pleura above the
spleen ; also rows of small tubercles along the lymphatics in the inter-
costal spaces up to 5th rib, but only a few above that level. Lungs
and pulmonary pleura were free, the pericardium was slightly affected
but around the large vessels at the root of the heart it was almost
entirely covered with a layer of small rounded fleshy tubercles ; bron-
chial glands slightly enlarged, but not tuberculous. Tubercle bacilli
were demonstrated in omental tubercles and in the retro-hepatic gang-
lion; none have so far been discovered in the mesenteric, oesophageal or
bronchial ganglia.

Guinea pigs inoculated from several of the lesions, showed at the
end of 9 days evidence of beginning tuberculous infection.

The author concludes that this experiment can leave no doubt as
to the source of the inf ection, all lesions being clearly connected with
the peritoneal infection, having the same distribution as those found
in rabbits and pigs infected with tuberculous products from human or
bovine sources.

[We doubt that the author has made out a case. In animal no. 2,
the inoculation experiment simply shows that the bacilli injected were
virulent and were absorbed into the gland, which, when inoculated into
a pig caused characteristic effects. The same is true of animal no. 3 ;
some of the ingested tubercle bacilli had evidently been absorbed but
they failed to produce tubercles in the calf ; but when transplanted into
the guinea pig from the tissues of the calf they proved still virulent.
These two cases not only fail to justify the author^s inferences, but
supply strong proof in support of Professor Koch, for it should ever be
bom in mind that the presence of tubercle bacilli in tissues, no matter
where found, does not constitute tuberculosis, but that the actual histo-
logic tubercle only, can be so interpreted. In the fourth case, the
actual tubercle was evidently present, but here is the serious element
of doubt, arising from the possible presence of tuberculosis, prior to the
inoculation, or to the presence of bovine tubercle bacilli in the milk with
which the calf was fed. We should prefer to take the latter views and
to attribute to the inoculation, only the inflammatory changes that
were found in the peritoneal and chest cavities, and which were evi-
dently not of a tuberculous character.

The author was just as likely to have selected two tuberculous
calves, as one, and had the first one not died as early as it did, and had
it been inoculated into the peritoneal cavity as was the fourth, identical
conditions would probably have been found. — ^Editor.]

THE INFLUENCE OF THE BACILLUS IN PULMONARY TUBERCULOSIS.

The above is the title of a paper contributed to the Medico-Legal
Journal^ Jime, 1901, by Dr. Hubbard Winslow Mitchell and read by
the author before the Medico-Legal Society and the American Congress
of Tuberculosis, last May.

The author states that "the idea seems to be everywhere accepted
that no case of lung disease can be called tuberculosis unless it shows
the presence of the bacillus of Koch, but if we accept it then a great
number of cases of lung disease in which the sputum shows no bacilli,

are not tuberculoBis.'' This was for a long time Dr. Mitchell's belief,
but the microscopical examination of the sputa in 675 cases of pul-
monary tuberculosis personally observed by him during the past five
years, showed that the clinical course of the affection is essentially
identical whether tubercle bacilli are found or not, and regardless of
the number of germs present. By these observations the author was
impelled to question the specific action of the tubercle bacillus in pro-
ducing pulmonary tuberculosis. He was led to the opinion that ^^ulcer-
ative disease of the lungs'' would be a better term than pulmonary
tuberculosis in case it could be shown that the bacillus does not induce
the disease; furthermore his attention was directed to the pus-cell
as the ^^carrier of the special toxic principle of this disease." That the
pus-cell and not the bacillus was the exciting cause, he believed because
'^cases where no bacilli or few bacilli were present were identical;
therefore the cases where they did not exist could not be due to the
bacillus," and therefore some other cause must be productive of the
disease. Since the puS'<^ll is always present, the author looks for the
etiological factor therein, and states that ^^the pus-cell which is the
carrier of disease in other maladies must be the carrier of the disease
in pulmonary tuberculosis." In support of this statement he says ^1f
we look through the microscope at a properly stained specimen of
tuberculous sputum, we see one or more or no bacilli. When met
they are very minute in size and seem incapable of setting up the mis-
chief we find in a diseased lung, but the same field under the microscope
is always crowded with pus-cells." In conclusion, Dr. Mitchell says that
''when we consider that the pus-cells are thrown off by the million, and
the minute bacillus in fewer numbers or not at all, we are forced to
the conclusion that the real carrier of the disease is the pus-cell and
not the bacillus."

[The foregoing would not have been deemed worthy of notice but
for the deplorable fact that even yet in this day of enlightened
knowledge there are still those who tske it upon themselves to attempt
to refute the most firmly established truths of exact scientific investi-
gation, and thereby, either from a pitiable ignorance or a bigoted
prejudice, promulgate theories which, though utterably imtenable, may
serve to do harm. Of such a character we believe to be the series
of illogical conclusions deduced by Dr. Mitchell in his feeble attempt
to deny the the etiological role of the bacillus of Koch in pulmo-
nary tuberculosis. In only one point is he not justly liable to criticism,
viz. — ^that the clinical course of tuberculous disease of the lungs
does not stand in relation to the demonstration of the specific germ in

the sputa, nor when present to the number of bacilli enumerated. Thig
no one will care to deny, for it is a fact long since established. How-
erer, by what system of logic Dr. Mitchell reaches the conclusion that
because not always present in the sputa the germ is not to be looked
upon as the causal agent in the production of the disease, is hopelessly
beyond our powers of comprehension. Neither can we appreciate the
delicate distinction which suggested the substitution of Ulcerative dis-
ease of the lungSy for tuberculosis.

In this connection it might be well to recall the fact that the term
tubercle has been employed as descriptive of the characteristic anatomi-
cal lesions peculiar to this disease ever since the time of Sylvius, and
that Koch's bacillus derived its name therefrom and that the affection
was not named for the bacillus. Again Ulcerative disease of the lungSy
can scarcely be considered as applicable inasmuch as ulceration is by
no means a process incidental to tuberculosis alone and neither is
tuberculosis an affection primarily ulcerative in character. A moment's
consideration of the special pathology will make it perfectly clear that
especially in the beginning, and in many instances throughout the
entire course of the disease we are dealing with closed foci of tubercu-
lous infiltration from which the escape of the germ and its presence
in the sputa is manifestly an impossibility. Only when destructive
processes, leading to caseation, softening and liquefaction have been
induced, and not before, do we expect to find tubercle bacilli in the
sputum. That in a given case they are not demonstrable, can not be
accepted as evidence of the absence of tuberculous involvement, and
in failing to appreciate this point. Dr. Mitchell made a most faulty
deduction.

ITow because in specimens of sputa he found that tubercle bacilli
were not as numerous as pus-cells, or that pus-cells were present and
bacilli absent, he jumped at the conclusion, perhaps by intuition, that
the pus-cell was the carrier of the special toxic principle of this dis-
ease, and that it, and not the bacillus, was the exciting cause, at the
same time questioning the role of the latter on account of its minute
size.

Had the author even an elementary conception of the pathology
of inflammation, he would see in the pus-cell nothing but a leucocyte,
and were he conversant mth the fundamental principles of bacteri-
ologic science and the relation of microorganisms to disease he could
not possibly maintain the opinion that because small the ^Dacillus in
question can not be the etiological factor in the production of tuber-
culosis. — Ed.]

EXPERIMENTAL PULMONARY PHTHISIS.

Baumgarten^ Wien. med. Wochenachr. Nov. 2, 1901, states that
heretofore it has been assumed generally that miliary tuberculosis of
the lungs could be produced experimentally, but that ordinary pulmo-
nary phthisis could not be imitated in this manner. The author goes
on to say that :

"As a result of this failure to engender the last named type of
disease, certain authors have even been moved to deny its bacillary ori-
gin, and to see in typical phthisis only the permanent lesions of inflam-
mation which eventually become a breeding place for the microorgan-
ism of milary tubercle, the germ having reached the lung-tissue by
inhalation.

"Such a hypothesis can not be proved on anatomo-pathological
grounds, but it is very difficult to disprove it ; for the inception of pul-
monary phthisis in mankind is seldom seen in autopsy, and the few
cases which come imder observation by chance, exhibit such complica-
tion with older inflammatory lesions that no decision can be reached
as to which type of alteration was antecedent.

"I am not so much concerned here with the refutation of this
improbable and unproved hypothesis of the origin of phthisis (which
would see in the very bacillus tuberculosis only a subordinate "noso-
parasite" so-called), as with the task of developing the special patho-
geny along experimental lines, since it is by experiment alone that we
can hope to attain to a more intimate degree of knowledge. I have
made many attempts, based on the amount and virulence of the bacilli
in cultures, to obtain a medium of inocukttion which could communi-
cate pulmonary phthisis; but for a longj^ggpod my efforts were unsuc-
cessful. In ordinary inoculation-tuberc|Ajosis, it is not such a rare
thing to find small cavities within the caseous conglomerations of tuber-
cles; and the longer the animals live the more likely are we to find
these formations. In the experiments of Troje and Tangl with arti-
ficially weakened tubercle bacilli, larger cavities were produced in the
lungs. But aside from the fact that all the cavities thus far produced
have been relatively small, the typical locality — viz. the apex, from
which the rest of the lung is infected — which characterizes clinical
phthisis was entirely unrepresented in the experimental form of the
disease.

"Finally, however, chance led me in the desired direction. Upon
the occasion of experiments as to the mode of extension of uro-genital
tuberculosis, which showed that the bacillus could infect the organism

at large through the intact mucous membrane of the urethra and blad-
der, I encountered for the first time pulmonary cayities in the experi-
ment animal with the typical localization in the apex. My attention
once drawn to the possibility of this occurrence, I have prosecuted my
researches along these same lines, and with such success that I am
now in a position to engender a disease in animals which in every
way corresponds to pulmonary phthisis in mankind. In order to obtain
positive results it is necessary to use bacilli of full virulence and in not
too large amount, and to employ them in the manner already outlined.

"I take the liberty of showing you a specimen, from one of my
most satisfactory observations, which illustrates in typical fashion this
experimental pulmonary phthisis. Here we see a cavity which takes in
almost an entire upper lobe and is lined with a continuous cheesy
deposit in which occur tubercle bacilli in abundance in pure culture.
This huge cavity like all others which I have produced, has been
formed solely by tubercle bacilli, which have received no assistance
of any sort from other microorganisms, accidentally present. Extend-
ing downwards from the cavity we find larger or smaller tuberculous
foci, the finest and more recent of which are seated in the base of the
lung. In the opposite lung no cavity has formed as yet, although there
is a large cheesy focus in the apex. Had the animal lived longer this
focus must have become a cavity. The same tendency of the infec-
tion of the lung from the apex downward may also be seen in this side
of the body.

^'If we now ask for an explanation of the production of this phase
of tuberculous infection, my own opinion would place the greatest
stress upon the probability that but few of the baciUi which penetrate
the stratified epithelium ofjx^e bladder are actually deposited in the
apex of the lung, in which locality they arrive in slow succession ; only
by a gradual and individual importation could a preference be shown
for a single locality of the body like a pulmonary apex ; had the bacilli
been injected in bulk within a vein, the entire lungs would suddenly
have become permeated with the nodules of miliary tuberculosis*
When the bacilli are introduced subcutaneously or within the eye-
ball, the explosion of the disease in the lung is much less violent and
extensive. In any case, the lungs show a predilection for the disease.
In metastatic miliary tuberculosis, the apex of the lung invariably
shows more of a tendency to infection than the lower lobes, and in the
first named locality we see large lesions with a greater tendency to
confluence.

"In miliary tuberculosis in mankind the marked tendency to

attack the apex has often been noted^ as Eibbert originally claimed.
This preference may not be so apparent in the advanced stages of the
disease^ for by this time the remainder of the lung has become per-
meated with the tubercles. The predilection of human tuberculosiB
for the apex has heretofore been ascribed chiefly to the defective ven-
tilation of the upper lobes in the act of respiration; so that inhaled
bacteria came to be retained within the apices. This predilection con-
stitutes the chief support of the inhalation theory.

^^In our experiments, however, the bacilli reached the apex not
by inhalation, but through the blood, yet the predilection was none the
less apparent. It is therefore no longer justifiable to explain this
localization by the inhalation of a specific bacillus. If it may be
regarded as proven that the apex is the most poorly ventilated portion
of the lung, the blood circulation in this locality must profit least of
all from the mobilization which follows the inspiratory act. We can
therefore comprehend that the retardation of the apical circulation
must favor the adhesion of bacilli to the pulmonary capillaries.

^The longer one investigates, the more one compares the various
pictures of human tuberculosis as seen in the autopsy, the more does
one become convinced that sharp lines of demarcation between the
three chief types of pulmonary tuberculosis do not exist ; and that acute
miliary tuberculosis, phthisis florida (acute caseous pneumonia) and
chronic ulcerative tuberculosis (ordinary consumption) shade into one
another by transitional gradations into common ulceration tubercu-
losis; so that there is a great temptation to regard the latter as of
haematogenous origin.

"This view can only be corroborated by the weakness of the evi-
dence adduced in support of the inhalation-theory; for there is not a
single recorded case in which such an origin of pulmonary phthisis has
been proven beyond doubt. It is self evident, however, that the possi-
bility of infection through inhalation of bacilli is not disputed; but
the prevalent view that this method is the chief — ^practically the sole —
method of the propagation of phthisis must be designated as unproven
and very doubtful.

"Recently Auf recht in his well known essay, Die Ursache und der
ortliche Beginn der Lungenschwindsuchty (Vienna, Holder, 1900),
repre^nts the view that pulmonary consumption no less than acute
miliary tuberculosis is of haematogenous origin, and due to the pene-
tration of the bacilli into the blood-stream with ultimate deposition
in the walls of the blood-vessels of the lungs. If I do not deem
Auf recht's proof suflScient to uphold his views, and do not agree with

Iiim in regard to the histological processes which underly pulmonary
phthisis, I nevertheless look upon his criticism of the inhalation-theory
as of value ; since it constitutes testimony from an independent source,
supported by clinical and anatomo-pathological evidence, to the effect
that the inhalation-theory is based upon defective data.

^^Kibbert has also expressed himself recently in favor of the
haematogenous origin of human phthisis. It is true that he still
adheres to the inhalation-theory, but holds that the bacillus is not
inhaled within the lungs. The microorganism, from his point of view
is absorbed through the intact mucous membrane and thus reaches
the bronchial lymph-nodes. From these structures it makes its way
to the blood and thence to the lungs. If I am unable to follow Ribbert
in his theory of the ^aerogenous' infection of the bronchial glands, and
of the haematogenous infection of the lungs from this primary bron-
chial tuberculosis, I am nevertheless pleased with the point made that
ordinary phthisis may occur through haematogenous bacHlary infeo-
tion ; and that such an etiology is far more frequent than that of direct
aerogenous infection."

[That Baumgarten's experiments have shown that tubercle bacilli
may penetrate the mucosa of the bladder and urethra, without leaving
a lesion at the point of entry, and that haematogenous infection of the
lung may supervene, with the development of a typical form of tuber-
culosis in the apex, we do not doubt.

Evidently the author's results demonstrate the occurrence of
haematogenous infection, but we do not believe that they furmsh suf*
ficient grounds for his opposition to the inhalation-theory, except in so
far as a direct infection, by inhalation, of the bronchioles and air vesicles
is concerned, and this we have long since held to be prevented by the
intricate ramification of the smaller tubes and by the constant presence
of residual air in the lung. We must, however, still remain of the
opinion that germs may be carried directly into the larger bronchi by
the force of the inspiratory air-current.

That the apex is commonly very early involved we all know and
that this is due to mechanical causes which render the circulation less
active in this region is the most plausible theory so far advanced as
explanatory of this fact. Baumgarten believes the apex to be the seat
of predilection in haematogenous infection, when but a limited i^^imber
of germs gain entrance to the circulation at a given time, whereas the
disseminated form of tuberculosis is dependent upon the introduction
into the blood of numerically larger quantities of bacilli. Whatever
mechanical cause we may attribute as accoimting for the peculiar ten-

dency of the apex to early involvement in phthisis, this must remain
a constant factor, while the number of germs which gain access to the
circulation at a given time must be variable. Therefore it seems not
illogical to conclude that the location of the primary port of entry —
be this situated in the bladder, intestine, a bronchus, or elsewhere —
would in no way influence the result. We would therefore assume
that inhalation of virulent tubercle bacilli might readily lead to the
establishment of haematogenous phthisis of the apex, with or without
primary lesion of the bronchial mucous membrane, the germs entering
the circulation directly through the bronchial wall or indirectly from a
primarily-involved bronchial lymph-node,

Baumgarten states that no case of inhalation-tuberculosis has ever
been proven beyond a doubt. In our opinion the results of the inves-
tigations of Koch, Tappenier, Comet and others with animals, and the
observations of Birch Hirschf eld in regard to the seat of the primary
lesion of phthisis, should tend to effectually negate such a statement.

In 1898, Comet demonstrated before the Medical Society of Ber-
lin, 48 animals, 46 of which had become tuberculous from inhalation
of powdered sputum, the latter having been placed upon a rug upon
which the animals were kept for several days. It seeps to us far
more reasonable to accept the inhalation-theory in this connection, than
to suppose that the infection occurred through the mucosa of the
genito-urinary apparatus, or in still some other manner.

In 30 or more cases in which death resulted from accident or from
acute disease, Hirschfeld found tuberculous lesions of the bronchi
which he held to be primary. These people had been in sufficiently
ix>bust health to check the infection, by reason of their excellent vital-
ity, before it could lead to secondary foci, and therefore the lesions
found were of the variety known as chance discoveries. It had taken
him many years to collect this material. In a small proportion of
cases, the initial lesion was in the interstitial tissue and these instances
he attributed to haematogenous infection. In the great majority, how-
ever, tuberculous ulcers of the wall of a branch of the "posterior apical
bronchus'' were demonstrated usually at the point of ramification into
smaller bronchi, whereas the lung parenchyma itself, remained intact.
Hirschfeld believed that he had shown beyond a doubt that the pri-
mary lesion of phthisis occurs in the wall of a medium sized' bronchus.
Undoubtedly he succeeded in making out an exceedingly strong case
in support of the inhalation-theory, and in our opinion, the latter must
still be held accountable for the majority of the cases of phthisis. Edi-
tor.]

MODES OF PROPAGATI(»^ OF PHTHISIS AND HOT TO ANTAGONIZE

THEM*

Fliigge, Zeitschrift fur Hygiene und InfectionshrafMieiien^ Aiig.
27, 1901, has recently made some new experiments which are a contin*
nation of those reported by him two years ago. At that time he showed
that dried sputum may be infectious under certain circumstances, but
that a more nearly universal source of dani^r was to be found in the
particles of infected spray projected by the consumptive in the acts
of coughing, speaking, etc. Since the earlier report Fliigge's results
have been confirmed by independent workers.

As we have no means of knowing the proportion of cases infected
by dried sputum, spray, etc., the author has made some fresh experi-
ments to throw some light on this aspect of the propagation of the
disease. Comet's dust experiment occurred under circumstances in
which natural conditions were greatly exaggerated. He further made
no distinction between dust which falls to the ground and dust which
remains suspended in the air.

The author made use of a glass cabinet for the dust to collect in,
and employed Comet's process of beating a carpet infected with dried
sputuuL The result appeared to show that the dust which falls is
coarse and heavy and very shortly becomes innocuous. The dust which
floats in the air, however, remains virulent for a half -hour or even an
hour. The fibres of an infected handkerchief which has been rubbed,
torn, etc., float in the air for a long period. This experiment was
simply intended to illustrate the two kinds of dust, as the conditions
wore exaggerated over those of real life.

The author found that the air of a phthisical patient's room
examined at different periods, was not often infectious. The floating
dust, to be dangerous, must be present in clouds, as during the act of
sweeping, and in manufactories where dust is constantly in the air.
These are the conditions where dried sputum, suspended in the air, is
a menace to health.

When now is the greatest danger from infected spray! How
much of this spray settles and how much remains to be breathed! A
patient was placed in a closed cabinet and allowed to cough for a
certain period, and the air of the cabinet was examined from time to
time. The conclusion reached was that the air continues to hold con-
tagious particles for a long period, although the latter doubtless tend
to precipitate to a large extent.

Other experiments were made to determine the tenacity of life

in bacilli coughed out ia spray form. It was ascertained that the germs
do not maintain their vitality for more than 4 or 6 days.

An objection to the doctrine of the infectiousness of dust and
spray lies in the absence of proof that the germs therein contained
reach the bronchi. This problem has been studied on animals, which
hare been allowed to inspire a spray of the bacillus prodigiosiis. The
ftTiinrmlfl having been killed and dissected within half an hour, cultures
made from various portions of the lungs have shown that the bacillus
must have penetrated into the finest bronchioles.

If the animals were not killed for several hours, however, such
cultures could not be obtained. It is not known whether the disap-
pearance of the bacilli was due to their death or to absorption.

This latter class of experiments instituted by Nenninger, shows
us the possibility of auto-infection of the consumptive. Thus he may
infect his neighborhood with spray which he later rebreathes and
perhaps thereby infects new areas of the lungs.

Those who live in intimate relations with consumptives must
necessarily run a considerable risk of infection from the spray. The
dried sputum is chiefly a source of danger where untidiness prevails.
It is not necessary for the patient to spit upon the floor, for a handker-
chief soiled with dried sputum is equally a source of danger in various
ways, as are other articles of wearing apparel or bedding similarly con-
tamiyated.

In regard to the important problem of disinfecting soiled articles,
Steinitz has recently tested the efficacy of the disinfectants in common
use. Most of the latter act only in high concentration and by pro-
longed exposure. The best he found to be sublimate (5-1000). .

Better than attempts at chemical disinfection is the use of
destructible spit-cups, which may be burned, or of vessels sterilized
by boiling. If handkerchiefs are to be used for expectoration they
should be made of paper and destroyed after short use.

Soiled handkerchiefs come in contact with the pockets and with
other soiled clothing. Such articles should be subjected from time
to time, to formalin-disinfection, as a general precautionary measure.

Formaldehyde vapor is the best disinfectant for rooms, furniture,
etc. When a patient cannot be induced to carry out these principles
and becomes a source of danger to those about him, isolation is the
only rational course to pursue.

ON THE DISPOSAL AND DISINFECTION OF TUBERCULOUS SPUTUM.

Steinitz, Zeitschrift fur Hygiene und Infectionskrankheiten, Bd.
XXXVIII, No. 1, states that our precautions thus far in the disposal
of tuberculous sputum consist principally of conveying it into the
waste pipes of the house after rinsing the vessels which contain it,
with or without previous application of chemical or thermic disinfec-
tion. Research has taught us that tubercle bacilli when mixed with
sewage do not perish for several weeks. Recently Musehold has
shown that these germs were alive 194 days after their introduction
iDto drain-water. Facts of this sort teach us that we should destroy
these bacilli before committing them to sewers, etc. It is advisable for
cuspidors to be treated with disinfectants which must have the qualities
of harmlessness, low cost and freedom from odor, and which, moreover,
must promptly destroy the germs.

Schill and Fischer have tested many disinfectants on tuberculous
sputum and have found that 5 per cent, carbolic acid is not fatal untH
24 hours when the amounts of sputum and disinfecting solution are
the same. Sublimate, 2 parts to 1000 was not fatal at the end of 24
hours. Gerlach instituted comparative tests with carbolic acid, lysol
and creolin of 5 per cent, strength each. He found that the lysol
solution was fatal in 3 hours without previous agitation, while the
other two substances proved themselves ineffectual even after 24
hours. Spengler used 10 per cent, solutions of aseptol, creolin,- car-
bolic acid and lysol, mixing them with equal parts of sputum without
agitation. He found that the lysol solution was eflScacious in 12
hours, while the others were inoperative at 24 hours. These two
authors with others have insisted that lysol should be our dependence
in the destruction of the bacillus. But lysol is a comparatively expen-
sive substance.

Other disinfectants have been tested in this connection. Traugott
employed solutions of iodine trichloride, (1-10 per cent, and 1 per cent.)
making a thorough emulsion of the sputum. In one hour's time all
germs had been destroyed.

Aniline vapor and absolute alcohol are too expensive for disin-
fection. Generally speaking we have no ideal chemical disinfectanti
and many authorities prefer to renounce the notion of chemicals in
connection with the problem of rendering sputtmi harmless.

Thermic disinfection comprises the use of live steam, boiling,
and burning outright. Schill and Fisher found that boUing killed the
bacilli in 30 minutes while live steam accomplished the same result
in 15 minutes. Grancher and de Gennes found the steam vastly^

superior to the chemical sulphate of copper, carbolic acid, potash and
sublimate. Various patterns of apparatus for exhibiting the steam
haFe been devised and that of Kirchner has proved of value in hoa<-
pitals. But these contrivances are too expensive for the poorer class
of patients.

Boiling the contaminated vessels is by no means readily carried
out. In the first place a certain result is obtainable only after half an
hour, while the shape and size of the vessel are not readily adapted
to this form of sterilization. Destruction by burning is simple and
efficacious if the vessels to be destroyed are only combustible. Praua^
nitz proposes that consumptives should expectorate into wood wool,
while others have suggested the use of receptacles of papier-mach&
Comet objects that unless care is used with these receptacles the heat
might volatilize the infectious sputum. This fear seems to be without
foundation.

Sputum prophylaxis has a much wider application than the disin«
f ection of cuspidors, for in addition to the gross masses of expecto-
rated material we have to destroy that portion which soils the hand*
kerchiefs and which is carried from the latter to the pockets, etc.
Further the sputum which remains in the patient^s mouth is projected
into the air of the room in the form of fine spray when the patient
talks, coughs, sneezes, etc. It is hardly practicable to destroy by com-
bustion every domestic article which comes in contact with the sputum.

Schill and Fischer made numerous experiments with dried spu-
tum, and regard the latter as much more difficult to dispose of than is
fresh expectoration, but Jaeger found that 5 per cent, carbolic acid
will destroy the bacilli in dried sputum in 5 minutes. Delepine and
Kansome warmly recommend 10 per cent, solution of chloride of lime^
it being necessary only to dip the contaminated clothing, etc., into this
solution and then to brush it.

For the disinfection of dwellings and furniture the agents most
highly commended are lysol, chloride of lime and sublimate (3-1000).
Formalin in solution appears to be inferior to the foregoing, but has
not been tested systematically. There is no doubt that formaldehyde
vapor is able to destroy the bacilli in dried sputum.

The author now details his personal experiments, first with fresh
sputum. He began with iodine trichloride, using various strengths
(1 per cent., 1-2 per cent., 1-10 per cent, 1-20 per cent., etc.). After
treating balls of sputum moderately rich in bacilli with these solu-
tions he proceeded to inoculate aniTnalH with the sputum thus treated.
He found that animals subjected to the 1 per cent, strength did not

become tuberculous, but that in the other cases the disinfection was
incomplete. This 1 per cent, solution required over 8 hours to kill the
bacilli, and in general the chemical did not give uniform results —
thus the 1 per cent, solution was sometimes less effective than the
1-4 per cent, solution.

The author next took up formalin, using it in various concentra-
tions. The 40 per cent, formaldehyde known as formalin was used
in the strength of 10 per cent, and 2-5 per cent. After the sputum
had been treated with the formalin the animal experiment was
repeated. As all the animals became tuberculous the inference was
that formalin even in considerable concentration was unable to disin-
fect ordinary sputum after due exposure.

Copper sulphate likewise proved inefficacious. Hydrochloric acid
was now tried, the commercial 35 per cent, strength being used in 4
per cent., 2 per cent., etc., concentration. Sputum treated with this
chemical was found to be virulent to animals and therefore the acid
was rejected from the competition in weak solutions. But in a strength
of 15 per cent., 12 per cent, and 9 per cent, the results were positive.
Generally speaking to be effective the acid must be used in high
degrees of concentration or if in weaker solutions it must be applied
when hot.

Hydrochloric acid was also used in alcohol, and some of the
results were positive, others negative.

With sublimate, it was found that a 5 to 1000 strength destroyed
bacilli in sputum in 1^ hours; a 2 to 1000 solution required from 3 to
5 hours, and a 1 to 1000 solution 6 to 8 hburs.

Comparative tests with infected handkerchiefs showed that sub-
limate was superior as a germicide to formalin or iodine trichloride.

Dried sputum on the floors, etc., of dwellings could be readily
disinfected by formaldehyde vapor, after a variable number of hours.
Many experiments, however, resulted negatively.

After detailing further experiments along the same lines the
author sums up as follows : — The fresh sputum must be received either
in combustible cuspidors, etc., or in spit-cups which can be disin-
fected by boiling, or in handkerchiefs which may be boiled or soaked
in 1-1000 sublimate solution for 5 hours, or in paper napkins which
may be burned. The habitations and clothing of phthisical individuals
may be disinfected as follows; when the floor is soiled with sputum
the latter should be treated thoroughly with sublimate solution 2 to
1000. Soiled clothing should be soaked in the same solution for 9
hours. Other room disinfection should be accomplished with formal-
dehyde vapor.

REGISTRATION OF TUBERCULOSIS,

I^wrence Flick, Maryland Med. Journal, Aug., 1901, states
that the medical world is agreed : —

1. That tuberculosis is a communicable disease.

2. That, being a conununicable disease, it is, theoretically at
least, a preventable one.

3. That if it is a preventable disease, it ought to be prevented.

4. That for its prevention such measures as are necessary are
legitimate and proper.

6. That prevention of disease is a governmental function.

6. That the arm of the government to which, in this country,
prevention of disease is usually entrusted is known as a board of
health.

Disputed points are : —

1. The contagiousness of tuberculosis.

2. The importance of communicability as a factor in the etiology
of the disease.

8. The practicability of prevention.

4. Kegistration as an essential factor in a scheme of prevention.

5. The expediency of intrusting boards of health with the pre-
vention of tuberculosis.

1. As to the contagiousness of tuberculosis, Dr. Flick states that
^^a contagious disease is one in which the offending matter passes from
one host to another without going through an intermediary host or
culture medium; an infectious disease is one in which the offending
matter goes from one host to another through an intermediary host
or culture medium."

In tuberculosis the contagion is transmitted directly from one
host to another. In transmission direct or indirect contact is an essen-
tiaJ factor and practically the most powerful factor. In seventy-five
per cent, of all new cases of tuberculosis, transmission is brought
about through family relationship, association in business or occupa-
tion, and the occupancy of quarters previously inhabited by tubercu-
lous subjects. This has been demonstrated by Dr. Flick, as well as
T)y others, in a topographical study of all cases with fatal issue within
a given district in a given time. This is also shown in a way by the
recurrence of the same number of cases year after year except as this
may be interfered with by the laws of immunity and by preventative
measures. Every old case is succeeded by a new one, and by practi-
<5ally but one, which shows that limitation and circumscription must
he instrumental in bringing about such a condition. This limitation

and circumscription mean (and this i& indicated by laboratory and
clinical work) that the tuberculous subject is the centre from which
contagion is given off and that the degree of communicability is in
proportion to the proximity to that centre. The closer the contact
between the actual tuberculous subject and the prospective one the
more liable is transmisison to occur. Certainly an affection which is
so very dependent upon contact for its perpetuation may be termed
a contagious disease.

2. The importance of commimicability as an etiological factor in
tuberculosis is considered by many as secondary to sociological factors
which predispose to the acquirement of the disease. In this connec-
tion the author emphasizes the fact that although sociological factors
play an important role in the spread of tuberculosis, they can not
produce the disease without the tubercle bacillus, while on the con-
trary; the tubercle bacillus can produce tuberculosis without the aid
of sociological factors. "Besides," says Dr. Flick, "we cannot remedy
the sociological factors but we can destroy the bacillus.''

3. There are many who believe in the communicability of
tuberculosis but doubt the practicability of prevention. These people
argue against prophylactic measures as useless on the ground that the
tubercle bacillus is given off by the millions from thousands of dis-
eased lung9, that it is everywhere in existence and that its victims
cannot be restrained. Dr. Flick points out that those who hold such
views do not understand the contagion of tuberculosis and are igno-
rant of the life history of the tubercle bacillus.

That of all diseases tuberculosis is most easily preventable, he
shows to be true, because the contagion is through chiefly but a single
source, because the sputum which contains the contagious element
can be disposed of, and because the bacillus once thrown off can not
multiply until it enters a new host and in a short time is destroyed
by the germicidal influence of air, moisture and sunlight. Thus living
tubercle bacilli are not everywhere in existence, nor are they inhaled
by everybody; in reality comparatively few inhale the germ in suffi-
cient numbers to produce the disease. The author admits that the
possibility exists of contracting the disease on the streets and in public
conveyances and buildings, but considers this danger sufficiently
remote as to demand no particular consideration. It is prolonged con-
tact with the tuberculous subject, or prolonged occupation of quarters
in which such a patient has lived which is essential to the contraction
of the disease by others, and consequently, as Dr. Flick asserts, in the
application of preventative measures it is necessary to consider only

the host and his environment. Disinfection of tuberculous matter
ijnmediately after its discharge renders the tuberculous subject innocu-
ous and checks a new contagion from that source. Every instance in
which prevention is successful exerts a far reaching influence in the
future, since all the cases which might have resulted from this one are
also prevented. Herein lies the explanation of the wonderful results
which liave been obtained wherever such methods have been put into
operation, and in order that they may be applied to every case the first
step necessary is registration.

4. In the consideration of registration as an essential factor in
a scheme of prevention, Dr. Flick points out that registration is most
frequently and perhaps most plausibly opposed on the ground that it
is unnecessary. Those who make this objection claim that the physi-
cian in attendance is competent to see to it that such practical pre-
ventive measures are carried out without publicity. The fallacy of
this proposition is best demonstrated among the poor, for the indigent
consumptive does not have a physician during that period of his dis-
ease in which contagion is most intense. He is very liable to contam-
inate several dwellings, because he is frequently compelled to change
his quarters because of inability to pay his rent. The truth of this
statement is the more forcibly brought home to us if we consider
that tuberculosis is largely a disease of the poor. Even if the poor
consumptive could avail himself of the services of a competent physi-
cian, eflScient preventive measures would not be carried out, because
their successful accomplishment entails a degree of technical knowl-
edge and diligent effort which few physicians are able and willing to
give and for which there is never any compensation. Until the public
is brought to the realization of the fact that prevention of disease is
worth paying for, it is unreasonable to expect the physician to assume
an uncompensated labor, especially when he needs the time which
would necessarily be thus employed, for the earning of his living.

6. The expediency of entrusting boards of health with the pre-
vention of tuberculosis has been questioned on the ground that they
are not safely to be entrusted with the prevention of the, disease.
Although all boards of health are not as competent or are not organ-
ized as well as might be wished, they constitute the only legal arm of
the government which has to deal with public health. If they are
imperfect the remedy lies in their reform and not in neglecting the
prevention of the disease. In addition to the opposition arising from
conflict of opinions on the part of the profession, there are those who
oppose registration because they think it brands the afflicted and

increases their afflictions. But this opposition is really based upon
fancy and sentimentality, for it certainly can not work to the disad-
vantage of him who has the disease, if his case is reported and the
proper prophylactic measures instituted. That such a patient should
receive a printed document explaining to him how to prevent the
spread of the disease, that he is visited perhaps by a health officer
who further explains the matter to him, that possibly opportunity is
afforded him to enter a sanitarium or hospital, that the house, after
he has vacated it by death or removal, should be sterilized, are all
measures which can certainly work no injury to him nor increase his
burdens. A further objection to registration which is purely a fanci-
ful and sentimental one is that the deaths of sensitive tuberculous
subjects would be hastened by the knowledge that they have tubercu-
losis. In refutation of this objection Dr. Flick states that in an
extended experience with such patients he knows of no single instance
where the patient has derived injury from a knowledge of the nature
of his affection. On the contrary the benefit which the patient has
obtained from such information has gradually forced him to conclude
that to conceal from a tuberculous subject the nature of his disease
is in fact almost criminaL In summing up Dr. Flick says ^Tuberculosis
is a contagious disease, it is a preventable disease ; the centre from which
contagion spreads is the host ; this centre is limited and circumscribed,
prevention of the disease is not only practicable but easy ; the keynote
to prevention is control of the host, the whereabouts of the host can
only be known through registration, opposition to registration is based
upon false notions, fancy and sentiment; for a comprehensive scheme
of prevention governmental interference is necessary, under existing
circumstances governmental interference can only take place through
boards of health."

I'No more practical contribution to the question of registration
of tuberculosis than Dr. Flick's forcible exposition of the subject has
as yet come to our notice. The author's arguments are so conclusive
and his deductions so logical as to be incapable of refutation. We
sincerely regret that limited space prevents the reprinting of his
paper in full. Ed.]

PROPHYLAXIS OF TUBERCULOSIS.

Dr. £. P. Lachapelle read a paper on this subject at the joint
meeting of the Medico-Legal Society and the American Congress of

Tuberculosis, which was published in the Medico-Legal Journal, Sep*
tember^ 1901.

After an appropriate consideration of the etiology of the disease
both as regards the speciflc germ-infection and from the standpoint
of hereditary as well as acquired predisposition, he points out these
two important indications which must be met in order to establish a
rational prophylaxis : —

1. To keep the organism from debilitation or to modify it if
there already exists a predisposition to tuberculosis.

2. To prevent contagion.

To meet the first indication the author urges careful hygienio
and dietetic management of children in all respects. Among the
measures which he advocates are, a sufficient supply of fresh air at all
times, wholesome food, moderate exercise to develop physical strength
and the avoidance of muscular or nervous exhaustion and overwork*

In cases of predisposition from heredity, scrofula and rachitis the
above measures should be the more carefully applied.

In adults any cause of diminished vitality should be opposed,
whether this be alcoholism, bad nourishment, insufEcient ventilation
or anything else.

The hygiene of dwellings, boarding schools, factories, prisons,
theatres, etc., should receive special oversight, particularly as regards
cubic air space.

Among the practical measures to which Dr. Lachapelle directs
attention as calculated for the prevention of infection the following
are of importance : Notification of tuberculous cases, disinfection of
places of abode of consumptives, the prohibition of dry sweeping,
formal defense of spitting upon floors, pavements and in public con-
veyances; further, regulation of food supplies, inspection of dairies,
public slaughter houses, butchers' stalls, etc.; fijially the enforced
teaching in schools of methods of prevention and the education of the
adult public by lectures, dissemination of literature, etc.

The author expresses the belief that by these means voluntary
cooperation of the masses will be secured and that the golden age of
hygiene in America will be realized.

SOME SUGGESTIONS FOR THE PREVENTION OF TUBERCULOSIS.

This is the subject of a paper presented to the American Con-
gress of Tuberculosis by Dr. C. F. Ulrich and which appears in the
Medico-Legal Journal for June, 1901. To hereditary influence in the

Bcqidrement of disease the author has first given his attention. He
proceeds with a short discussion on digestion, assimilation and tissue
building on the part of the organism, and states that so long as health
prevails each organ and tissue, by a selective activity, assimilates that
particular portion of the digested food which is essential to its indi-
vidual function and well being, at the same time rejecting that which
is inappropriate. Now the author inquires what is the result when an
individual has inherited in a deficient degree this power of assimila-
tion. In answer to this question he states that, "Substances not appro-
priate to the organ or tissue to be built up are deposited and form
tubercles. These tubercles occupying the place of the true tissue,
set up inflammation, break down, causing ulceration and suppuration.
If this takes place in the intestines we have miliary tubercles, giving
rise to all sorts of intestinal diseases ; if in the stomach there arises
a variety of lesions appropriate to that organ, among which I include
all forms of gastric carcinoma. If this deficiency exists in the lungs
they are filled with unhealthy deposits which interfere with natural
respiration."

In such cases drugs are of no avail, fats, cod-liver oil, etc., do not
accomplish the desired end. The author's observations have taught
him that the only solution lies in hygenic, dietetic and general sani-
tary measures with the view of prevention, and he believes that the
most favorable resort for those with consumptive tendency is in moun-
tainous regions with pure air and clear, sparkling water. But of
these advantages comparatively few can avail themselves. Therefore
they seek to obtain the best conditions possible at home. Such is the
author's position in regard to the question of prevention; he con-
tinues with the following advice on the principle of the "greatest
good to the greatest number" : — ^"Tn every case of confirmed tubercu-
culosis, cease your efforts to prolong life, devoting your entire energy to
the endeavor to make your patient as comfortable as possible, even
though the means employed should have a tendency to shorten life."
This method of procedure Dr. Ulrich urges for a number of reasons,
chief of which is that "Every young, incurable victim of tuberculosis
that dies before he or she has had an opportunity to bring into the
world other infected beings, lessens by that death the amount of
human suffering;" and further that legislative restriction of marriage
in such cases can be but partially effective.

[The space at our disposal is too limited to admit of a lengthy
criticism of such a contribution as the preceding. We can offer no
comment as to Dr. Ulrich's conception of the pathology of the disease;

for it is so impossible that were we to consider it, we would appear to
seriously question the intelligence of our readers.

Indeed his contribution would have been entirely ignored were
it not for the cruelly inhuman means which the author suggests for
the prevention of the spread and perpetuation of tuberculosis. Why
did he not go a step farther and advocate the wholesale execution
of those afflicted with the disease and a systematic slaughter of the
innocent progeny of tuberculous parents? It may certainly be occa-
sion for gratification on the part of the unfortunate victim of a pre-
ventable and in many instances curable affection, that the medical
profession as a whole does not entertain the extreme views of Dr.
Ulrich.— Ed.]

A NOTEWORTHY CASE OF TUBERCULOSIS OF THE TRACHEA AND SIM-

ULTANEOUS FORMATION OF VARICES IN SITU,
VITH FATAL TERMINATION.

Gideonsen, Munch. Med. Wochen., Oct. 15, 1901, relates the case
of a patient treated at the Falkenstein Sanatorium. She was 41 years
old and had suffered with a harrassing cough and dyspnoea for a year
before admission. Physicians assured her that she had neither pul-
monary nor laryngeal tuberculosis. There was a further history of
arthritis at the elbow joint, and this fact coupled with consumption-
deaths in blood relatives caused a suspicion that the present affection
was tuberculous. Expectoration was abundant but bacilli had never
been found therein. The general condition was otherwise good.

The state on admission to the sanatorium was as follows : respira-
tion forced, with slight cyanosis, prolonged expiration, abbreviated
resonance over left apex, broncho-vesicular breathing in right upper
lobe, a few whistling rales over both sides of the chest; enlarged
terminal phalanges.

After a week in the sanatorium her temperature, which had been
normal, rose suddenly to 38^ C. with coincident increase in dyspnoea.
She remained in bed for three weeks and upon getting up had, for the
first time, a moderately severe attack of hemoptysis. She returned
to her bed for four additional days as a precaution, and then got up in
excellent condition, afebrile. That same evening, howjever, she had
a profuse haemorrhage, and lived but twenty minutes afterwards, death
having been of the suffocative type.

Autopsy showed pulmonary emphysema with areas of atelectasis.
There were no tuberculous changes in the lungs. The trachea con-
tained several varicose veins, while upon its posterior wall, just above

the bifurcation was a typical tuberculoua ulcer of the size of a penny^
in close proximity to the dilated veins. The bronchi beneath were
filled with blood.

Microscopical examination of the floor of the ulcer showed tuber-
cle of characteristic histological structure. All attempts to demon-
strate the presence of bacilli in the ulcer met with failure.

It was evident that the destructive process in the trachea had
encroached upon one of the dilated veins and had caused the haemor-
rhages, the last of which had induced death by asphyxia. The lungs
having lost their elasticity as a result of the emphysema (which was due
in turn to months of forced expiration necessitated by the diminished
lumen of the trachea), were unequal to the task of expelling the blood
from the bronchi.

This case, while extremely rare, is by no means unique. Avellis
has described a similar example of fatal suffocative haemorrhage fol-
lowing the rupture of tracheal carices and M. Schmidt cites similar
cases in his work on diseases of the upper air-passages.

!N'ot the least striking feature about this case is the isolated char-
acter of the tuberculous lesion. Unfortunately the greater part of the
cadaver was not subjected to autopsy, in accordance with the wishes
of relatives ; so that it is impossible to be certain that the lesion repre-
sented primary tuberculosis.

Tracheal tuberculosis is notably rare, as an independent lesion.
Comet cites but a single authentic case. Secondary tracheal tuber-
culosis, as a sort of variation of tuberculous laryngitis is relatively rare.
Statistics show that in laryngo-tracheal tuberculosis consecutive to pul-
monary consumption, some 4 per cent, of the cases have an exclusively
tracheal localization.

A NEV FORM OF TUBERCULOSIS OF THE PENIS,

Sabrazes and Muratet report a case of nodular tuberculosis of the
prepuce in La Semaine Medicaley Sept. 18, 1901. They state that we
have never had any test for tuberculosis in this locality other than
the microscope and animal-experiment.

Secondary tuberculosis is occasionally noted in this locality, and
primary infection has followed ritual circumcision, copulation, etc.

Clinically the open ulcer is the most common type encountered,
and this lesion may be likened to a tuberculous chancre, the differential
diagnosis of which from syphilitic chancre, chancroid and epithelioma
may be very difficult.

The literature on this subject, while once very scanty, is beginning

to accumulate^ no less than three monographic studies having appeared
within the past decennium.

If an adult male, between 20 and 30 years of age, develops a
persistent ulcer or ulcers of the penis, having a yellowish gray, uneven
surface, with but a small amount of thin discharge which dries into
a shallow crust, we should think of the possibility of tuberculosis.
Such ulcers are almoet always multiple. Their base is infiltrated.
They may develop upon the glans or inner aspect of the prepuce, and in
the former locality may involve the meatus and encroach upon the
calibre of the urethra. There is some inguinal adenopathy, which
bears but little resemblance to the characteristic picture of enlarged
glands, which accompany primary syphilis. The course of the affec-
tion is slow, and a radical cure may be effected by excision.

In some of these cases examination reveals tuberculosis of the
neighboring genitals (epididymis, prostate, etc.); or perhaps of some
remote visceral location. But there are cases in which we can find
no other nidus of the disease, and we are then justified in regarding
the lesions as primary, especially if we can find any evidence of an
infectious contact.

In regard to the possibility of inoculation in situ we must con-
sider the sexual exposure of the individual. Cohnheim was the first
authority to consider the possibility of transmitting tuberculosis by
sexual relations, and since his day many animal-experiments have been
made with a view of learning if such transnussion was possible. Miss
Gorovitz has summed up what is known in this field in a thesis of recent
date. It is possible to inoculate the female genital x>a88age8 with the
bacillus, and the disease thus inoculated is propagated by local exten-
sion and by the lymphatic route. Hence it is possible in theory for a
woman with tuberculous lesions of the genitals (and secondary deposits
of tubercle are not extremely rare in these localities) to infect a man
through copulation. Under such circumstances inoculation of the
male would be facilitated by the presence of herpes or abrasions.
There is as yet no evidence of sexual transmission of genital lesions.

The occurrence of primary tuberculosis of the penis in Jewish
infants as a result of inoculation incident to ritual circumcision is too
well established by numerous cases to require comment. At their
tender age the victims of infection are quite prone to perish from acute
secondary tuberculosis of the lungs or meninges.

There is a third 5form of tuberculosis of the penis which may
readily pass for a simple benign lesion — a sebaceous cyst possibly —

until its nature is disclosed by histological and bacteriological research.
The case about to be described is unique as far as known.

The patifent was a man 26 years old, who came to consultation for
a complication of genito-urinary affections. Both testicles were nod-
ular, and haematuria was also present. There was a history of pul-
monary disease and scrofulous glands in childhood. The thoracic
symptoms suggested implication of the tracheo-bronchial glands.

In the course of a general examination a lesion was discovered
in the thickness of the prepuce. Its size and shape were those of an
olive, and its appearance was that of a fibroid tumor. This nodule had
first appeared two years before; and during its evolution a second
nodule had formed, but had imdergone suppuration, the scar being in
evidence. In addition to the other unro-genital symptoms, there was
a discharge of pus from the urethra, and Koch's bacillus was recog-
nized in this discharge, as well as in the urinary sediment.

The general state of the patient was excellent, although he had
some dubious evidences of apical disease, clubbed fingers and other
evidences pointing to a general tuberculous disposition and evolution.

The nodule was excised and examined; its centre was caseous
and contained Koch's bacillus. There could be no doubt that this lesion
was of the same type as the nodules present elsewhere in the uro-gen-
ital tract.

EARLY DIAGNOSIS OF PULMONARY TUBERCULOSIS

Perkins, Practitioner^ July, 1901, after passing in review such
topics as insidious onset (dyspepsia or anaemia), acute onset (as by
pneumonia), tachycardia, hyperaesthesia over the apex, the tuberculin
reaction, and other conditions which pertain to the beginning of
phthisis, gives special prominence to another phase of the matter not
so commonly discussed. He thinks that we may often refer back to
some long forgotten affection which has really been the primary lesion
of the disease. How often do we see an attack of hemoptysis leave
the patient in perfect health, for years perhaps ; but how few of these
cases ultimately escape death from phthisis. It is the rule in these
primary hemoptyses for physical examination to give perfectly nega-
tive results. In the opinion of the author this experience necessarily
means that a minute focus of tubercle has from its peculiar locality
led to the erosion of a blood-vessel. The physician, failing to discover
anything wrong is forced to believe that the blood has proceeded from
the larynx or nose. It is necessary in all cases to prove that such
haemorrhages come from localities other than the lungs. Such patients

must be treated as tuberculous^ and with such an early start the best of
results are to be anticipated.

A condition analogous to hemoptysis as a remote forerunner of
phthisis is pleurisy ; acute, idiopathic pleurisy occurring independently
of other affections is of tuberculous nature in the vast majority of
cases.' This can be shown beyond doubt in serous pleurisy by the ani-
mal experiment, and is to be inferred in dry pleurisy as well. The
cumulation of records teaches us that very many of these pleuritic
patients have ultimately died of phthisis. These sufferers from
pleurisy had better be placed at once in the tuberculous category and
told of their probable condition, for they too have an excellent chance
to recover.

THE DIAGNOSIS OF TUBERCULOUS DISEASE OF THE LUNGS BY MEANS

OF THE ROENTGEN RAYS.

Beale and Walsham contribute a paper with the above title to the
"Second Tuberculosis Number" of the Practitioner ^ July, 1901. They
state that the introduction of powerful induction-coils and improved
tubes has given us the means of approximate diagnosis of tuberculous
affections. Many clinical observations have been made by means of
the skiascope; whether in bedside observations or from recording the
shadows thrown by the solid portions of the thorax and its contents,
it is absolutely necessary to employ a powerful induction coil capable
of yielding a 12 or 14 inch spark. The coil should be worked with two
four-cell accumulators of 21 hours ampere capacity and an electro-
motive force of 16 volts. The anticathode of the tube should be
placed directly opposite the centre of the part to be examined, and
from 12 to 20 inches from the chest-wall. The rays diverge from their
point of origin, hence the tube must not be placed too near the chest-
wall. Skiagrams should always be taken from both the front and rear
of the chest. The room must be darkened, and the eye of the operator
ought to be able to discern objects in the dark. An exposure of 2
minutes is all that is required, except in the corpulent or massive, when
twice that interval may be necessary. No harm can come to the skin,
etc., from short exposures.

In well marked tuberculous lesions, the affected area in the lung
may at once be recognized by the shadow when the limg is examined
by the screen. The shadow appears larger than the area recognizable
by physical diagnosis ; hence the doubt that it necessarily corresponds
to die deposit of tubercle.

The shadow of the bony components of the thorax is always
instructiye and often contradicts the naked eye picture of the chest.
Thus a broad chest in the ordinary acceptation may have a weak and
narrow bony thorax and vice-versa. Since the thorax and its contents
are always in motion, more or less blurring of the shadows is natural.

In regard to the limits of Roentgen diagnosis in tubercle we
know that the earliest deposits of the disease are not recognizable; a
certain number of tubercles must be aggregated before a shadow is
noticeable. It is a conservative claim that in some cases the rays are
our earliest diagnostic resource. It is equally true that when a shadow
is cast the disease is no longer in the initial stage. If pleurisy coexists
we see shadows only in some cases where pus is present. If the med-
iastinal glands are markedly involved we should see evidence to this
effect in the skiagram.

The earliest shadows of tuberculous infiltration consist of faint
mottling. When opacities form, caseous areas are usually present.
Cavities exhibit translucency. The study of the elevation and move-
ments of the diaphragm is of much incidental importance in arriving at
a conception of the functional activity of the lung — ^indeed this is one
of the earliest and best known results of the application of skiagraphy
to pulmonary tuberculosis.

LEOTHIN IN TUBERCULOSIS.

Claude and Zaky, La Presse Medicaley Sept. 28, 1901, refer to the
animal experiments which prove beyond a doubt that lecithin is a great
promoter of nutrition, and to the testimony of Lancereaux and others
that this substance is of clinical value in tuberculosis, neurasthenia and
diabetes.

The authors have made numerous experiments on guinea pigs,
intended to demonstrate the change in weight and metabolism induced
by lecithin. The animals were first inoculated with tuberculosis. The
progress of the latter affection was not arrested, but it appeared to be
delayed, the animals which received lecithin, living considerably longer
than the control. These lecithinized animals appeared to exhibit less
waste of phosphorus, corresponding to a superior avoirdupois, during
the progress of the malady.

The author next made a research into the action of lecithin in
human tuberculosis. All phases of this affection were subjected to
the test. Every case under treatment at the St. Antoine hospital was
put under treatment, including those patients who were in the initial

6tage of the malady^ but it is admitted that this classification may
recover under rest and regimen.

Seven of the cases treated, were in the inception of the. malady,
but far enough advanced for the exhibition of physical signs. The
results here were of the best, appetite and strength returning. The
injection of lecithin was followed, immediately by a reduction in the
elimination of phosphorus; so that the drug appears to act through
setting up phosphorus-retention. Increase in the coefficient of nitro-
gen in the urine shows that the nutrition was improved.

Six of the cases treated, were in the second stage of phthisis, and
these were mostly severe in degree, and tending to pass into the third
stage.

The effects of lecithin were to promote increase of weight in those
patients who had been emaciating rapidly. Naturally this feature was
neither so marked or as constant as in Class A. Arrest of phosphorus
waste was apparent here, as well as increased elimination of urea.

Four cases of phthiais of the third stage were included in the
aeries. The results in these were almost negative, for in but one of
the four did the weight increase. It is possible that the progressive
emaciation was somewhat retarded, and it may be affirmed from the
single favorable result, that lecithin can be of service in, the third stage
of phthisis, if the local mischief predominates over the general condi-
tion. In other words not much can be done if secondary infection is
under way, with pronounced hectic fever.

ITo benefit accrued in two cases of acute tuberculous broncho-
pneumonia ; but a very favorable result was obtained in a case of ordi-
nary phthisis with very rapid evolution, the disease having been
arrested in the first stage.

BOOK REVIEWS.

Entstbhen uni> Bbkampfung der Lungentuberkulose. By Dr. Paul
Jacob, Berlin, and Dr. G. Pannwitz, Berlin. Vol. I., 372 Pages, Liepsig: Georg
Thieme, 1901.

This volume is entirely devoted to the etiology of pulmonary tuberculosis and
is by far the most comprehensive and at the same time one of the most carefully
prepared contributions to this subject. Volume II which will treat on Prophylaxis
and which is to appear in the near future will be based upon the evidence and
conclusions from the etiological study of 3295 cases which form the basis of the
present volume.

The etiological data are obtained from the histories of the aforesaid clinical
cases which were at the time under treatment in 33 German sanitaria for tubercu-
losis, with the cooperation of their respective medical directors. The inquiries and

answers are uniform throughout, taking cognizance of everything of importance
that may have contributed directly or indirectly to the acquirement of the disease
from the period of infancy to its actual outbreak.

Besides the question of direct infection the subject of hereditary and
acquired predisposition is most fully dealt with, and nearly 200 pages of the work
are devoted to special and general analytic tables which supply an amount of
ready information that cannot but be of the greatest interest to the student.

The critical analysis which follows is conservative and logical in its conclusions^
showing that while the bacillus of Koch is the direct cause of tuberculosis, for its
localization and for the formation of tubercles in the organism to which the germs
have gained access, a certain predisposition, consisting in an heredity or acquired
general debility of the whole organism or of the particular part, is essential.

Not since the reading of Prof. Cornet's work on Tuberculosis has the writer
met with so interesting and satisfactory a monograph on this subject. It should
be in the hands of every sanitarian and student of practical medicine.

ZuR Pathologischbn ANATOMnt DBS KiNDLiCHBN Altbrs. By Dr. A. Steffen,
Stettin. 327 Pages. Wiesbaden: J. P. Bergmann, 1901.

This volume contains the pathologic findings in 234 postmortem ezaminationa
of children, 62 of the deaths having occurred from tuberculosis; the remainder
were due to diphtheria, chronic hydrocephalus, diseases of the mediastinum, the
thymus gland, the kidneys, brain, heart, lungs and pleura, bones and joints, etc.
Critical remarks, studies and references to literature are given with each group,
constituting a most valuable collection of pathologic experiences in the domain of
the diseases of childhood.

The large percentage of tuberculous affections, over 25 per cent. , is particularly
significant, showing the prevalence of tuberculosis in children and the organs most
frequently involved.

In the 48 in which pulmonary tuberculosis was present, both lungs were
involved in 30, the right lung alone in 13, and the left lung alone in only 2 instances.

The right upper lobe was the beat of the disease in 40. In only 8 cases were
the tracheal and bronchial glands free from the disease, and in 37 instances more
or less extensive caseation of these glands was found.

Tuberculosis of the gastro-intestinal tract is recorded in 24 instances, always
associated with pulmonary lesions; one case only is excepted. The mesenteric
and retro-peritoneal glands were found tuberculous 35 times out of the 62 casea
examined. Many other highly interesting data are presented in connection with
the various diseases considered, and the student of tuberculosis will find here much
which has an important bearing on the elucidation of the question of the primary
seat, the extension of the disease to other organs, and more particularly th»
clinical course and symptoms during the life of the patient.

The importance to the clinician of such pathological studies is nowada3r8 so
fully recognized that it is not necessary to say more in comment of this contribu-
tion to the literature on the subject, except that it bears evidence of most careful
preparation and of critical examination and in so far as the subject of tuberculosia
is concerned, we highly commend it to our readers.

Bbitragb Zur Kbnntniss Dbr Lunoentubbrculosb. By Dr. Ernst Meissen,
Hohenhonnef. 349 pages. Wiesbaden, Germany: J. P. Bergmann, 1901.

The author is the medical director of the Sanitarium Hohenhonnef and th»
present work is practically a report oi its activity and of the scientific and clinicaL
experience during the ten years of its operation.

The first part deals with the location, environment, construction, and hygienic
features of the iostitntioo itself, showing how well it is planned and adapted to its
purposes. A full consideration of the hygienic, dietetic and general management
of the disease gives evidence of much practical and painstaking observation and
the succeeding sections are supplementary in scientific and clinical demonstra-
tions of the correctness of the principles which are enumerated in the foregoing
pages.

We regret, however, that in the results obtained the author thought best to
deal with the cases as a whole, instead of making a classification of the stages,
degree and complications of disease existing on admission, thereby giving little or
no opportunity of comparing them with those of other institutions, in which dif-
ference in climate and in modes of treatment obtained.

The clinical material, after deducting cases which were under treatment for
too short a time, or were still in the institution, consists of 1731 cases of pulmo-
nary tuberculosis of which 278 or 16 per cent, reached a result that may corres-
pond to a cure ; 621 or 36 per cent, were so greatly improved that the result ap-
proached a cure, while 412 or 23.8 per cent, were sufficiently benefited as to justify
the claim of being improved.

This gives a total of 66 per cent, in which the patients derived various degrees
of benefit.

Specific treatment was not employed ; the author's experience with the first
tuberculin of Koch having been so discouraging that he has since abstained from
its use.

The succeeding pages contain special contributions by Dr. Meissen and his
assistants on various subjects in connection with tuberculosis, all of which are ex-
cellent, and although most of them have already appeared in current literature,
they have been rewritten and conform to the present advanced thought upon their
subjects.

The book as a whole impresses the reader that the scientific and clinical work
are made to supplement each other as should be the case in a well conducted in-
stitution, and that the opportunities in either direction have been carefully utilized
by the author.

Hbmmbtbr. Disbasbs of thb Iktbstinbs. Their Special Pathology, Diag-
nosis and Treatment. With Sections on Anatomy and Physiology, Microscopic
and Chemic Examination of the Intestinal Contents, Secretions, Faeces, and Urine.
Intestinal Bacteria and Parasites; Surgery of the Intestines; Dietetics ; Diseases of •
the Rectum, etc. By John C. Hemmeter, M. D., Philos, D., Professor in the Med-
ical Dept. of the University of Maryland; Consultant to the University and Director
of the Clinical ^^boratory; etc. In two Volumes. VOLUME I— Anatomy,
Physiology, Intestinal Bacteria, Methods of Diagnosis, Therapy and Materia Medica
of Intestinal Diseases, Diarrhoea, Constipation, Enteralgia and Enterodynia,
Meteorism, Dystrypsia, Enteritis, Colitis, Dysentery, Intestinal Ulcers, Intestinal
Neoplasms, etc. With many original Illustrations, some of which are in colors.
Published by P. Blakiston's Son & Co., 1012 Walnut St., Philadelphia, 1901, Large
Octavo, 740 Pages. Price $5.00 per volume.

In his preface the author states that this work has been undertaken with the
view of furnishing the practitioner with a complete work of American origin, from
which he may readily instruct himself concerning the most approved and modem
methods of diagnosis and treatment of intestinal diseases. That he has accom-
plished his task with credit in all respects to himself and to American medical

literature will be conceded by all who are competent to offer an opinion. Showing
most extensive study, research and practical knowledge in every section, the work
leaves nothing to be desired from a scientific, clinical or literary standpoint.

At first sight one mignt feel that so large a volume, which is to be followed by
another, presumably of like size, could only be intended for the specialist, and that
the general practitioner could hardly afford to enter into the study of intestinal
diseases to the extent that so large and comprehensive a work implies. Such a
feeling, if entertained, however, as one reads gives place quickly to one of
fascinating interest. In the phjrsiologic, pathologic and bacteriologic sections as
well as in the clinical parts, the author is most complete, and neither in diagnosis
nor in treatment does he leave the student in doubt, while he supports his views
by ample evidence and good authorities.

Very gratifying to the student of this work will be the detailed directions as to
methods of treatment, especially in regard to diet in the various diseases considered
and which, in gastro-intestinal affections is the keynote to effective prophylaxis and
to successfiiP treatment. We take pleasure in quoting the author's directions for
prophylactic dietetics during epidemics of cholera, typhoid fever, and dysentery,
as follows:—

** Nothing raw or uncooked is permitted ; nothing that has been exposed to
the air; that has been much handled, or that may have come in contact with
unboiled water. Every digestive disturbance is to be carefully avoided. The
drinking water of the locality in question is the greatest source of danger, therefore
all water which is used (whether for drinking, for cleansing the food or the dishes,
for rinsing the mouth, for washing, for bathing, etc.) must be boiled for 15 minutes
before use and kept in the vessel in which it was boiled, until used. Besides this,
water intended for drinking or rinsing the mouth should be slightly acidulated half
an hour before using by means of hydrochloric acid or citric acid : it is sufficient
if the acid can just be detected. The acidulation is best done in large quantities,
and the test for it is blue litmus paper which must change its color to red. If
in some cases it is impossible to boil all the water, then that used for external use,
as for washing, should have soft soap added to it half an hour before using. Finer
soap may also be used, but its results are not certain.

Rain-water, collected under personal supervision, should be used for washing
if possible; the tubs, etc., must not previously have been cleansed with ordinary
water, or, if they have been thus cleansed, they must first be filled with boiling
water."

The author considers as dangerous artificial soda water or seltzer, also ice,
unless made from distilled water or from water of known purity.

Hemmeter does not seem to believe much in the use of mineral waters for the
treatment of intestinal affections, except in chronic enteritis and colitis. The so-
called herb, whey or grape cure he regards as deleterious in delaying proper
methodic treatment, and in often aggravating the symptoms by monotony of the
diet and by causing diarrhoea. Having never observed any himself, he says that
the benefit exists in the imagination of the proprietors of the various European
sanatoria in which these diets are inflicted.

The chapter on rectal feeding is likewise highly instructive. According to the
author foods administered per rectum are digested probably by pancreatic ferments
which pass through the bowel, by bacteria and by the su ecus entericus which even
in the colon has an amylolytic action. Grutzner's marginal ascending motion of
particles can not move the ingesta antiperistaltically ; the propelling force of the

normally acting intestine is in one direction only. Antiperistalsis is a pathologic
phenomenon and all the author's efforts to force the bowel to work in the wrong
direction proved negative. As to the method and technique of rectal feeding
nothing more can be desired, even by one who has occasion to consider the
question for the first time, and if every physician were to bear in mind the eight
rules laid down, rectal alimentation would not so frequently fail in accomplishing
its object.

In the chapter devoted to intestinal ulceration, tuberculosis is adequately
considered. While the primary intestinal ulcer is admitted to be rare in adults,
the author says it is more frequent in children. As to general frequency, the
author quotes Wiederhofer who found the intestine involved in 101 instances of 418
cases of children dead of tuberculosis. The small intestine was tuberculous in 98,
the large intestine alone only in three cases, the large and small intestine in 22
cases. The bowel-lesion was associated with pulmonary phthisis in 76, with tuber-
culosis of the brain and membranes in 14, with granulation tuberculosiaof the lungs
in 8, with tuberculosis of the glands in 3, and with tuberculosis of the mesenteric
glands in 83 cases. Among the latter were 48 cases of tuberculosis of the intestine,
coexisting with that of the mesenteric glands. In about half of the cases of the
intestinal and mesenteric lesions the children were less than 5 years old.

The exclusion of secondary infection from the swallowing of sputum in about
25 per cent, of these children is significant of food infection, and the absence of
intestinal lesions in 35 out of 83 cases of tuberculosis of the mesenteric glands points
to the otherwise established fact that tubercle bacilli can penetrate the wall of the
intestine and become lodged in these glands, without leaving a lesion at the point
of entry. This is of particular interest at this time when the question of infection
from animal food products is so prominently before the profession.

We could easily continue our comments without finding any just cause for
criticism, the author and the book-maker having each done his part exceedingly
well. If we were to suggest anything at all, it would be that the reader could
follow the subject more easily if the frequent references, incorporated in the text,
were g^ven at tlie end of the chapters or in foot notes.

BOOKS RECEIVED.

Systbm of Physiologic Thbrapbutics. Vol. Ill, 336 pages, and IV, 420
pages, on Climatology, Health Resorts, Mineral Springs. By P. Parkes Weber,
M.A., M.D., F.R.C.P. (Lond.), Physician to the German Hospital, Dalston,
etc., with the collaboration for America of Guy Hinsdale, A.M., M.D., Secty.
American Climatological Association, Pres. Pennsylvania Society for Prevention of
Tuberculosis, etc. Edited by Solomon Soils Cohen, A.M., M.D., Professor of
Medicine and Therapeutics, Philadelphia Polyclinic, Lecturer, Clinical Med., Jef-
ferson Medical College, etc. Illustrated with maps. Philadelphia: P. Blakiston's
Son & Co., 1901.

84
EDITORIAL.

THE RELATION OF DROPLET-INFECTION TO THE PROPHYLAXIS OF

TUBERCULOSIS.

The question of the danger arising from droplet-infection in
tnberculoeifl has been the subject of extensive investigation during
the past two or three years, and as a result of the facts established by
various experimenters has assumed an importance which demands the
careful consideration, not only of those especially interested in the
prophylaxis of phthisis but of every general practitioner as well. It
has been clearly demonstrated that the consumptive by coughing,
sneezing, clearing the throat, talking and even by whispering, projects
into the air of his vicinity many minute drops of moisture, often con-
taining tubercle bacilli. The distance to which these droplets are pro-
jected varies, but has been shown to rarely exceed a metre, and it has
been further determined that they remain floating in the air during
intervals of from fifteen minutes to an hour and a half before they are
precipitated. The precipitated spray soon becomes dry and remains
upon the floor and furniture in the form of dust, ready at any time to
again rise when the contents of the room are disturbed. The germi
have proven virulent in a fair proportion of instances from two to flve
days after they have been given off and exceptionally, when in dark-
ened rooms, they have retained their vitality as late as the twelfth and
eighteenth day. These facts would appear significant, particularly
since many of the experiments have been conducted under perfectly
natural conditions which permitted of no exaggeration of those actually
obtaining in every day life.

From the purely scientific data at hand it requires no very great
mental calculation to make it clear to us that a single consumptive, as
he moves about, might render infectious every cubic foot of air not
only of one room but even of an entire house. Wherever he goes he is
liable to scatter broadcast great numbers of germs which may easily
find ingress, in fewer or greater numbers, into the air passages of those
who share his habitation and are more or less intimately associated with
him in his daily life. Surely, if the danger be so great in reality as
scientific research proves it to be in theory, a question is here involved

which, in the conflideration of the etiology and prophylaxis of so wide
spread a disease, wonld be of momentous importance to the whole
human race.

In this connection, therefore, we may very appropriately inquire
into the relation existing between the tubercle bacilli suspended in
the air in spray and the actual transmission of tuberculosis to those
who are intimately associated with the consumptive.

The very large proportion of tuberculous subjects by whom infec-
tious droplets are projected into' the air by talking and even by whisper-
ing, would lead one to expect contagion to occur much more frequently
and constantly than clinical experience has shown to be the case.
It is a well known fact that transmission of the disease to the healthy
personnel has very rarely occurred in institutions for tuberculous
patients where proper measures have been taken merely for the destruc-
tion of the sputum. During a period of thirteen years although no par-
ticular precautions have been taken to guard against droplet-infection,
no case of contagion has been known to have occurred in the Winyah
Sanitarium. Again we are not aware that laryngologists. who must
again and again have received cough-spray directly in the face while
treating cases of tuberculous laryngitis, have shown a greater mortality
from tuberculosis than any other class of physicians. Under such cir-
cumstances, if the danger, is in reality so great, it is difficult to explain
why contagion does not occur with greater frequency. Insusceptibility
does not afford a logical explanation, for unfortunately not every one is
insusceptible, individual predisposition and resistance being but rela-
tive, and exposures to contagion in this manner have been so numerous
as to render such a theory of immunity wholly untenable.

Kitasato has proven by experiment that tubercle bacilli contained
in sputum are not always virulent and capable of development, and
in fact that the great majority of them are dead. This element of
relative virulence of the germs coupled with the fact that many of the
bacilli are actually dead when projected, is quite compatible with the
experience that in animal-experimentation a considerable number of
germs must usually be introduced in order that infection may prove
buccessful. If this be true for the induction of laboratory tubercu-
losis, it seems not unreasonable to assume that it is also true for human

tuberculosifi as acquired in the usual manner by contagion. Further-
more the living germ^ after its discharge in the sputum as well as in
projected droplets, does not retain its vitality indefinitely, for sunlight,
direct or diffused, and changed temperature conditions sooner or later
effect its destruction.

It is not our purpose to belittle the danger as it exists, but for the
reasons already stated we believe that without exceeding the limits of
conservatism we may look upon this danger of contagion from cough
spray, etc., as less menacing than at first thought might be supposed.
Still, whatever the danger may really be it is not to be ignored and
every effort should be made toward the institution of efficient preven-
tive measures. In this connection that which may perhaps first sug-
gest itself is the wearing of a mask as proposed and devised by
Fraenkel. But if the mask is to be resorted to, in order that it may
be effective, it should be worn constantly, not only by day but also by
night. In theory, this would be the ideal resource but that in practice
the tuberculous patient would consent to the adoption of a measure
so radical is hardly conceivable. At best its application would in all
probability be limited to charity institutions in which the patients
could be subjected to the strictest discipline.

Supposed germicidal inhalations have long been exploited as cura-
tive of the actual disease, and those who pin their faith to these would
naturally seek by such means to render the germs innocuous during
their outward discharge. The writer has often pointed out the inefficacy
of such attempts in the rational treatment of the disease, and if further
reference to the natural limitation of inhalations and inhalants in
the disinfection of sputum-particle in their outward discharge is essen-
tial, it is necessary only to revert to the numerous experiments which
have been made with all sorts of chemical germicides in the efforts
to destroy the germs in sputum already discharged. A detailed
account of the results of such experiments appears in the review of a
paper by Steinitz, in another part of this Journal.

A more effective prophylaxis consists in the systematic use of anti-
septic mouth-washes which, while also limited in so far as concerns
any germicidal effect upon tubercle bacilli in the mouth, afford the
advantage of at least mechanically cleansing the oral cavity. If

employed at frequent intervals, we may reasonably expect to dinux48h
the number of virulent germs which would otherwise be projected in
the spray; and thus we may lessen to a considerable extent the dan-
gers arising from infectious droplets. Such a mouth-wash should be
used at least three times a day, preferably before meals, and in so far
as practical we should advise its employment as frequently as the
cough is attended by expectoration.

An additional efficacious precaution, consists in the holding of the
handkerchief before the Ups during coughing, sneezing, clearing the
throat, etc. Better than the, handkerchief are squares of cheese-cloth
which after treatment with a 5 to 10 per cent, solution of glycerine in
water, will retain sufficient moisture to prevent in a measure the dry-
ing of spray-droplets. After use for a reasonable length of time before
desiccation has occurred the cloth should be burned and substituted
by a fresh one. Japanese paper napkins, which are still cheaper, may
be used instead.

Inasmuch as all spray which is projected into the air, dries and
settles as a fine dust, proper room-hygiene is a factor of prime import-
ance in practical prophylaxis. Sweeping should not be permitted, but
all dust should be removed from floprs, woodwork and furniture with
damp cloths. If this is carefully done the danger of contagion will
be still further diminished.

Finally in order to prevent direct inhalation of projected droplets,
we may suggest the maintenance of a distance of a metre or more from
the patient, except at such times as necessity demands a closer approach
on the part of those in attendance.

SUPPLEMENT TO THE JOURNAL OF TUBERCULOSIS.

In this part the whole subject of Pulmonary Tuberculosis will be covered
by a continued series of articles written by Dr. Karl von Ruck to appear, in the
following order :

Article I — ^The Cause oi Tuberculosis, and l*he Conditions Which Pre-
dispose to its Acquirement. Article II. — ^The Prevention of Tuberculosis.
Article III. — The Pathology and Symptomatology of Pulmonary Tuberculosis.
Article IV. — ^The Diagnosis of Pulmonary Tuberculosis. Article V. — ^The
Prognosis of Pulmonary Tuberculosis. Article VI. — ^The Treatment of Tuber-
culosis, Dietetic, Hygienic and Symptomatic. Article VII. — ^The Climatic
Treatment. Article VIII. — The Specific Treatment. Article IX. — Laryngeal
Tuberculosis, its Diagnosis and Treatment. Article X. — Institutions for the
Treatment of Pulmonary Tuberculosis.

THE SYMPTOMATIC TREATMENT OF TUBERCULOSIS.

THE TREATMENT OF HAEMORRHAGE.

[Continued from Vol. Ill, Page 111.]

Such a mental state produces circulatory disturbances, just as
when from fever or from powerful emotions induced by other cauflea,
the heart action becomes excited, irregular and weak. The respira-
tion also grows irregular and superficial, tending to cause or to increase
pulmonary congestion by which the haemorrhage may be not only main-
tained, but even increased.

To obviate or to diminish such a result of hemoptysis, some authors
have recommended that all phthisical patients be made acquainted with
the fact that they are liable to bleed from the lungs, that they be
assured in advance that no serious harm will follow such an accident,,
and that at the same time they be given directions as to what to do in
case of its occurrence.

I doubt the wisdom of such a course and also the benefit to be
derived from it, and while it may be justified in individual cases these
are difficult to select. My own experience has taught me that most
patients who have previously suffered from hemoptysis without the
occurrence of serious consequences, become as much excited and
demoralized upon the advent of a new haemorrhage as they were in the
first instance. They often live in constant fear of a repetition and for
months thereafter are continually on the lookout for bloody expector-
ation. A seeming composure on the part of a patient who experiences

^ haemorrhage can not always be accepted as real. This fact I have
verified on numerous occasions with men who although they suppressed
practically all visible evidence of excitement, and even soxight to reas-
sure their anxious relatives, betrayed their agitation and fear by
marked pallor, by trembling hands, and by a small rapid pulse, symp-
toms which quickly disappeared upon my arrival and assurance that all
would be well.

A much better plan, in my judgment, is to instruct the patient
what he must do to avoid the occurrence of haemorrhage, from over-
exertion, by giving minute and detailed directions in regard to rest and
•exercise; and incidentally we should warn him that noncompliance
with directions may result in haemorrhage, stating that although not
•often serious, it is nevertheless to be guarded against and that haemor-
rhage is but rarely seen in patients who conscientiously follow advice.

Actually confronted with a pulmonary haemorrhage of a degree
that does not demand immediate interference for fear of serious con-
.sequences, our first step should be to assure the patient that there is
no danger, and we should justify this assurance by a perfectly calm
'demeanor, and by encouraging the patient to cough up the blood as
fast as he feels the inclination ; at the same time seeing to it, that he is
in a comfortable position (partly reclining upon a couch, easy chair or
bed), that he is provided with a large bowl or wash-basin in front of
him, into which he can easily expectorate without changing his posi-
tion more than by bending a little forward. While doing this we have
time to observe the effect of our assurance, to note the pulse and heart
action and consider what we shall do, if more active measures must be
taken. If the patient's fear is not allayed, some more visible means
for him to pin his faith to are required, and whatever this may be, it
^should have the advantage of being harmless. I have frequently seen
a prompt result from a hypodermic injection of water, or from the
administration of some reputed internal haemostatic before any
therapeutic result could be expected, but a small dose of morphia
with or without atropine can always be depended upon to tranquilize
the patient.

If the state of circulation does not offer an indication for treat-
ment in the manner hereafter to be considered, and we want to inter-
fere effectually by bringing such a haemorrhage promptly to cessation,
there is probably no more effective remedy than an emetic. As soon
as the patient becomes nauseated, the blood pressure sinks and the
haemorrhage ceases before or after the vomiting. The emetic has

also the advantage of safety and of causing simultaneous expectoration
of retained clots.

It is in the treatment of such slight and moderate haemorrhages
that a great number of drugs and other remedies have earned more or
less repute as direct and indirect haemostatics, which is bj no means jus*
tified by closer study and observation. On the contrary the whole list
of internal hapmatostics in which I include ergot and its preparations,
hydrastis, haemamalis, acetate of lead, and all other vegetable and min-
eral astringents, I believe to be without actual influence, and in so far as
their internal administration may cause gastro-intestinal disturbances,
or as in the case of ergot and lead, may act otherwise detrimentally, I
consider them actually harmful. I am well aware .that in thus sum-
marily rejecting these remedies I oppose a cherished tradition, and am
apparently at variance with the experience of many physicians, who
from: the empirical use of such remedies have witnessed times without
number the desired result ; just as I believed I had done in my early
experience. Many years of study and the advantages of observation
in several hundred haemorrhages which came under my notice in my
institution and consulting practice, have, however, convinced me, that
the great majority of pulmonary haemorrhages cease spontaneously
and that in perhaps not more than ten per cent, of those that I have
seen, was direct interference actually required. In such instanced,
however, the use of this class of remedies proved futile, and when
after trying one or more of them in succession the haemorrhage was
finally controlled, the termination appeared as likely to be due to the
use of the one as the other, that had before failed, either in the same
case, or in others. The only reasonable explanation, I think, is, that
in such instances as in most others the cessation of bleeding was due to
the diminished quantity of blood in the lungs, and to the lowered pres-
sure consequent upon the loss of blood itself.

In the more severe forms of haemorrhage, the state of the circu-
lation, as shown by the patient's color and pulse, and by auscultation
of the heart, affords often the indication for treatment. In urgent
cases the experienced physician must sufficiently comprehend the sit-
uation at a glance to guide him in his action. If the patient is pale
and has a weak rapid pulse, whether because of fright or from actual
loss of blood and beginning heart failure, cardiac stimulants are indi-
cated for the relief of the passive pulmonary congestion. Particu-
larly are cardiac stimulants to be employed if there is an accentuation
of the second pulmonary sound which in well marked venous conges-
tion of the lung is always to be noled, unless the right ventricle is also

losing its power. If the situation is not yet critical we maj succeed
in bringing about a better circulatory condition with digitalin and
strychnine, given in full doses, hypodermically. At the same time the
patient should be urged to take deep inspirations and hot applications
should be made to the extremities. If digitalin or strychnine are not at
hand a small dose of morplpa and atropine will usually act satisfactorily,
because of the primary stimulative effect.

Should conditions appear critically urgent and should the bleed-
ing continue profusely, I would in addition to these measures, resort
promptly to the ligation of the extremities, this being the quickest
means by which we can relieve the overburdened heart and diminish
active or passive pulmonary congestion by impeding the return of the
venous blood and by storing it in the veins below the ligatures. The
ligation is most effectually accomplished with elastic bands encircling
the lower limbs immediately above the knee, and in urgent cases, the
arms also in their middle portion, drawing the bands only tightly enough
to impede the venous circulation, just as in preparation for venesection^
In the absence of specially constructed bands with buckles, a common
elastic bandage answers equally well; this may be improvised from
elastic suspenders, or if no elastic fabric is available, an ordinary cotton
bandage which can be torn from the bed-linen can be made to answer
the purpose. In the cases in which I have resorted to this measure
the results were very satisfactory, the bleeding growing less and the
pulse improving promptly. If, however, the pulse should become
smaller and more frequent, or if the patient grows faint, the con-
stricted limbs must be partially released by loosening one or more of
the bandages. When the haemorrhage is controlled the bands should
be gradually removed, allowing an interval of 10 or 15 minutes after
the release of each limb. Patients are likely to complain of numbness
and pain in and below the constricted parts which, as well as the oedema,
disappears soon after the circulation ' is allowed to resume its nor-
mal course.

The administration of nitro-glycerine has been warmly advocated
by various authors but it is only permissible if there is still a good heart
action, with well marked power of the right ventricle; when the latter
has grown weak this remedy is contraindicated.

The use of digitoxin as a cardiac stimulant in this class of cases
has been recommended as being most prompt and effective. I have
no personal experience to offer, and have hesitated in its employment
on account of its bad effect upon the digestive organs which some
authors have emphasized as following its use. Sticker, however.

claims that this is due to impure preparations or^unsuitable administra-
tion, and recommends beginning doses of 1-300 to 1-150 of a grain in
solution of warm water, to be given by the rectum not oftener than
twice in 24 hours and only for one or two days.

In another class of severe haemorrhages, the clinical picture dif-
fers from the foregoing in that the pulse is strong, the patient is
flushed, or at least there is no pallor, and the haemorrhage appears to
be caused by active hyperaemia which is maintained by an overexcited
state of the circulation. This class requires arterial sedatives rather
than stimulants, and here it is that an emetic will prove most prompt
and satisfactory. If we have no urgent need of instantly moderating
the flow of blood to prevent suffocation, hydrochlorate of apomorphia,
hypodermically, in emetic doses of 1-10 to 1-5 gr. will lower the blood
pressure and relax the arterial tone as soon as the patient becomes
nauseated, and I have on several occasions seen a severe haemorrhage
stop entirely before the emetic effect occurred. In the absence of
apormorphia, which has the advantage of quick action because it can
be given hypodermically, other emetics may take its place. In their
choice ipecacuanha deserves preference because it is not irritant to the
gastric mucous membrane, as are the sulphates of zinc or copper.
Tartar emetic is too slow in its action. As an additional sedative to
the heart, the effect of ice is reliable ; it may be given internally, or an
ice bag may be applied over the heart or over the supposed seat of the
haemorrhage; either or both will aid in allaying the vascular excite-
ment. Veratmm viridi has also been used successfully for this pur-
pose.

In the presence of immediate danger ligation of the extremities
should be resorted to as the first step. Before knowing the advantage
of this measure I have, in one such instance, resorted to venesection,
with a most prompt and satisfactory result ; after the removal of about
12 ounces of blood the patient grew faint and the haemorrhage stop-
ped.

Upon the theory that it lowers the blood pressure and reduces
pulmonary congestion, atropine alone in large doses (1-50 gr. to 1-25
gr.) has of late years been highly recommended in all forms of severe
pulmonary haemorrhages, but I must confess to have lacked the cour-
age to give the doses which are claimed most effective, fearing the
mental and physical excitement which they might produce and which
would defeat the first step in all treatment, namely the securing of
absolute mental and physical rest. In one instance a number of years
ago, when T gave only 1-100 of a grain to check night sweats, the

patient grew perfectly wild and uncontrollable, springing out of bed
and attempting to jump from the windows, and otherwise behaving in
a manner that I would of all things avoid in the presence of haemor-
rhage. It took several hours before I could control this state of wild
delirium, and I have ever since been extremely cautious with this drug,
giving it first in 1-200 or 1-150 grain doses and feeling my way to
larger ones if these proved ineffective. When combined with mor-
phine the state of excitement is less liable to occur, but I should not
exceed 1-100 of a grain for a first dose even when so combined, imless
I knew something of my patient's previous toleration*

To siunmarize my experience I may state : —

1st. That internal haemostatics are of no value in pulmonary
haemorrhage.

2nd. That slight and moderate and some severe forms of pul-
monary haemorrhage cease six>ntaneously under rest, and the more
readily, if we can remove the element of fear and excitement in the
patient by a quiet and composed demeanor and by giving proper assur-
ances as to the absence of danger. To this end the administration of
some harmless remedy may, on account of its moral effect, become an
aid. A small dose of morphine, vdth 1-100 gr. of atropine allays both
the cough and the patient's excitement, and an emetic will as a rule
bring the incident promptly to a dose.

3rd. That in severe, profuse or long continued forms of haemor-
rhage, which by their degree, in loss of blood, or rapidity of its dis-
charge, imply more or less danger, we should distinguish between the
presence of active or passive pulmonary congestion by observing the
state of the circulation and apply cardiac stimulants, if the heart action
is wekk, while sedatives should be given if there is vascular excite-
ment ; we should in either case resort to ligation of the extremities, if
danger is imminent, as a means for immediate control.

4th. That if in. doubt as to the use of stimulants or sedatives, the
latter deserve preference, apomorphia being the best and quickest in
its action ; otherwise a small dose of morphia with atropine 1-100 gr.
should be given h3^podermically.

The treatment of haemorrhage as above described is based upon
the indication to diminish passive and active congestion, and to lower
the vascular pressure in the pulmonary system. To meet the further
indication of favoring the formation of clot at the orifice of the bleed-
ing vessel subcutaneous injections of a solution of gelatin have been
reconmiiended and employed with apparent success, in otherwise uncon-
trollable cases. In a normal salt solution (6-10 per cent.) two per cent.

of gelatin is dissolved^ and three to six ounces of the solution are
injected into the subcutaneous tissues. The injections are said to bo
painful and to be contraindicated in all structural diseases of the kid-
neysy in the presence of which haematuria has been observed.

With the same object in view local astringents have been used
by inhalation of a spray from an atomizer. A solution of perchloride
of iron in the strength of ^ to 1 per cent, is most conmionly employed.
While I have seen apparent success from such inhalations in instances of
frequent recurrence of slight oozing under which a few mouthf uls of
blood were expectorated several times during the day, I have in at least
one instance seen a decided recurrence of haemorrhage caused by cough
and dislodgement of clot induced by the inhalation. Inhalations are
obviously impracticable during the progress of any but slight degrees
of haemorrhage^ and their use after the haemorrhage has ceased^ in
order to prevent recurrence seems of doubtful advantage^ especially
if the inhalation causes irritation and cough which it frequently does
even in ^ per cent, solution.

The after treatment is often all that we are called upon to man*
age ; especially is this so in private practice^ where the physician has to
be summoned from a distance. Unless after severe or profuse haemor*
rhages, we usually find the patient to be comfortable and tranquil, his
mental state having improved with the cessation of the free expectora*
tion of blood. If the haemorrhage has, however, been very copious,
we may still find ourselves confronted with the serious problem of
gradual suffocation from obstruction of bronchi by clotted blood. If
this threatens, the patient has a livid appearance, the inspiration is
short and gasping, gurgling rales are usually audible at a distance, the
cough is irritable, frequent and unavailing, or there may be expectora*
tion of bloody tinged mucus, or of small quantities of dark liquid blood.
Such patients should be made to take deep inspirations and if, as usual,
the pulse is small and frequent, stimulants should be administered
hypodermically, brandy, whiskey, or even sulphuric ether being proper
for this purpose. In a case of this kind I succeeded in causrog the
expectoration of the bronchial thrombus by letting the patient inhale
sal ammoniac from a bottle held to his nose and mouth. The clot was
expelled with a violent attack of coughing, which was followed by
expectoration of more partially clotted and clear blood, after which
the respiration and general condition of the patient improved promptly.
Should the pulse be still of fair quality a free emetic dose of apo-
morphia may be tried in the hope that with the vomiting and straining
the clots will be dislodged and expectorated.

Another complication of haemorrhage which may present itself
is acute anaemia which may be of two forms. If , as is most frequently
the case the cause is a mechanical one depending upon deficiency in
bulk and quantity of blood in circulation, an attempt should always
be made to augment the circulatory fluid as quickly as possible.
Nature does this herself to a sufficient degree if but a moderate amount
of blood has been lost^ but when the patient becomes drowsy, when
the face becomes pale and pinched, and the eyes recede into their sock-
ets, and when in addition to these symptoms muscular twitching occurs,
respiration grows shallow and hurried, the pulse small and fluttering,
we can not hope that she will succeed in her task without artifldal aid.
To anticipate such a train of symptoms, after severe or profuse haemor-
rhage, I am in the habit of giving a warm salt water enema of about a
pint, as a routine practice. Should the symptoms appear more urgent,
or grow so after these measures have been adopted, subcutaneous injec-
tions of a pint to a quart of normal salt solution can usually be made,
even if the exact apparatus is not at hand. In an instance that came
to my notice the attending physician employed a Davidson syringe to
the discharging end of which he attached his hypodermic needle and
succeeded in injecting a sufficient quantity to relieve the patient;
neither did he observe any abscess, although there was no time to give
the syringe, which had been in use in the family, any other than rapid
cleansing by the passage through it of hot water. While this may be
superfluous in many cases, it is certainly a harmless procedure which
may obviate the necessity of other measiures for which the required
instruments and apparatus may not be ready at hand. The patient's
thirst is of course also satisfied, and a horizontal position advised the
moment the patient begins to feel drowsy or faint, or whenever circu-
latory deficiency is manifested by the character of the respiration and
pulse. Intravenous infusion of physiological salt solution, while sim-
ple enough in application demands absolute asepsis which would at
most be available in hospitals and institutions. I have never had
oceasion to use it in any of the cases of pulmonary haemorrhage which
I have been called upon to treat.

In instances in which repeated profuse bleeding has occurred, at
short intervals during which physiological absorption of fluid has never-
thdess tended to make good the bulk of blood lost, a successive haemor-
rhage may at once cause an acute anaemia of still more serious import
which is due not so much to the diminished quantity of fluid in circula-
tion, but to deficiency in number of the oxygen-carrying red corpuscles.
In other words a state of hydraemia is induced. Saline injections are

naturally useless under such circxmiBtances and ligation of extremities^
serves only to make matters worse. In these cases we are practically
powerless and the only remedy is transfusion of homologous living
blood. The f itilures reported, and the practical difficulties and the acci-
dents incidental thereto are such that few would care to undertake it
even if the means were ready at hand which, of course, they seldom are.

Fortunately there are relatively few pulmonary haemorrhages in
which death occurs as an immediate consequence. In my own casea
an immediately fatal termination followed in only three instances, each
time from suffocation, before any effectual aid could be given. In
seven the bleeding was so severe as to require ligation of the eztremi- •
ties. Venesection was resorted to in one, apomorphia in about ten,
while in about half of the other cases a small dose of morphia with atro*
pine was administered.

Immediate danger from the haemorrhage itself having passed, the
after treatment has for its object the prevention of recurrence, the
removal of retained blood clots and aspirated infectious material, and
the restoration of the patient's blood state, and of the loss in weight and
strength.

As to the primary object of preventing recurrence, we are most
likely to be successful in cases where the haemorrhage has occurred
from physical overexertion in the absence of softening and extension
of destructive changes in caseous deposits, whereas the bleeding is more
liable to recur when the haemorrhage appears without apparent excit-
ing or contributing cause, especially in connection with softening and
cavity formation. Kecurrences are also to be anticipated when pneu*
monia follows the haemorrhage, during which I have frequently wit-
nessed the daily expectoration of a few ounces of frothy, clear blood.
The first essential in preventing a recurrence is rest, and this should
be absolute, in bed, and should be the more rigidly enforced and the
longer maintained in those cases in which experience has shown that
we have reason to be on guard. In milder forms and in those in which
the absence of fever justifies the assumption that softening and excava-
tion does not stand in relation to the haemorrhage, it is my custom to-
keep the patient in bed until the expectoration has been entirely free
from blood or bloody color for 86 hours thereafter. In others the
existing fever naturally demands rest in bed, and I am sure that 10
days is not too long a period to enforce, after which we may assume
that sufficient organization of the clot has occurred to prevent a recur-
rence of bleeding from the same vessel. For the first 36 or 48 houra
especial watchfulness is necessary, the patient must be kept free from

97*

all mental excitement, and visitors should be excluded. The diet
should be light and non-stimulating, and all food and drinks given^
should not be heated above 100^ F. It is well to secure daily free and
easy evacuation of the bowels, especially if morphia has been given to
control the haemorrhage, or if opiates are used to prevent excessive
oough thereafter. For this purpose Apenta, Carlsbad, or other ape-
rient mineral waters are most useful. Straining at stool should be
prohibited and enemata should be employed to aid the evacuation if
necessary. The room should be kept cool, but not cold and plenty of
fresh air and sunshine should be admitted.

After most haemorrhages there will be, during the first day or
two, some slight expectoration of blood, or of bloody sputum at increas-
ing intervals ; whatever cough is necessary for the purpose of expec-
toration must not be interfered with. Only when the cough is dry or
when irritation is complained of in the throat and bronchi to a degree
that the patient can not resist the cough, or when it is otherwise severe
or paroxysmal, should measures be taken to moderate, or if expectora-
tion is absent to suppress it.

For this purpose I prefer heroin or codein and by the hypodermic
method rather than by the mouth. If I fear that infectious material
has been aspirated into the deeper portions of the lungs during the
haemorrhage, I seek its discharge by the use of expectorants, giving
apomorphia in doses of 1-40 gr. and increasing the doses until the secre-
tions are materially augmented or become of more fluid consistency,
without, however, causing nausea. Instead of apomorphia I have
found muriate of ammonia with syrup of licorice to answer the same
purpose. Although the benefit from expectorants is not susceptible
to proof, I can say that I have seen fewer pneumonias since using them
after severe haemorrhages, than I did before, and if the favorable
reports and my own favorable experience of the action of kresatol or
carbonate of guaiacol in the treatment of pneumonia is further con-
firmed, we may hope that their administration for the first three or four
days in the cases under consideration may still further reduce the fre-
quency of this serious sequella to haemorrhage.

Li instances where the retained coagula appear to have undergone
putrefactive changes, as evidenced by the fetor of the expectoration,
the internal administration of rectified spirits of turpentine and the
inhalation of glycozone from an atomizer have afforded satisfactory
rdief.

The administration of iron preparations on account of the loss of
blood, and the return to a full diet, should not be undertaken hastily.

and under ordinary circumstances it is best to delay until all danger
from haemorrhage is past. If then the quality of the blood is shown
to be deficient by examination, peptomangan, and a more liberal dietary
are in order. Many patients make up the quality and quantity of the
blood in a very short time, and especially those who are free from fever
and other complications, rarely show deficiency in blood count or
haemoglobin per cent, as compared with previous records by the time
they are allowed to gradually resume their out of door life and exer-
cise.

With plethoric patients who have cavities, moderate haemorrhages
occur at times at regular intervals; as in such individuals there is
usually no active progress of the disease and but little or no expectora-
tion, their haemorrhages are rarely attended with danger. In such
eases a continued non-stimulating and somewhat restricted diet, ape-
rient waters, with as much systematic exercise as is otherwise permis
sible, are indicated until through shrinking and cicatrization of the
cavity walls recurrences will cease.

Internal haemorrhage has been observed in connection with soft-
ening of a caseous focus that has as yet no connection with a bronchus ;
the diagnosis is, however, obscured by the coexisting lung disease, and
the evidence of increased percussion dullness and dyspnoea is usually
referred to other causes.

Haemorrhage into the pleural cavity occurs at times in connection
with pneumothorax which may be presumed to be the case when within
half an hour or an hour a liquid exudate appears in the pleural sac of
the affected side. The treatment consists in the application of an ice
bag over the seat of the ruptured cavity, if its location can be deter-
mined, otherwise it is symptomatic, and the haemorrhage may stop from
compression of the lung, if air enters the pleural sac at the same time.
Such a result has been sought in severe and repeated haemorrhages,
without perforation, through intentional compression of the bleeding
lung by the application of Dr. Murphy's method which consists in the
introduction of nitrogen gas into the pleural sac of the affected side,
and some successful cases have recently been reported.

THE TREATMENT OF PLEUKIST.

Pleurisy is so frequent a complication in the course of phthisis that
few patients escape altogether the experience of its symptoms, and in
those in whom the lung affection progresses to an advanced stage more
or less extensive pleural thickening and adhesions are present. Even
in the early stages of tubercle-formation if the disease reaches the
periphery of the lung, the pleura participates in the subjacent inflam-

matory processes and the patient complains of various painful sensa-
tions — often of only a dull ache or soreness which at times becomes
more acute or stitch-like on deep inspiration. These pains are so fre-
quently mistaken for myalgia or for those of muscular rheumatism,
when located in the upper lobe, or for intercostal neuralgia when at a
lower level, in instances in which no other marked symptoms of phthisis
are manifest, that they should receive much more discriminating atten-
tion as diagnostic signs in the early stage than is usually given to them.

In the majority of instances pleurisy occurring in the course of
pulmonary tuberculosis is circumscribed and of the so-called dry variety.
In location it usually corresponds to a subpleural tuberculous focus or
to an area of lung which is the seat of softening and impending excava-
tion.

In certain cases in which tubercle is forming and in others in
which destructive changes are occurring in the subjacent lung tissue of
the upper lobe, pleurisy may supervene at this point without the expe-
rience on the part of the patient of any symptoms whatever. At the
same time or soon thereafter the patient may complain of pain at a
lower level, often perpendicularly below the process described as occur-
ring in the upper lobe. The latter pleural involvement would seemingly
be explained on the ground that it is secondary to the occurrence of a
primary painless pleurisy above, in which the associated microorganisms
have penetrated the pleura and have gravitated between the two
pleural surfaces toward the base of the lung.

A more frequent complication of phthisis than pleurisy we are
not called upon to treat. In the consideration of the therapeutic meas-
ures applicable it will be well to deal first with the dry forms and lastly
with those in which there is effusion.

The treatment of the circumscribed dry form which is most fre-
quently met with resolves itself largely into efforts to relieve subjective
symptoms and to prevent extension. As I have stated in the chapter
on the pathology and symptomatology of pleurisy (Vol. II, pg. 89) this
form is not so exquisitely painful, nor is it attended by marked general
symptoms as is the case at the onset of the acute exudative variety. In
many instances the aching or stitch-like pain on deep breathing, cough-
ing or change of position, is all that attracts attention, the temperature
being elevated but slightly or not at all.

In such cases the external application of antiphlogistine or of
counter-irritation in the form of the flaxseed and mustard poultice,
together with the avoidance of all active exercise and deep breathing,
is usually all that is required for relief. Even without any interfer-

100

ence the BymptomB, as a rule^ disappear in a few dayi. If the pain is
chiefly experienced on coughing and the latter is a prominent feature
the use of heroin in small doses — 1-16 gr. to 1-12 gr. hTpodermicaliy^
or if the cough is dry and irritating, in the form of glyco-heroin — ^wiU
usually prove effective without disturbing the digestion. When the
pain is very severe and always when the temperature is elevated, rest
in bed is necessary, with restriction of the diet according to the degree
of fever.

Again when there is very severe or excruciating pain, and the
cough is frequent and aggravating in cases in which the involved area
corresponds to the lower lobe, immobilization of the chest affords often
complete and always partial relief. Immobility is best secured by
strapping. For this purpose strips of adhesive plaster, 1^ inches wide,
and cut long enough to e]^nd half way around the thorax, are
employed. Starting on the back an inch or two on the opposite side of
the spine, the strip is drawn tightly around the affected side to the
sternum and fastened during forced expiration. After the first is fixed
in position a number of others are applied, in like manner during forced
expiration, one overlapping the other successively by a quarter or half
an inch. The patient should avoid all efforts at deep inspiration until
all the strips are firmly placed in position.

Morphine should be employed only in severe cases when other
measures have failed to afford relief.

The circumscribed dry form may, by extension and persbtenoe in
a sub-acute degree, lead to an extending chronic form which may finally
involve the entire pleural sac. In this chronic, extending, dry variety
there usually occurs a fibro-plastic exudate and extensive pleural thick-
ening. While the percussion note in the circumscribed dry form
remains unaltered, in this form a considerable amount of dullness
results, which is especially to be detected on gentle percussion.. The
absorption of the exudate is an important indication, because the lung
haa become practically immobUe and the respiratory surface wluch on
account of the primary pulmonary disease is already impaired is stiU
further encroached upon. In chronic dry pleurisy unaccompanied by
fever, it is not absolutely essential to enforce rest in bed; the patient
may be out of doors but should be kept quiet, all exercise being pro-
hibited.

Rest in bed is, however, preferable, because arrestment of the
pleural inflammation is to be the more speedily obtained the quieter
the patient is kept, and because we may then have recourse to continued
and prolonged counter-irritation by means of hot flaxseed poultices to

ioi

wbieh enough muBtard haB been added to maintain decided redness of
the skin. I prefer poulticing to blistering as well as to painting with
idoine, because the effect of the former can not be continuous^ too long
interrak being required between applications and because from paint-
ing with iodine my results have never been decided enough to convince
me that it really accomplished any good.

Acute forms of pleurisy with serous or sero-fibrinous effusion,
which usually begin with considerable fever and sometimes with a
chill, may occur abruptly or may follow immediately upon the occur-
rence of the dry circumscribed variety. In a very few instances I
have seen an acute inflammation, followed by abundant serous effusion,
occur suddenly in the course of a chronic extending fibro-plastic
I^eurisy. The pain, in the acute forms with effusion, may often be
controlled by counter-irritation. When this form makes its appear-
ance abruptly there is at the beginning no effusion yet formed, and in
this stage strapping may be resorted to, in order to diminish or remove
the pain. But if the chest be strapped great watchfulness must be
exercised to detect the effusion which is likely to appear in the course
of a few days. As soon as fluid is present in the pleural sac the pain
ceases and the straps which are now no longer necessary for its relief
must at once be removed to permit full expansion of the chest wall and
to prevent more extensive compression of the lung itself. Of course
from the onset the patient should be kept absolutely and uncondition-
ally at rest; this is the most important essential in the treatment of
acute pleurisy with effusion. Cough must be allayed by heroin, codeine
or even morphine, the choice being in the order named, but only when
required on account of severe pain. I have also employed papine,
which has given me very satisfactory results and which possesses the
very desirable advantage of not causing constipation.

The fever needs no interference unless it reaches 108° or 104°
when fractional doses of thermol or phenacetin may be given — 1 gr. to
2 gr. every two or three hours until the fever begins to decline, when
less frquently repeated doses suffice. The employment of the coal-tar
antipyretics is indicated only when the degree of fever is excessive, and
this is usually the case for the first two or three days only. They
should not be administered over long continued periods under any cir-
cumstances, and of course the condition of the heart as well as that of
tlie patient in general must be taken into consideration. Applications
of cold water to overcome the pyrexia are most undesirable. In fact by
causing deep inspirations they not only aggravate the painful symp-
toms but tend to delay recovery. In the cases which I have treated

lOS

I feel quite sure that hot flaxseed and mustard poultices have been
beneficial ; they certainly make the patient much more comfortable and
tend to promote the absorption of the exudate.

Internal remedies such as diaphoretics, diuretics and iodine
employed with the view of hastening absorption of the effusion I have
discarded years ago. Whatever their merit may be in the treatment
of pleurisy other than that which complicates the course of phthisis, in
the latter their prolonged use generally does harm by interfering with
the appetite and digestion.

If after the third week the effusion has not diminished, aspiration
in advisable although there may be no urgent sympt<»ns. My expe-
rience has been that by aspiration the duration of the affection is mate-
rially shortened and what is of much greater importance the final result
as to the subsequent functional activity of the lung is much better. An
expectant course is unsatisfactory because absorption is often a very
tedious process, because there is apt to remain much more fibro-plastic
residue and because the lung is decidedly more liable to remain penna-
nently crippled than when aspiration is early resorted to.

Purulent exudates require surgical measures which it is not my
purpose here to discuss. However, I wish to record a very exceptional
experience with two cases in which I removed by aspiration 800 c. c.
and 1100 c. c. respectively, of a purulent effusion, expecting to resect
and drain later. Resections proved unnecessary as these patients naade
good recoveries without further interference.

The after treatment of exudative pleurisy with a view of restoring
to functional activity the more or less crippled lung is of very great
importance ; this may be instituted when the fever has subsided, after
the effusion has been removed or has been absorbed, and when pain has
permanently disappeared upon as deep inspiratory efforts as the patient
can make, and finally if no contraindications exist. The expansion
of the compressed and retracted lung and the final restoration of its
functional activity is best promoted by the systematic use of the pneu-
matic cabinet which at the same time prevents the organization and con-
traction of adhesions. Care must, however, be exercised not to apply
too much pressure in the beginning; my rule is to start with a differ-
ential pressure of only one inch on the water scale, to maintain this for
a week and then to increase very gradually. Upon the occurrence of
the slightest pain, the sitting should be stopped, and should not be
repeated until after a few days' intermission. At first the sitting
should not last over five minutes, but they may be lengthened to ten
minutes in the course of a month. With these precautions I have never

108

observed an exacerbation of the pleurisy. In the absence of the pneu-
matic cabinet systematic breathing exercises should be employed, but
they ^ould be strictly prescribed and limited. Denison^s in-and
exhaler will be found very useful for this purpose.

THS TBBATMEKT OF PNEnMONIA OOHPLIOATINO PHTHtSIS.

Intercurrent pneumonic inflammation is a much more frequent
complication in the course of pulmonary tuberculosis than is apparently
conceded.

In many instances it initiates the phthisical stage, developing upon
a latent tuberculous deposit in the course of acute bronchitis and espe-
cially in that of influenza. In the section on pathology and symptoma-
tology I have referred to this subject at some length ; here I may add
that apart from inflammation of the lungs, incidental to influenza, etc.,
in the course of phthisis, pneumonia is caused most frequently by aspira-
tion of sputum during coughing, and by its gravitation during sleep.
The pneumonias which follow haemorrhage and constitute so unfavor-
able a scquella of its occurrence are produced in like nlanner, the liquid
blood acting as the vehicle, which, more or less mixed with the sputum,
is aspirated into the smaller bronchi.

The pneumonic area is often confined to but a few lobules, when
it^ diagnosis by physical examination may be very difficult, or even
impossible; in not a few instances, however, considerable lung portions
become involved, and several foci may exist in one or in both lungs. In
' other cases pneumonic areas occur in the peripheral tissue of recently
formed cavities, and this is undoubtedly due to penetration of the cavity
walls and invasion of the adjacent lung by pathogenic microorganisms.

The diagnosis is always greatly facilitated by a carefully kept tem-
perature record, since the pneumonic complication is attended by a
continued form of fever for at least the first few days. The fever
which may have previously been absent or has pursued a hectic type,
rises abruptly, perhaps with a distinct chill, or with chilly sensations
and reaches 102° F. or over on the first day. The temperature does
not return to the normal or subnormal on the following morning
although the fever remits, just as it does in pneumonias of a catarrhal
type, apart from phthisis, the degree and duration of the fever depend-
ing upon the amount of the lung involved and extension to adjacent
lobules. In the pneumonias complicating tuberculosis, we do not of ten
observe the recrudesences which occur in the course of acute capillary
bronchitis, because new areas become involved only after the aspiration
of new infectious secretions, which does not happen frequently in the

104

same patient. We therefore find that the fever moderatea as a mbi
on the second or third day and that it usually subsides in the course of
a week. If we can exclude acute, exudative pleurisy which is generally
not difficult; such intercurrent continued fever in the course of phthisis
will be found to be due to pneumonia in almost all instances^ and if
reliable records exist as to the previous auscultatory and percussion
findings, painstaking and repeated examinations of the chest will^ as a
rule, confirm this view.

The treatment of such pneumonias deserves the greatest attention
because its success or failure will markedly influence the future course
of the patient's illness. Absolute rest in bed is to be enjoined. Moist
heat, with or without counter-irritation, should be applied over the
pneumonic area in the form of mustard and flaxseed poultioes, or of
antiphlogistine.

If the fever is very high and prevents sleep, and if the heart fur-
nishes no contraindication, fractional doses of thermol or of pyramidon
can be used with advantage for the first and second day, when the
fever naturally declines. Until several years ago, I had much faith in
the administration of one or two full doses of quinine (10 to 16 gr.)
and while I still believe its use to be valuable, I have for the present
abandoned it in favor of full doses of kresotal which has appeared to
have a decided influence in diminishing the ordinary duration and in
bringing about resolution of the pneumonic process. My experience
extends now over upward of 20 cases, in none of which the pneumonic
area progressed to caseation as is so apt to be the case in pneumonias
complicating pulmonary tuberculosis, especially if the inflammatory
area is already the seat of tubercle. This may be of course, a fortunate
coincidence, and I would still consider it so were it not for the favor-
able results reported by various clinical writers, in other forms of
pneumonic inflammation.

In patients already exhausted by reason of the advanced stage of
their pulmonary phthisis (and they represent the greater number in
which these pneumonias occur) the use of stimulants, strychnine 1-30
to 1-10 gr. three times a day, and of alcoholics, or of both is often neces-
sary. The patient's nutrition should have especial attention, and
recourse should be had promptly to rectal feeding if the amount of food
taken by the stomach appears inadequate.

[to be continued.]

THE

Journal of Tuberculosis

VOL. IV APRIL, 1902 No. 2

ORIGINAL CONTRIBUTIONS.

LIGHT— rrS THERAPEUTIC IMPORTANCE IN TUBERCULOSIS
AS FOUNDED UPON SCIENTIFIC RESEARCHES.

BV J, MOUNT BLEYER, M. D., F, R. A., M. S., LL. D., VICE PRESIDENT AMERICAN

CONGRESS OF TUBERCULOSIS.

It ifl a trite saying that 'There is nothing new under the sim!''
Like many other familiar phrases, this is. frequently uttered without
any real perception of its scope. Nothing neWy indeed, and yet the
world moves ever onward 1 Then what is progress, or is there anything
or any idea to which the word progress may be applied? Every now
and then the world is electrified by some new idea, or some new dieh
covery I Then, lo I some delver in ancient lore, some seeker in forgotten
mines shows that the new idea is even old, perhaps the new discovery
nearly as old as the world itself. Facts are ascertained, demonstrated,

taught, learned and forgotten. Theories, vague and uncertain,

even in the minds of their weavers, are accepted for science 1 Then, lo I
the old forgotten facts spring again into view and the theories flee, to
be forgotten in their turn, only with this difference, that there is no
resurrection for them I

It is not very many generations since the world knew nothing of
the solar system, its marvelous revolutions and the laws that govern
its sun, moon, stars and planets. Sir Isaac Newton made some astound-
ing discoveries, and there was doubt, astonishment, consternation. The
world was not unwilling, but unable to believe. To-day, men look
back and wonder how any one ever believed otherwise than in accord
with the now accepted science of astronomy which has acquired a count-
less number of facts since Newton assigned to our sun its rightful

106

place and authority in the Bjatem of astronomy that is ahnost an exact
science.

Since Newton's daj^ it has been ascertained that numy centuries
<bef ore, even in the sixth century before the era of the ^Sun of Right-
eousness/' the famous Ionian philosopher, Anaximander, the first sys-
tematio writer on philosophy, had an inking of some of the marvelous
facts of astronomy. Strangely mixed with wild theories, were the ideas
conceived of the solar center and its relation to the earth and heavenly
bodies revolving around it. Then we learn that the great Pythagoras
actually knew all the chief facts concerning the movements of the sun,
the stars and the planets. He even knew that the stars were suns of
systems like ours, and i^dvanoed the theory that the planets are worlds,
cheered and animated with life, similar to, if not like, ours; he was
also acquainted with the two physical forces, attraction and repulsion ;
nay, he knew what modem science has not fully rediacovened ; that
the visible suns were emanations from and dependent upon an invisible,
original, central sun, the sun of the universe, the celestial power whence
the forces of nature are derived. We learn that from time to time,
there were others who knew more or less of the truths which science
proved, even before the time of Copernicus whose knowledge was mar-
vielous, and of Oalileo, who had to answer to the Boman heirarohy for
knowing more than the Church. Indeed, so much of the Newtonian
philosofdiiy do we find in the ancient, that we cannot doubt that he had
been exploring the old mines of cabalistic lore, and reached his great
discoveries by following up dews gained therefrom.

But the special purpose oi this paper is to promote the well*beiiig
of mankind in this probationary world, by advocating light and its rays
AS the great remedial agent for the human organism when from any
•cause whatever, internal or external, the equilibrium of health is dis-
turbed and disease wastes the body and deranges the mind: — nay,
even when there is no clearly defined disease, but only feebleness and
an indisposition for physical and mental effort. Of course to apply
any remedy successfully, it is essential to know the characteristics and
qualities of that remedy, and the features and functions of the organ-
ism in the condition of health. There are idiojsyncrasies or differences
in individuals, but the human organism in health, is much the same,
not only throughout each race, but even throughout the family of man ;
and while some medicines act promptly and effectively in some eases,
refuse to p»ct in others, and act injuriously in still others where the
symptoms are identical, yet light and its rays will be found exceptional

in this respect ; and they seldom fail to effect just what they are des-
igned to effect, when rightly administered. We can attribute this excep-
tional eficacy of light to the fact that it is essentially and especially
nature's remedy, and therefore, peculiarly adapted to assist nature la
banishing disease and restoring health.

Bacon declared : — "There can be no real knowledge but that which
is based on observed facts;'' and the undisputable truth of this fact
has been admitted by all eminent thinkers since his time.

A fact new to man's knowledge — ^the blackening of a white salt of
silyer presents itself and naturally the discoverer seeks to find the cause
to which this phenomenon is due. The salt of silver remains perfectly
white as long as it is kept in darkness; but it blackens when exposed to
the sunshine. Consequently the change of color, which is all that was
at first observed, appearing to be connected with light, calls for an
interpretation of thei phenomenon. Man starts to solve the problem,
forms an hypothesis and says : "The calx of silver separates the phlogis-
ton from the light and retains the superfluous phlogiston of light.''
Men of science have changed their views ; but their mode of reasoning
on this phenomenon is as much guided by preconception as was that of
Sched.o^ when he was disposed to refer the decomposition of chloride
of silver to phlogiston.

Conjecture is a process, common to every mind; we all frame
hypotheses as we endeavor to advance from effects to causes. The
strictest inductive philosophy allows of this; but the hypothesis
must not be permitted to take the place of a theory, which is an explan-
ation based on a large number of well observed facts. Newton's funda-
mental rule was: "JTo more causes, nor any other causes of natural
effects, ought to be admitted than such as are both true, and suflcient
for explaining their appearances." To account for many of the phe-
nomena of light, philosophers have conjectured that the unknown
something to which they are due has a wave motion, that the eSher per-
vading aU space, being set in vibration or tremor, affects the eye
with the sensation of light. Since this hypothesis explains the greatest
number of luminous phenomena, it is generally received. However,
it must not be forgotten that we arrive at this hypothesis by reasoning
from analogy. If we cause a stretched string to vibrate, its pulsations
are communicated to the surrounding air, and the waves thus produced
beat upon the auditory membrane and produce sound. We know this
fact of the existence of the air; the fact of the vibrating cord; and
if we place some peculiar arrangements of mobile bodies between the

108

cord and the ear, we prove that the air partakes of the undulations of
the string. Upon a fancied analogy, hypothesis creates the ether^ and
then sets it vibrating to produce an effect on the eye of a similar order
to that which the air produces on the ear — ^that is undulations, in one
case, give rise to sound, in the other to light. A most eminent European
thinker has written : ^'Kotwithstanding all arbitrary suppositions, the
phenomena of light will always constitute a category sui generis, neces-
sarily irreducible to any other ; a light will be forever heterogeneous to
t motion or a sound."

Let us, for example, take the strange fact that chloride of silver
darkens upon exposure to sunshine, or to daylight; that is what w&
have to examine into. We may take this simple phenomenon of change
as representing all that I shall bring to your notice in this paper, the
differences being only of degree. Since this white salt of silver will
not darken in the absence of light, it was reasonable that the change
should be referred to the luminous element ; hence those pictures pro-
duced in the camera by the influence of the solar rays have been called
photographs. When, however, we proceed with an examination and
clearly understand all the conditions under which chloride of silver
changes color in the sunlight, we cannot fail to observe the several
peculiarities following :

1st. Those rays which give the most light — the yellow and the
orange rays — will not produce change of color in the chloride of silver^

2nd. Those rays which have the least illuminating power — the
blue and violet — ^produce the greatest change, and in an exceedingly
short space of time.

8rd. The rays which pass through certain yellow glasses have no
effect on chloride of silver.

4th. The rays which pass through very dark blue glasses, rapidly

change the color.

The yellow glasses obstruct scarcely any light; the blue glaaaes^
may be so dark as to admit of the permeation of only an exceedingly

small quantity.

5th. Where there is no sensation of light under ordinary circum-
stances, beyond the violet rays of the spectrum, the chemical change is
speedily produced.

Reasoning upon these facts and some others of a still more strik-
ing character known to us, it appeared to M. Berard that "solar light
consisted of three substances," to which severally belonged, "the cal-
orific chemical phenomena." This hypothesis did not, however, receive

109

any support from the physiciets of his time, and the weight of several
eminent names was broi^ht in support of the opposite view. The emi-
nent Dr. Toung^s experiment demands an attentive consideration how-
ever, though it proves no more than this, that, as in the ordinary
refracted spectrum, the chemical action is found at its maximum about
the region of the violet rays; so in the interference spectrum, the
chemical change is confined to the violet rings.

We must certainly come to the conclusion that the rays which
produce the chemical changes under consideration, are subject to the
laws of refraction and interference like light. But, if they were light
rays, it cannot be conceived why, in the yellow, and therefore most
luminous rings, no chemical change occurred.

Again M. E. Becquerel and Prof. Stokes have proved that the
chemical impressed spectrum — over those spaces which are more
especially chemically active — exhibits inactive lines which exactly cor-
respond with the dark lines of that same portion of the spectrum when
rendered luminous. This, however, proves no more than that the cause
which occasions the absorption of light along certain lines does, at the
same time, occasion the absorption of the principle to which the chemi-
cal agency is due. This view, as will be seen in the sequel, received also
the support of M. Arago, who, although most favorably predisposed
to urge the theory of undulations, wherever it was posible to do so, did
not fail to perceive that the phenomena of light and chemical action
were heterogeneous.

"That there exists some, one, all-pervading principle — an ether
— ^which may, under different conditions of motion, give rise to effects
of a dissimilar character, is a probability which is not denied; it is,
however, contended that the facts observed do not support such a con-
jecture in connection with the chemical changes produced by the solar

rays.''^

"The undulatory theory supposes heat — ^I refer here, entirely to
the conditions of the prismatic spectra — to be the result of a set of
vibrations of a certain length and rapidity, and the ether thus vibrat-
ing, is, by the prism, bent only slightly out of its path. Light is the
result of the same ether pulsating to a qtdcker time, consequently in
shorter waves, the refraction being much greater.

Chemical action is produced by a system of vibrations, smaller
and infinitely more rapid ; while the bending of this set of waves — ^the
chemically active ray — ^is to a much greater angle than either of the

* Robert Hunt, F. R. S., London, 1884.

110

others. This is the hypothesis; xnpw, take a lact By means of two
prismjs^ two spectra are formed, each of which jxroduces opoii chlorLio
of silver, a che^cal cha^e from the gre^n ray to some distance ibeyiOiid
the visible violet. Each spectrum is now so arranged, that the inactiTe
yellow and orange rays of one are thrown upon the most active blue
and violet rays of the other. The result is, that the chemical action
is entirely stopped. This may be said to be due to interference ; but,
I must confess, I cannot understand upon what principle the action of
rays undulating 535 millions of millions of times in a second, and pro-
ducing light, can interfere with rays vibrating 737 millions of millions
of times in the same period, and producing, as experiment proves, chem-
ical change. To support the view, that light regarded as an undulation
produces chemical change, since the chemical cause must reside in —
must be — the particular ray and nothing else, it is necessary to prove,
that when a colored ray of light is obliterated, all ^emical action
should cease over the space which belongs to that special ray: and also
that when the luminous colored ray is not obstructed, its chemical power
should still exist undimimshed. Experiment shows in the action of an
absorbent modiupfi that the blue rays, regarded as the rays to which the
maximum chemical effect belongs, may be entirely obliterated without
the chemical effect ceasing; and that under other conditions, the blue
ray may appear clear and intense in the spectrum thrown on the chlor-
ide of silver, and yet produce no chemical effect."

Kobert Hunt says : ^' After many years of close experimental exam-
ination, and an equally long and careful study of the hypotheses applied
in explanation of the phenomena of light in the first place, and subse-
quently to the chemical phenomena associated with light, I cannot bring
my mind to adopt the view, which refers the photographic phenomena
to the agent produciag the luminous and calorific phenomena of the
solar rays. As it respects light, I am quite ready to bow to the numer-
ous high authorities who support the undulatory theory. Not so,
however, with regard to the chemical radiation."

Careful study shows the amount of support which the following
views receive from experiment.

light, heat and chemical power come to us associated in the sun-
beam. No two of the phenomena produced by these agencies are simi-
lar. They do not obey the same laws of refraction, although they ap-
pear to be capable of undergoing the conditions of polarization, etc.

A diaphanous body for light may be perfectly opaque to the chem-
ical power, and a medium nearly opaque to light may be quite trans-

Ill

parent to tlie chemical principle. Heat, not being the snbjeet hettr
under consideration, doee not require imy particular mention ; tiie power
that we poeaeas, however, of aeparatifig light and heat ia ^onm
aeeitrately*

Therefore, regarding the diemical principle as something dia^
tinct from either light or heat, it becomes necesaarf to establish scttfiSi
term by which it may be recognized. Mr. Hunt's views, based on eicpi^
iment, as here stated, were not hastily adopted by him, as is shown by
the fact that the term acUnistn is now umveTaally adopted.

"The science of thermoties (Whewell), or of thermochroology
(MeUoni), is considered of sufficient importance tb have ita momelicliK
ture, and M. MellonI in a paper published in tiie BMiotheque Umv$f^
selle de Oenevey October, 1841, has entered very fully into the matter.
It is therefore essential to the successful prosecution of this inquiry
that the third class of phenomena, in the consideration of which I haV9
been particularly engaged, should have a term by which it may be
distingmshed. Sir John Herschel, in his memoir, "On the Chemical
Action of the Bays of the Solar Spectrum,'' used the epithet, adino-
graph to indicate an instrnment of a very ingenious kind, devised
by him, for registering the different degrees of chemical power acoom*
panying the solar light, during the day.

At the meeting of the British Association at York, the value of
the term was discussed. Sir John Herschel read a paper entitled
"Contribution to Actino-Chemistry," on which he spoke before the
section of chemistry. It was thought advisable to adopt the term
actinism^ when desiring to speak of the chemical power of the sun**
beam.

It may be necessary to remark here, that the chemical powen
belonging to light and heat are scarcely to be confounded with actin^
iam. light does, by exciting vitality, in living organisms, produce
chemical decomposition, and there is reason for believing that light
acts chemically on dead organic matter, but never on inorganic masses.
Heat, as a radiant force, also produces changes of a peculiar kind, but
these are broadly distinguished from the effects produced by actinism.

It may be asked, at the outset, what has all this talk to do with the
therapeutic study of light, or with physiology or the allied application
of the whole science of medicine. I answer my critics thus: — ^The
physical study of light from all its varied physical phenomena is most
essential to our knowledge, if we wish to apply it in this domain. Even
each ray of the spectrum gives its own specific reaction according to

112

aoientific research, which is now known to us and it is theref ore, that
specific uses and study of these independent rajs in the treatment of
disease must be thorough, if intelligent application of them be made.
With these remarks, I propose to give here some of the most interesting
phenomena discovered in connection with light rajs in order to permit
jou to pass judgment on the value of light from both the phjsiologic
and therapeutic points of view.

There are, in science, few subjects so obscure as that of which I
shall speak : What is the essential nature of light t How do we see the
universe? How does a luminous bodj radiate, and bj what vehicle
do its rajs reach our ejes? What are, even, these rajs? Man has
discussed this great problem for thousands of jears. The ancients
believed that the rajs might be shot forth from our ejes to laj hold
of objects far awaj; Newton thought, on the contrarj, that objects
emitted luminous particles, which pass through space and strike our
retina. Young and Fresnel have since shown that luminous bodies
do not emit anj material particles, but cause the surrounding- fluid to
vibrate, as' a bell makes the air vibrate. This has led us to imagine,
as indispensable to the propagation of Ught, a certain fluid named
eiheVy which is extremelj light and dissenunated through all space. To
Young belongs the honor of having stemmed the flood of authoritj
which, since Newton, had opposed the progress of optics, and of leaving
established this theorj on a basis which now appears to be definitelj
assured.

Just as we see the circular waves of a sheet of water succeed one
another round the point where the water has been struck, as air con-
denses and dilates in spherical waves, round the resounding tuning-
fork, so the ethereal fluid which fills space gives birth to a series of
spherical waves, succeeding one another all round a luminous bodj.
The waves of water are transmitted so slowlj, that the eje easilj
follows their motion; those of the air flj with the velocitj of 1,100
feet per second, varjing with the temperature and the densitj of the
atmosphere ; those of the ether pass through immensit j with the dizzj
velocitj of 186,000 miles per second. The most marvelous fact is that
everj star, everj sim in space, is the centre of constant imdulations,
which, thus, perpetuallj cross one another through immensit j, without
ever being confused or mutuallj mingled.

In the final analjsis, everj thing is reduced to several causes
which are goverened bj certain laws that explain the entire subject.
Taking this altogether, it is found to be a universal harmonj which

118

the physical ear cannot hear, but which the intellectual ear can under-
stand, as Pythagoras supposed. And is it not music itself which
▼aguely lulls us on its seraphic wings^ and so easily transports our
minds into ethereal regions of the ideal where we forget the fetters
of matter ? Do not the sonorous undulations of the organ, the sweet
quiverings of the bow on the violin, the nervous languors of the cythara,
or the still more captivating charm of the human ,voice, unite the rap*
tnres of life with the warm colors of harmony? What is it except an
xmdulatory motion of the air contrived to reach the mind in the depths
of the brain and to impress it with emotions of a special order t When
the spirited tones of Yankee Doodle and other national airs are borne,
in the heat of the conflict, to the excited battalions, or, when, under
the Gothic vault, the sad "Stabat Mater^* pours out its mournful notes,
it is the vibrations which affect us by speaking a mysterious language.
Now, all in nature is motion, vibration and harmony. The flowers of
the garden sing, and the effect which they produce depends on the
number and agreement of their vibrations relatively to those which
-emanate from surrounding nature. In violet light the atoms of the
«ther oscillate with the unheard of rapidity of 740 billions of vibra-
iions per second ; red light, which is slower, is produced by undulations
vibrating even at the rate of 380 billions per second. The violet color
is, in the case of light, what the highest notes are in the case of sound,
.and the red color represents the lowest tones. As we see an object
floating in the water, obeying with docility the waves which come
from different sides, so the atom of the ether undulates under the
influence of light and heat ; the atom of air undulates under the influ-
ence of sound, and the planet and satellite circulate under the influ-
ence of gravitation.

Harmony is in everything. To the eye of the person acquainted
with the principle, nothing is more interesting than the crossing of
wares of water. By their interference the surface of intersection is
■aometrmes so divided that it forms a beautiful agitated mosaic of ryth-
mical motions, a sort of visible music.

When the waves are skillfully produced on the surface of a disc
<d mercury, and this disc is illuminated with a pencil of intense light,
this light reflected on a screen reveals the harmonious motions of
Mhe surface. The form of the vessel determines the form of the figures
produced. On a circular disc, for example, the disturbance is projected
-Qiider the form of circular waves producing the magnificent chasse-

croiste, repretented ia fig. 1. The light redeotad hy a simiW ivrfaee
givM ft dettign of eztraordinAiy beautj ; vhen tke maixiQry is slangy
Agit^ed with the pwit of a nee^ in a direetum (xmeentrio with tke
oircnmferenM of the r««iel, t^ lines of light tnm rowKl in a ring
under the f ons of distorted, interiaoiDg thnada, revMling ma anothoi'
in an admirable manner. The most ordinioy aavaee prodnoe the nuMt
exqaicite effeots.

The nndalationB of aoond nu^ he ej^reaeed to the eye by figntea
no leaa harmonieoB, no lea* pleasing, than the preceding <siea. Let oa
take in iniitation of Chladni, a plate <^ glaae or a thin plate of oc^per^

Pig. 1.
and sprinkle it with fine sand. Let ua deaden one of its edges at two
points, with two fingers of the loft hand, and pass a bow ahnig the
middle of the opposite side. We shall see the sand trembling, fall-
ing back from certain parte of the sarfaoe, following the sounds
obtained and designiDg the figures here produced (Fig. 2). By Tary-
ing the experiment we thus obtain these admirable designs, which
appear at the command of the bow of the skillfull experimentalist. The
notes of the gamut are, besides, nothing else than ratios of numbers
between the sonorous vibrations. Combined in a certain order, these
numbers give perfect accord. Here, the major mode rouses and enrap-
tures us ; there, the minor mode afFects us and plunges us into melan-
choly and reverie. And, yet, there is here but a matter of figures t

115

^/*-

p> ^.

/
^ I

■

51-

/^7 JS".

TO-

/^/tf

Fig. 2.— The Chladni Figures from Dr. J. Mount Bleyer's article on "Voice
Pictures and the Wonders of Sound-Force."

We cannot only hear these sonnda, bat may btbh Bee them. Let us
make two tmiing-forkfl vibrate by the ingenious method of Lissajons,
one vertical, the other horizontal, fitted with little mirrors reflectiiig
a luminous point on a screen. If the two tuning-forks are in unison
and give exactly the same note, the combination of the two vibrations
rendered visible on the screen by the little mirrors that inscribe them
in lines of light, produces a perfect circle; that is to say, the simpleat

FiR. 3.
geometrical figure ; as the amplitude of the vibrationa diminishes, the
circle flattens, becomes an ellipse, then straight lines. This is the fint
row of fig. 3 in which the number of vibrations is in the absolutely
simple ratio of 1 to 1. If, now, one of the two tuning-forks is exactly
an octave from the other, the vibrations are in the ration of 1 to 3,
since every note has for an octave a number of vibrations exactly
double, and instead of a circle it is an 8 which is formed and modified
as we see in the second row. If we take the combination of two tones

117

of 1 to 3, say do with the sol of the octave above, we obtain the figures
of the third row. If we combine 2 to 3, as do and sol of the same
octave, we produce those of the fourth row. The union of 3 with 4, of
sol with the do above, gives the fifth series.

What is most curious is, that in the complete figures (those
of the middle of each series) the number of summits in the vertical
direction and in the horizontal direction indicates the ratio of the
vibrations of the tuning-forks. Yes, in everything and everywhere
numbers rule the world. Many curious experiments among those
made by Dr. J. Mount Bleyer, Voice Pictures, and those of Miss Watts
Hughs are also evidences of the facts just spoken of .^

Why, however, seek in scientific analysis testimony to the har-
mony which nature has shed over all her works t Although it may be
necessary for us to rise to the ideal of music to contemplate the beau-
tiful color of the sky or the splendor of the setting sun; we may on a
dull winter day, in the grey and monotonous hours when the sno"^
falls in innumerable flakes, examine with the microscope, some of the
flakes and the geometrical beauty of these light crystals (Fig. 4) will
fill us with admiration. As Pythagoras said, "God works everywhere
by geometry."

The velocity of light has been approximately known for more than
two centuries. The honor belongs, however, to the modem physicist.
Prof. Harkness, who has made the most correct calculation, in 1891,
and found it to be 186,337,000 plus or minus 49.723 miles per second.

Thus, when we see an eruption shoot out from the solar limb,
eight minutes have elapsed since the event occurred. When we see
a satellite of Jupiter lose its light, it is at least thirty-four minutes
since the eclipse took place. When we observe Neptune, we see it as
it was four hours previous. When we look at a star, we see it but, not as
it was at the moment the luminous ray left it — that is to say, four years
ago with reference to the nearest, and ten years, twenty years, fifty
years, one hundred, a thousand, ten thousand years, according to the
distance. Likewise, a transcendent eye placed at these suc^^essive dis-
tances would now see the earth as it was four years, ten years, or more
according to the distance. light makes the past an eternal present.
Such is the prc^essive transmission of light. But how shall we rep-
resent the action of the sun in the production of this light?

^ Journal of Eye y Ear and Throat Diseases, Baltimore. Voice Pictures;
or the Wonders of Sound-Force; Their Production and Their Photography.
Sept. and Oct , 1900.

118

'^-

M
^

J c

Pig. 4. — Snow FlaJtes^Shovfinfi their Geometrical Forms.

Let 118 remark, first, that the radiant star sends us heat at the
same time as light, and that, very often the two species of rays are
mixed up. Every-day experience shows us also, that heat raised to
a certain degree becomes light. On the other hand, we know that heat
is nothing else than a mode of motion : it is the motion of the molecules

119

in rapid vtbraiion which is feU as heat^ Light is otherwise but a
vibrcdion^

There ia no solid matter, properly so called, and this is a fact no
less worthy of attention than that of astronomical magnitudes and
motions* In the densest mineral, in a piece of iron, of steel, of plat-
inum, the molecules do not touch. Cohesion which is the attraction of
the atoms, maint>ainft them ; but heat increases their distance from one
another, more or less, by animating thCTi with a vibratory motion. If
this heat is sufficient the cohesion loses its power, the solid state dis-
appears and the molecules glide over one another; this is the liquid
state. If the heat is raised higher, that is to say, if the vibratory
molecular motion is more violent, the molecules even escape altogether
from cohesion and the body becomes vapor or gas. Thus, there is no
solid matter, and the heat-motion makes bodies pass through the three
states. It is assuredly strange to think that our own body is not more
solid than the rest, but formed of molecules which do not touch and are
in perpetual motion. Perhaps even the constituent atoms of bodies
rotate on themselves and around one another. If you had sufficiently
good sight to see exactly the materials which compose your body, you
would see it no longer, because your sight would pass through it. And
how small are the ooastituent parts I The red globules which color the
human blood have the form of microscopic lenses measuring only the
hundred and thirtieth part of a millimetre in diameter. It would be
necessary to place ISO of these little bodies end to end to form the

I - - — — "^ -■- I - - - ' - ^ — - — - — — — ■ —

' Let us strike a piece of iron. The muscular motion of the arm is trans-
mitted to the molecules of the iron, which are in a state of invisible motion,
and it is this invisible motion that we call heat* Friction produces heat, and
this was the first source of fire among the ancients. Thermodynamics has es-
timated the mechanical equivalent of heat and we know now that the heat
necessary to raise one pound of water i^ in temperature is equivalent to a
mechanical force capable of raising 772 lbs. i foot in height and conversely.

^eat is a mode of motion, A ball of lead of one lb. falling from 772 feet
of height arrives with a velocity of 322 feet per second, and, as its calorific
capacity is one thirtieth of that of water, its collision with the ground would
raise its temperature by 30^ if the soil itself were not heated by the fall. Such
a ball shot with a velocity five times greater, or 1,110 feet, would attain a de-
gree of heat twenty-five times higher, or 750 degrees, in striking a target
which could not be heated. That is to say, that if the Supreme Will were to
stop suddenly, this ball, thus shot out into space would melt on the spot and
flow like water.

120

length of a miUimetre. A drop of blood of a cubic millimetre contains
about five millions of globules; a litre of normal blood contains 6,000
millions, and there flow in our arteries and veins, twenty-five to thir^
thousand millions of these little organic bodies.

Let them become either reduced or multiplied, and we are dead t
Let them coagulate, or become cooled or heated, and we are dead ! Let
them stop, and we are lost I At each throb of the heart, a violent and
rapid impulsion projects the blood to the extremities of the members.
One hundred thousand times a day, 36 millions of times a year, the
same pulsations reconunence, until the day when the fatigued muscle
stops, and compels us to lull ourselves profoundly in the last sleep.

The constituent molecides of bodies do not touch. It is thus, and
thus only, that the expansion and the change of the state of bodies
under the influence of heat can be explained. We do not doubt the
energy of the atomic forces in action around us. Let us heat one
pound of iron from zero to 100 degrees; it will expand about 1-800,
a span imperceptible to the eye, and yet the force which has produced
this expansion would be capable of lifting 12,000 lbs., and raising them
to the height of one yard. The power of gravitation almost vanishes
in comparison with these molecular forces; the attraction exercised
by the earth on the weight of half a kilogramme (about a pound)
taken in a mass, is nothing compared to the mutual attraction of its
own molecules. Li the combination of 1 lb. of hydrogen with 8 lbs. of
oxygen to form water, work is performed capable of raising by 1 degree
the temperature of 84,000 lbs. of water, or of lifting 16,000,000 lbs.
to the height of one yard. These nine pounds of water, in being
formed, have fallen molecularly down a precipice, equal to that which
would be passed over by a ton of 1,000 kilogrammes rolling down to
46,000 feet of depth 1

When a bar of iron is heated and becomes sufficiently hot to be
luminous, it sets the ether in vibration at the unheard of velocity of
460 billions of undulations per second.

The length of the wave of the extreme red is such that it would
require 38,000 placed one after the other to form a length of one inch.
As light travels 300,000 kilometers per second, or 30,000,000,000
centimeters, multiplying this number by 15,000 we obtain the num^

121

ber given above ; all these waves, 460,000,000,000,000, enter the eye
in one second !^

Let ns receive a ray of light on a lens in order to produce a very
pure pencil, then on a prism (a triangular piece of glass) ; in passing

The dispersion oF white light
by its paesa5e throush a prism •

Pig. 5.

Fig. 5 shows how a beam of parallel rays of white light, such as sun or eleo
ric light, etc., B, is changed into a fanlike beam, B', by a prism. This fanlike beam
falling upon a screen, S S, produces an illuminated band R V, called spectrum^ which
is red at the end R and passes by insensible gradation through orange, yellow, green
and blue to violet at the end, V. The beam of light, B, is said to be dispersed by the
prism. The fanlike beam, B', produces white illumination when concentrated by a
covering lens upon a small portion of a screen.

through the prism, this luminous ray is refracted, and in passing out,
instead of forming a white point, it forms a ribbon, colored with the
tints of the rainbow. In making this experiment, Newton proved that
the white light gave birth to all these colors. These are arranged in

* What comes from the sun and from all sources of light and heat is not
then, to speak accurately, either light or heat (for these are merely impres-
sions), but motion^ motion, extremely rapid. It is not heat which is scattered
through space, for the temperature of space is, and remains everywhere, glac-
ial. It is not light, for space has constantly the darkness seen at midnight. It is
motion, a rapid vibration of the ether which is transmitted to infinity, and
does not produce a perceptible effect until it meets with an obstacle which
ransforms it.

122

the following well known order : — Violet, indigoy blue, green, yellow^
-orange, red.

The colors are separated, each according to its character; the
jnost intense, the red, does not allow itself to be turned aside from its
path, and passes in a straight line; the orange submits a little to the
influence of the prism, and is placed to one side; the yellow submits
etill more, the green, then the blue, are still milder and weaker, and
continue the ribbon. It is this colored streamer which bears the name
of the solar spectrum (Fig. 6). In reality there are not seven colors ;
there is an unlimited number. In the time of Newton the number Vii
was still secret.

The length of the spectrum only represents the Ught, that is to
say, the solar rays — ^perceptible by our retina. Our eye begins to see,
when the ethereal vibrations reach the number of 450 billions, and
stops seeing when they exceed 700 billions (purple-violet) ; but beyond
these limits nature still acts — ^unknown to us. Certain chemical sub-
stances as those used in the screens for X rays, etc. — the photographic
plate is another example — see further than we do, beyond the
violet; these are invisible rays for our eyes and numerous other
examples could be cited for illustrative purposes.

Our ear perceives aerial vibrations from 32 vibrations per second

WHITE U6Kr

RIlD

YBL 6REEN

BLUE

VIOIET

Solar Spec^rum<

Fig. 6.

<low tones) up to 36,000 (high tones) ; beyond this we hear nothing.
Thus our senses are limited, but not the facts of nature. The colors
are, like the notes of the gamut, effects of number; in painting as in
music there are tones.

It is the molecular arrangement of reflecting or transparent sub-
stances, which gives rise to the different reflections of light, that is
to say, the colors. A slight difference produces here a blue eye, pen-
sive and thoughtful ; there a brown eye, with half -hidden flames ; there
a look, dull and distasteful. The dazzling rose which blooms in the

123

flower-garden, receives the same light as the lily, the buttercup, the
cornflower or the violet; molecular reflection produces all the differ-
ence; and we might even say, without Inetaphor, that objects are of
all colors except of those which they appear. Why is the meadow
green ? Because it keeps all except the green, which it does not want
and sends bacL White is formed by the reflective nature of an object
which keeps nothing and returns all; black, by a surface which keeps
all and sends back nothing. Project the solar spectrum on black vel-
vet ; it is absolutely extinct ; place a band of red velvet in the blue part

fDM

■ OF* D CB*A i^ » A

Pw. 9.— Laii8l«7*Biiorm«11x>loiniBtrkfpectnim,iliowiiigeii^

Pig. 8.— Laaglej*! latect spcctnun. The whita portion on the left is the vialble *ep«ctni]n, the ihaded poitton on the

right repreeenting the iniielble or infiriried (fnok tiMjPMogrtan),

Pig. 7,
Pig. 7, a photographic plate reveals the existence of invisible rays beyond V,
the ultra-violet ra^, especially in sunlight; and a thermopile or bolometer shows the
existence of rays inside of or below R, the infra-red rays. The portion of the spec-
trum between R and V is called the visible spectrum,

of the spectrum ; it becomes blacky because, it is not able to send back
anything but red, etc.^

[to bs ooktinusd.]

^ With reference to this, I have noticed a rather singular fact during some
experiments. A white ray which passes through a yellow glass is projected
in yelloWy and a ray which traverses a plate of blue glass is projected in blue;
projecting these two colors on each other, on a screen, we obtain a pure white;
because these two colors are complementary. But, if we place the same plates
of yellow and blue glass in a single apparatus we obtain green.

124
OF£RATIVB INTERVENTICm IN LARYNGEAL TUBBRCUL06IS.*

BY W. FREUDENTHAL, M. D., NEW YORK, CONSULTING LARYKGOLOGIST TO MON»

TSFIORE HOMSy BEDFORD SANATORIUM FOR CX>NSUMPTIVES AND

BETM ISRAEL HOSPITAL ; LARYNGOLOGIST TO ST.

mark's HOSPITAL, ETC.

During the last few yeaiB, it seemB to me, very little progress has
been made in the surgical treatment of laryngeal tuberculosis. It was
not with the intention of presenting much that is new that this article-
has been written, but rather in compliance with the request of the
Editor of this Journal.

When shall we operate in laryngeal phthisis ? Shall we operate at
all ? In a criticism of a certain book, Dr. A. Kuttner, of Berlin, says
that there is at present a general consensus of opinion in regard to the^
indications for surgical intervention in cases of laryngeal tuberculosis.
I cannot agree with him here, as I know that there is a wide difference
of views regarding this matter, even in this country. ^The question of
operative interference is one not definitely settled, nor is it likely to
be for some time to come," says Lake in his booklet on laryngeal phthi-
sis, and this is my opinion as well. In Germany and Austria far more
cases have been operated upon than in this country and England, and
it seems as though some of our American colleagues have gone too-
far in this direction, i. e., they have not operated at all. Even Dr.
Shurly* says: "The range of surgical measures for the relief of this
disease" (i. e., tuberculosis of the larynx) "is necessarily lunited* * *
There is no doubt that it" (i. e., Heryng's curettage) "may be a very
efficient and practicable measure in cases of isolated ulcerations in the
upper part of the larynx, but for a large proportion of cases of laryn-
geal tuberculosis presenting no limited lesions, but a simultaneous
breaking down of many spots separated from each other, this plan of
treatment will necessarily be limited in its application."

Masucci^ believes in Heryng's method, wherever he finds tubercu-
lous ulcerations present. Otherwise he applies lactic acid and iodo-
form. This author, by the way, found among 198 cases of laryngeal
tuberculosis, 25 with primary tuberculosis of the larynx. This number
is simply appalling to me. Although I have had exceptional opportuni-
ties of seeing a large number of cases of laryngeal tuberculosis during
the last s ixteen years of my practice — at least 800 or 1,000 cases — I

* Read before the Med. Ass'n. of the Greater City of New York, March
lo, 1902.

^ Diseases of the Nose and Throaty p. 313, New York, 1900.
^ Iniernat. CentralbLf. Lar,, p. 432, 1901.

125

oannot remember having encountered one single instance of primarv
tuberculosis of the larynx. This does not mean, of course, that such
instances do not occur ; but I believe they must be extremely rare.

Very interesting is a discussion on this topic some time ago, in
the Himgarian Society of Otologists and Laryngologists, in which Prof.
V. Navratil spoke in favor of the removal of the diseascid foci by meand
of laryngofissure. He said that when the pathological changes were
circumscribed and the general condition favorable, laryngofissure
ought to be resorted to, as all diseased tissue could thereby be removed
easily and safely. Baumgarten and ^emai were opposed to such a rad-
ical procedure. While the former would remove as much as possible
by endolaryngoal methods, Nemai on the other hand, does not favor
much surgical interference in such cases for the reason that the patients
did not survive long after it.

Pienazek and Griinwald have formulated indications for laryngo-
fissure similar to those of v. IfavratiVs. Gleitsmann, of New York,
is a great believer in curettage of the larynx.

Concerning my own ideas on this question, I remarked in an article
published about a year ago: "I am able to report 29 cases the his-
tory of which I have found, although I know that more than double
this number have been operated upon by me. I will, ho^rever, base my
conclusions only upon these 29 accurately described cases. Of these 18
were not improved, in 7 a slow amelioration occurred which could be
attributed to the operation, and in 4 an almost immediate improvement
took place. Of the 18 unimproved cases, 18 were in an advanced stage
of pulmonary phthisis, that is, with formation of cavites, etc., and 5
were in the earlier stages. None of these 18 patients experienced any
relief after curettement ; the majority, indeed, attributed the deteriora-
tion in their health to the operation, and in many cases I was of the
same opinion. I was struck by the fact that a large number of infiltra-
tions, with or without formation of ulcers, were in the interarytenoid
space, forming the well known polypoid excrescences on the posterior
wall. In the 7 patients of the second class slow improvement occurred,
and I have noted this in affections of almost all parts of the larynx. As
this amelioration constantly followed on the surgical treatment, I con-
sider myself justified in ascribing it to the latter. In considering the
last 11 cases, one would be inclined to regard these surgical operations
in the nature of a salvation, but unfortunately we must not lose sight
of the first 18 cases, in which the results were not good. And if I
were asked to give the indications for curettement I would not be able

126

as yet to state them accurately, in spite of the fact that many laryngol-
ogists have studied the subject for over a decade. An important factor
is that we are still unable to observe or appreciate the extension of the
tuberculous process to the invisible portions of the larynx, or the con-
tiguous parts, or otherwise to form an idea of its progress, which is gov-
erned by laws as yet unknown to us. As for me, I always regard such
intervention as an experiment, and leave the decision to the patient.
We learn, therefore, from the above statistics, that while we have been
able to effect some excellent results, we have not been spared marked
disappointment in a large number, and, indeed, in the majority of
cases." Then I continued :

"This was my standpoint somewhat over a year ago. I therefore
resolved to try for one year without curettage. There were several
cases in which, according to former views, curettement was indicated.
Although I was tempted to do it repeatedly, I abstained, and after a
year's trial without curettement, I believe my patients are just as well
and perhaps better off than they would have been with the operation.
Whether in the future I might not come across any cases in which it
will be indicated, I cannot say."

Another year has passed by, and now I believe that there are
two indication^ to be fulfilled when we do operate ; 1st — intense pain;
2nd — dyspnoea. The covered infiltrations, if I may use this term, I
leave alone as long as possible, for fear that they may change into
open ulcers by any surigical measure. This is also the opinion of
Nemai. The ulcerations, however, I treat topically in most instances,
as I have witnessed many satisfactory results from such treatment. I
use the orthof orm-menthol emulsion, which in many clinics goes xmder
my name, and the exact formula of which is given in my article
referred to above.* Whenever I can reach the ulcer with my emulsion,
and whenever the patient can retain it for a few minutes so that it is
absorbed, I am generally quite confident that it will relieve the pain
and the dysphagia. During the last year I have again observed repeat-
edly this beneficial effect of the emulsion, at the New Sanatorium for
Consumptives at Bedford Station, where many patients suffering from
tuberculous laryngitis have been treated in this manner. Many of
these had been treated elsewhere previously with lactic acid, up to 80

* Treatment of I^r3mgeal Tuberculosis at the Montefiore Home — Jour.
Am. Med, Ass^n,^ March i6, 1901.

per cent, or 100 per cent., but felt much better after the use of the
emulsion. Of all the cases I have treated in this way, permit me ta
refer to one occurring in my private practice. I kept this patient
aEye for nine months mth this simple treatment. When he consulted
me first he was almost starved as he had been unable to swallow food
or drink for nearly a week. His temperature ran up from 101° to
104^ constantly, and it is a surprise to me how he could live so long.
Still, he was grateful, that he could enjoy a meal again. Of course he
was abed all this time and extremely weak. Whenever those terrible
pains returned the orthoform-menthol emulsion was applied and he
felt better and was able to eat, sometimes even a steak I This condition
remained the same up to three weeks before his death, when he could
not sit up any more and I was unable to make the application thor-
oughly.

!N'ow, there are cases where we cannot reach the ulcers well with
the emulsion, as those in the interarytenoid fold. We can reach this
place, but the fluid does not remain in contact with the parts but runs
down into the trachea. As it thus cannot be absorbed in locoj it exerts
no efFect at all. Such cases with interarytenoid thickenings most often
give satisfactory results when curetted, but, alas, these are not of long
duration. Still, I would recommend curettage in some of these cases
when no other means will relieve the pains of the patient, though being
fuUy aware that the amelioration might not in some instances last
longer than a week or ten days ! As there is very little bleeding during
and after operations at the interarytenoid fold, we should remove the
infiltrated and ulcerated parts freely and as thoroughly as possible.
There is no danger in taking away too mnch in these instances.

The second indication for endolaryngeal operations is dyspnoea.
As soon as we have laryngeal dyspnoea we must relieve the patient by
every means possible. All will agree on that point. The question is
only, how should we operate? Is curettage, tracheotomy or laryng-
ofissure preferable? Excepting in very acute urgent cases, I should
never recommend tracheotomy. I see no curative benefit from such a
procedure. On the contrary, the patient has to undergo an operation,
which is always weakening ; has to be bothered with a tube, and derives
no relief from his pains. Besides, he is not able to talk, which has a
depressing psychical efFect on every patient. Laryngofissure would be
more advisable, as all diseased parts could be thereby removed. But, as
I have said above, most patients cannot stand such operations. They
are generally too far advanced and from the long sickness too debili-

128

taited, to have much vitality left. As a rule they sink rapidly after suck
an operation.

The only thing left for us to do is, therefore, curettage. Allow
me to repeat the history of a patient whom I demonstrated before the
German Medical Society of the City of New York, February 8rd, 1902 :

M. S., 23 years of age, newsdealer. He became sick a year and
a half ago, when he commenced to cough and had '^trouble with the
throat." He went to a clinic, where he was operated on. Nothing
further could be elicited from him. On examination I found a tumor^
like infiltration on the right ventricular band. He had dyspnoea,
which he attributed to the condition of his lungs. I removed the infil-
trated parts and he immediately told me that he could breathe more
freely. Although the patient was in an advanced stage of pulmonary
tuberculosis, he stood the curettage very easily. In fact, he hardly felt
that I was operating on him. There was no loss of blopd to speak of,
no rise in his temperature, and he felt as comfortably as could be
expected. Two weeks later, however, he had a haemorrhage and fever
up to 102.5^ F. When I examined him again, six days later, at which
time he had recovered, I found that there was a recurrence of the infil-
tration. At the end of another week, this had reached the same dimen-
sions as before. I operated again, and now, L e., three weeks later,
the patient feels well and so far there is no visible recurrence. How
long this will last, is naturally uncertain.

Although the haemorrhage occurring after the first curetting
might have been a mere coincidence, still there is a possibility that a
new active process had started within the lungs right after my surgical
intervention. I have observed another case where the same thing hap-
pened, viz. : haemorrhage, high fever, etc. We ought to keep this in
mind before resorting to operation.

In conclusion I will say that for the last two years I have operated
very little on patients with laryngeal tuberculosis, and even in these
cases succees did not always follow. Still, if we select our cases care-
fully, we may now and then find a few where these endolaryngeal pro-
cedures are of some benefit.
1003 Madison Avenue.

129
NUTRITION IN PULMONARY TUBERCULOSIS.

BY A. W. PERRY, M. D., AND ALBERT ABRAMS, M. D., SAN FRANCISCO.

Pulmonary tnberculoeis is an affection invariably manifested by
^turbed nutrition. This defect in metabolism, anabolic and catabolic
is brought about by the conditions which cause and maintain the dis-
ease. The words phthisis and consumption convey a description of the
iiffection, viz. : a wasting away, not only of the lungs, but of the entire
organism. The stomach, in fact the entire digestive canal, is implicated
in the disturbance of nutrition and, if the healthy stomach is one of
the best guarantees against consumption, it is likewise one of the
chief aids in restoring the diseased lung. In our experience, one of
the best prognostic factors of phthisis is a stomach capable of digesting
food. No matter how auspicious the symptoms otherwise, a rebellious
stomach is always a bad omen. Good assimilation is proved by gain of
weight, provided the same is permanent. Analyses made by one of
us in a large number of phthisical cases prove that, while in a number
of instances dyspeptic disturbances could not be attributed to any
<li9turbance of the gastric function, yet, in the majority of the patients,
■amylaceous indigestion associated with hyperchlorhydria was present.
In the former group of cases which may be specified as pseudo or ner-
vous dyspepsia, no means more propitious was found to correct the
.gastric anomaly than the feeding system embodied in the Weir Mitchell
method for the treatment of hysteria. Such treatment will often
^ive marvelous results where all other legitimate methods have failed.
This treatment means, of course, absolute rest in bed, isolation, mas<
sage and the other requirements embodied in this method. No dietetic
method wiU prove satisfactory imless we associate it with those hygienic
measures which empiricism has taught are of direct avail in the treat-
ment of the white plague. The etiologic factor of phthisis is by no
means the tubercle bacillus alone. The latter orgamsm is a mere
guest constrainedly invited by the subnutrition of the host. The last
-decennia have witnessed the rise and fall of theories which attempted
the introduction of bacterio-therapeutic methods.

Any exclusive dietetic method in the treatment of phthisis is
manifestly absurd. . The organism must be supplied with all the ele-
ments concerned in nutrition. Aside from the problem of nutrition,
we are confronted by other problems, problems which conciliate the
-appetite and promote digestion and assimilation. The maintenance
of the corporeal weight and strength requires a minimum production

130

of 2800 caloriefl which was found by Ranke to be prodaoed by the
consumption of the following:

Dry proteid matter 100 grammes.

Fat 100 grammes.

Starch 240 grammes.

This is much less than the esticnation of Voit and a little more than
that of Playfair. The latter found a seamstress living on:

Proteid 54 gnunmes.

Fats 29 grammes.

Carbohydrates 293 grammes.

For the purpose of determining the least food which will prevent
loss of weight in an invalid (normal) who presumably does no work
and is well protected from cold we may take a mean between the last
two estimates and aver that a person with incipient phthisis must take
a minimum of

Carbohydrates 820 grammes.

Fats 65 grammes.

Dry proteids 77 grammes.

No matter how favorable the climatic influence or the action of
specific medication, if this equivalent of food is not digested, only retro-
gression will mark the trend of the disease.

The foregoing estimates of food values may be translated for
practical purposes as follows: 320 grammes of carbohydrates, 53&
grammes of hard bread; 65 grammes of fat, 65 grammes of fat; 30
grammes of dry proteids contained in the bread, in addition to 47
grammes of dry proteids, the equivalent of which is roast beef, 179
grammes — a total estimate of 777 grammes.

In health we may replace for a time both fats and carbohydrates^
by meat, but the enormous quantity requisite soon produces disgust
and digestive troubles. To maintain an equilibrium on exclusive meat
diet requires 3000 to 4000 grammes. For these observations we note
that in a person whose appetite is poor as well as in incipient or devel-
oped consumption, we cannot change the proportions of the minimum
normal diet without increasing the total weight and bulk of the food. If
nutrition is to be maintained 3500 g. of meat are required to furnish
2300 calories. Of fat, even in health, in temperate climates not more
than 300 grammes can be digested and absorbed ;when these large quan-
tities can be tolerated 12 per cent, to 35 per cent, is lost in the faeces.
In phthisis there is a deficient assimilation of fats, and we cannot

131

replace the carbohydrates by the fats to a much greater extent than
given in this minimum diet.

The nutritive problems for a person with pulmonary tuberculosis
or a condition of marasmus, (whose average weight should be 148
pounds) are the following :

1. Minimum ingestion of 538 grammes of bread, 47 grammes
of dry albuminoids which would be represented by 179 grammes of
cooked meat, and 65 grammes of fat

1. To secure the digestion of the albuminoids, starch and fats.

2. The promotion of the passage of the food into the intestines.

3. The absorption and assimilation of the food.

The obstacles to nutrition in pulmonary phthisis are :

A. Difficulties in taking the food.

B. Difficulties in digestion and assimilation.
A. 1. Anorexia.

A. 2. Dysphagia from laryngeal disease.

A. 8 Vomiting from excessive cough.

A. 4. Vomiting from gastric disease.

Appetite is made up of two factors or more. The first is a demand
of the tissues for nutritive material to replace that which has been
lost by exertion; it comes from all parts of the body to the brain to
what may be called the htmger-center although we do not know just
^here it is located ; the perception of this feeling may be inhibited by
;)sychic causes, by toxins circulating in the blood, the result of fever,
uremia, diphtheria, and other infections. The second factor in appe-
tite is an empty condition of the stomach ; a freedom from food, mucus,
f 3rmenting liquids ; it is locally expressed as an uneasiness at the epi-
|!astrium or behind some part of the sternum, and may be prevented
for a time, by pressure or by filling the stomach with any innutritious
substance; an excess of the organic acids of fermentation, acetic and
butyric, destroy the appetite; while tmder some conditions an excess
of hydrochloric acid alone irritates the gastric mucous membrane, and
causes a gnawing feeling which is relieved by taking any food, espe-
cially albuminous. This constitutes a pseudo-appetite. A few sub-
stances like small doses of alcohol, the vegetable bitters, which increase
the motor activity of the stomach, may increase the appetite in phthisis,
but only when it is dependent on a moderate stagnation of the stomach
contents, not caused by organic or spasmodic stenosis of the pylorus.

The appetite stands in a constant proportion with the amount and
.strength of the gastric juice which is secreted, when anything is eaten.

182

Psychic impressions while eating have a far more powerful effect than
the contact or presence of food in the stomach.

The bitters and condiments which excite the appetite do not cause
an increased secretion of gastric juice when introduced directly into
the stomach through fistulae, or when prevented from perception in
the mouth or nose by being enclosed in pills or capsules. To be effect-
ive in stimulating appetite to the utmost they must be used in solution
or powder. It will be seen that the cases of phthisis in which we may
hope for increase in appetite from drugs are f ew^ the two most com-
mon causes of anorexia being the action of the toxins of the tubercle
bacilli and streptococci, and a chronic glandular gastritis.

If the anorexia cannot be relieved by the vegetable bitters, or by
treatment directed to any existing stomach disorder, it may be disre-
garded.

A. 1. Patients must be persuaded to take the food as a duty or
as a medicine. If solid food is refused it may be reduced to a thick
liquid form and drunk. It is easier to take a thick liquid food than to
-chew solid food soft enough to swallow. Very large quantities of liquids
(3000-4000 g.) are to be avoided, as Debove and others found dilata-
tion of the stomach to develop soon after such a diet.

A. 2. The violent spells of coughing in laryngeal disease are fre-
quently caused by small pieces of food becoming detached from the ali-
mentary bolus and falling into the larynx ; so far as this occurs any of
these foods may be gelatinized by heating and adding to the liquid, two
per cent, of gelatin which has been soaked in water.

A. 3. Vomiting from cough may be controlled by sedatives such
as heroin, codein, antipyrin, etc. If the cough is caused by laryngeal
irritation insu£9ations of orthof orm are indicated.

A. 4. Emesis of gastric origin may be obviated by treatment
directed toward the stomach. Daily lavage with hot water not only
inhibits gastric anomalies but improves the appetite, digestion and
assimilation.

The method of forced alimentation (gavage) was devised by Prof.
Debove in 1881. For those patients who would not, or could not eat or
retain sufficient food, or when the food is vomited, it was found that
when given through the stomach tube it was oftener retained and assim-
ilated in enormous quantities. A preliminary washing of the stomach
before the gavage was often effective. His results were confirmed by
others. Although forced alimentation is not suited to many cases of
phthisis, yet we learn from these results that the digestive and assim-
ilative capacity are often far in exceas of the appetite, or toleration of

183

the stoniaoh; also from the good effects of the preliminary lavage, that
chronic gastritis may be an obstacle to retention, and that it may be^
easily remedied by the lavage.

Becords of examinations of faeces from phthisical patients rarely
show undigested residues, an effective argument in favor of superal*
imentation.

Digestive disturbances may also be induced by anomalous digestive-
secretions and tardy intestinal peristalsis.

B. 1. During the febrile period of phthisis the salivary secretion
is entirely suspended, and its digestive capacity is enfeebled. Its place-
can be supplied to some extent by very slow chewing and by the use
of starchy food partly transformed towards dextrose with vegetable-
diastase, during meals. The gastric secretion is of tener excessive than
not, excepting in the last stages of phthisis.

The biliary and pancreatic secretions together effect the diges*
tion of the fats and when deficient, as is usually the case the Pan-
creatic Pepetonising Powder is reliable and invaluable. If the biliary
and pancreatic secretions are entirely cut off from the intestine of
dogs, fats when emulsified are absorbed to the extent of 50 per cent.

FAEGAIi BXAMIKATION.

Whether the food ingested is digested and assimilated may be
judged grossly and after some days by loss or gain in weight excluding,
of course, alterations due to oedema. A much better and quicker
method is founded on an examination of the faeces for undigested food.

There may be found (indicating serious derangement of digestion)
pieces of muscular and connective tissue visible to the naked eye;
undigested starch enough to produce a bluish color when the faeces-
are moistened with iodine.

The presence of starch grains in small amount visible under the
microscope, and also of muscular fibres does not show any serious
digestive disorders. Fat in amount from 2 to 4 per cent, is always
present in faeces and the presence of over 6 per cent, shows serious
disorder, faecal examinations are not more disagreeable than the exam-
ination of tuberculous sputum. The examination for fat to be of ser-
vice must be a quantitative one. We have found the following to be
comparatively easy and not unpleasant: — With 30 grams of faeces
mix an equal bulk of plaster of Paris, one quarter bulk of powdered
charcoal, and 10 drops of sulphuric acid. This makes a mass which is
dry enough to powder in a few hours, and may be exhausted on a filter
with ether or benzine, and the fat determined by weighing, on evapor-

134

ation of the solvent. The charcoal removes all the smell, and the
process is far easier than drying the faeces by heat, and powdering,
or by shaking up with ether and water. Having by these methods deter-
mined the deficiency of any particular digestive function it can be
treated with more certainty of success.

Most phthisical persons do not eat enough. It will not do to allow
them to be guided by their appetites. They must be persuaded to take
the minimum we have given, unless they actuaUy vomit. If this cannot
be remedied by medicines gavage may be tried.

The reasons for superalimentation are :

1st. The digestive capacity is far greater than the appetite, as
shown by Debove's results.

2nd. Our examinations made with faeces from twenty consump-
tives in the first and second stages of the disease have shown no abnor-
mal amount of meat fibre or starch, and .09 to 3 per cent, of fats.
As these cases were taking as much food as they (thought) could,
absence of undigested or unabsorbed residues in the faeces shows that
the digestive power of the patients was not being worked up to its full-
est capacity, which is certainly the important point in the treatment.

8rd. The results at Dr. Walther's Nordrach Sanatorium and
others conducted on the principle of over feeding the patients show the
excellent results which can be attained by superalimentation.

The more exact our directions, the more faithfully they are car-
ried out ; consumptives must take a miTiinrmnri of : —

Starch 320 g.
Represented by

Dry toast 592

Bread 729

Crackers 508

Sugar 256

Brown flour 400

Roasted flour .... 400
Cereal foods .... 400

Boiled rice 1680

Mushes 1800

(t
It
(I
II
(I
i<
II
li

Fats 65 g.
Represented by

Butter... 77 g.
Cream... 300 "

Fat 65 "

Oil 65 "

Bacon. . . 68 "

Dry Proteid 77 g.
Represented by

The weighing of food
spring balance hooked into
The following plan of

Roasted meat... 226 g.
Boiled " ..226 *

Eggs 550 •

Brains 960 '

Fish 385 *

Meat powder... 110

Plasmon 103 '

Somatose 96

Tropon 86

Eucasein 100

Sanatogen 100

at the table is easily done by a post-office
a double slip of paper holding the food,
feeding unwilling patients is offered:

135

All food is brought to the state of a liquid, thick enough to be
drunk easily ; this liquid consists of milk slightly thickened by boiling
with 2 per cent, of com starch or gelatin, in which is suspended
14 per cent, of roasted flour or some of the deztrinized foods of com-
merce, such as Imperial Granum, Mellins Food, etc.

In case TnilV disagrees, we may use thin barley-gruel or any other
similar liquid and suspend in it the carbohydrate-food.

The requisite amount of albuminoids is supplied by suspending in
these thick liquids from 70-80 grammes of meat powder or Tropon,
Plasmon, Somatose, or Eucasein. From 12 to 14 per cent, of any of
these finely powdered preparations can be suspended in thin mucilag-
inous liquids, making a mixture which can be easily drunk.

To get enough nutriment in 2000 grammes of liquid, we may give
1500 c. c. milk, thickened by boiling in it 80 grammes of com starch,
in which is suspended 210 grammes of brown flour.

Dextrinized with tlus may be taken 500 c. c. barley-gruel or other
mucilaginous liquid in which we may suspend 70 g. meat powder^ Flas-
mon, Somatose, Eucasein, or Tropon.

This schedule gives a normal nutriment (quantity), and furnishes
2387 calories, with only 2 litres of liquid.

The advantages of preparing food in this way are: It can be
taken easier than solids and semi-solids, owing solely to the carrying
power of the liquid. The amount of liquid to carry this food is so
moderate that it will not overburden the stomach, and cause or develop
a (preeirisitiTig) dilatation, as found after an exclusive milk-diet of
3500 to 4500 c. c.

The question of extra-buccal feeding is an important one in deal-
ing with the nutritive problems in phthisis. Two avenues, the rectum
and skin, present themselves for such feeding and may be employed
in uncontrollable vomiting, hematemesis and other gastric disorders,
or they may be used in supplementing conventional nutrition.

Beotal larrsinoN. It is now conceded that enemata subserve a
very useful purpose in nutrition. The fact, however, must be borne
in mind that the rectum is endoired with the power of absorption only.
Its capacity for digestion is so limited that it need not enter into con-
sideration. Investigations demonstrate that certain food products are
easily absorbed. Such products, in brief, are meat juice and peptone,
raw eggs, small quantities of fat, milk and solutions of sugar. Each
enema should not exceed 800 grammes of fluid, otherwiBC peristalsis
is excited and the enema is discharged. As a result of long continued

186

clinic and physiologic experience, Leube presents the following nutri-
ent enemata which may be employed with advantage :

1. Peptone enema: 60 grammes of peptone to 300 grammes of
milk.

2. Egg enema : 3 eggs in 300 grammes of milk with 3 grammes
of salt.

3. Starch enema : 60 grammes of starch to 300 grammes of milk.

4. £gg-starch enema: 300 granmies of milk, 3 eggs^ 3 grammes
of salt and 40 grammes of starch.

To maintain daily nutrition in the average individual, 2000 cal-
ories are necessary. Each of the above enemata represents only 800-
450 calories, therefore, if employed three times a day, we would sue*
ceed in furnishing the patient with only one-half the necessary calories.

SuBOirTANBOus AUTKiTiON. For this purpose oU which has been
sterilized by boiling is the best agent. From 60-100 g. of warm oil
are thrown under the skin by means of a large syringe to which a needle-
is attached. At least an hour is consumed in injecting the oil. If we
supplement the rectal by the subcutaneous nutrition we may succeed
in furnishing the patient with the necessary calories to maintain normal
nutrition. Thus two nutrient enemata a day composed of 800 grammes*
of milk, 40 grammes of starch and 3 eggs, 1100 calories together with
100 grammes of oil (930 calories) afford 2030 calories.

INTRATR ACHFAL MEDICATION IN DISEASES OF THE RESPIRATORY

TRACT.

BY JOSHUA L. BARTON, M. D. , NEW YORK.

The employment of this method, in a field of labor well adapted
to test its efficiency to the utmost, during a period of seven years has
led the writer to regard it as one of the most valuable means of treating
persons afflicted with diseases of the trachea, bronchi and luDgs.

In simple acute tracheo-laryngitis, tracheo-bronchitis, bronchitis,
and asihma when secondary to bronchial disease, a rapid cure may be
confidently predicted. The subacute and chronic forms yield more
slowly, owing to changes in the mucous membrane, but persistent treat-
ment even in these obstinate cases will give the most gratifying results,
while in pulmonary tuberculosis and in phthisis the beneficial effect
of topical applications is very marked.

It is not strange that many physicians look askance at this method,
since nearly every one can recall cases of severe cough and strangula-

137

tion caused hj the accidental dropping of a little water or a crumb of
bread into the larynx. Naturally the following objections are suir-
gested :

1. Interference with respiration.

2. Excitation of severe cough.

3. That it can be used only by a laryngologist.

4. That it has no value as a therapeutic agent.

An examination of the anatomical parts concerned in the act of
respiration will convince the most skeptical that the first objection has
no foundation. Bespiration may be arrested by destruction of the
cerebral nerve centres, by section of the pneumogastric nerves or by
shutting off the supply of oxygen. In this instance we have to deal only
with the fear of flooding the respiratory tract.

If we recall the fact that the human trachea is about four and
one half inches in length, and from three fourths of an inch to one
inch in diameter,* and that it opens into the bronchi which in turn
open into the lungs, the respiratory surfaces of which are estimated to
be 180 square meters,^ and that this large pulmonary surface is covered
with epithelium which is capable of absorbing liquids as well as gases
and vapors,' and furthermore that the quantity of liquid thrown into
the trachea at one sitting rarely exceeds one-half ounce given one
drachm at a time, it is plain that there is no danger of shutting off
the supply of oxygen.

The fear of inducing severe cough is equally groundless. It should
be borne in mind that remedies introduced into the trachea are dis-
solved either in olive oil, distilled glycerine or in one of the bland
petroleum oils, substances which do not irritate even that portion of the
larynx supplied by the superior laryngeal nerve, and that when these
solutions are properly administered the quantity which comes into
contact with the larynx is so small that very little cough is produced.
Those portions of the respiratory tract below the larynx are much more
tolerant. Solutions which would greatly irritate the larynx produce
only a feeling of comfort when applied to the mucous membrane of
the trachea, bronchi and lungs.

In a paper read before the Laryngological Section of the Academy
of Medicine in 1896, I outlined the technique then used which pre-
supposed a knowledge of laryngology. A larger experience has shown

* Kirk^s Physiology^ page 380, Edition 1892.

* Gray s Anatomy, page 927.

' Dalton's Physiology , page 274.

188

ithat special laryngological training is unnecessoy. This method of
4ieatment can be used by any physician, and f urthennore patients may
'>be instructed to administer it to themselves.

An ordinary aspirating syringe holding two drachms, to which
Ihas been fitted a curved endolaryngeal tube seven inches in length is
-tJl that is required in the way of apparatus.

The patient is seated with his tongue drawn out, and his head
thrown back. He is instructed to breathe out The physician then
introduces the tube, keeping in the median line and carrying the curved
portion over the base of the tongue, raising the elbow high enough
io insure the point of the tube passing under the edge of the epiglottis.

The patient is then instructed to avoid swallowing, to keep the
tongue well drawn out and to take a deep inspiration. As the patient
inspires, the contents of the syringe is thrown quickly into the larynx,
the ingoing current of air causing it to pass directly into the trachea
which causes almost no laryngeal irritation.

This process is repeated, giving one or two drachms at a time until
the requisite quantity for one treatment has been administered.

Thsbapxittio Valus. Any form of medication is useful, just in
proportion to its power to fulfill one or more of the following indica-
tions:

1. To remove the cause of the disease.

2. To modify the course of the disease.

S. To restore normal physiological action.

4. To disinfect the diseased tract.

5. To add to the comfort of the patient.

The value of remedies depends upon the manner in which they
.-affect the organism. If they promote constructive tissue-metamor-
phoeis, they are tonics. If they increase retrograde tissue-metamor-
phoeis they are alteratives. If they destroy microorganisms or mor-
bific germs they are antiseptics.

Methods of medication as well as remedies have a therapeutic
value. It is well known that medication by inunction or by hypodermic
injection is frequently more efficacious than medication by the stomach.

Intratracheal medication has like obvious advantages.

It is objected that medicine introduced directly into the tradiea,
•l)ronchi and lungs, passes over and into portions of the respiratory tract
which are not diseased. This is true. It is also true that remedies
given by the stomach affect not only the diseased portion but modify
the nerve action of the whole body.

13D

It is probable that the good results of medication may be largely
due to this fact. It has long been recognised that if one member suf-
fers all the members suffer with it, and that by a modification of the
action of the whole nervous system, the normal equilibrium is the
sooner restored. Primarily, a local impression, a topical effect is
intended, but it is probable that no action can be confined to the part
iicted upon. Absorption takes place, producing effects analagous to
ihcse produced when the remedies are given by the stomach, in addition
to which there is a mechanico-therapeutic action due to a stimulation of
the end-organs of the nerves supplying the part, causing a reflex tonic
influence to be sent to the diseased tract from the brain or spinal cord,
or from the ganglionic centres, which have been shown by Vulpian Qslz
and Heidenhain to esist in the nerve supply of the vessels and which
perform the functions of nerve centres within their immediate sphere.^

The effect of stimulating an afferant nerve, by its influence on
the vaso-motor centre may be either to dilate or to constrict the arteries,
producing a paradoxical effect, viz. — a general vascular constriction
•and therefore a general increase of blood pressure, but at the same tibne
a local dilatation which must evidently have an immense influence upon
nutrition by increasing the flow of blood through the part. The vaso-
motor and trophic systems are peculiarly impressionable to peripheric
■Stimulation and therefore through the intermediation of this nervous
apparatus important changes may be wrought by even slight counter-
irritations.

This plan of treatment has an immense advantage over all other
methods. The remedy is applied directly to the irritated mucous
surface in a quantity sufficiently large to immediately alleviate the
most distressing symptoms. In a certain number of cases the antisep-
tic effect is very pronounced, as shown by the longer interval between
the febrile attacks and by their lessened intensity when they do occur.

In cases characterized by an atrophic condition of the tracheo-
bronchial mucous membrane or pulmonary disease with cavitation
leading to retention and decomposition of the secretions, intratracheo-
l>ronchial medication rapidly changes the character of the sputa and
removes the disgusting fetor of the breath.

This alleviation of annoying symptoms adds greatly to the com-
fort of the patient. He breathes more easily and deeply. His appe-
tite improves. His color is better. His courage returns. Hopeful-

* Kirk^ s Jfhysiology ^ Edition, 1896, page 241.

140

ness takes the place of despair and he is encouraged to make a deter-
nuned effort to regain his health.

Notwithstanding its many advantages, intratracheal medication is
not brought forward as a sure cure for tuberculosis^^ but rather as a
powerful adjunct to other treatment and I venture to hope that this
article may contribute something towards calling the attention of the
profession to a method of medication at once simple, safe and easily
applied

CULTURE PRODUCTS IN THE TREATMENT OF TUBERCULOSIS.*

BY r. M. POTTENOER, PH, M., M. D., LOS ANGELES, CAUFORNIA. FORMERLY

ASSISTANT TO THE CHAIR OF SURGERY IN THE ONaNNATI COLLEGE

OF MEDiaNE AND SURGERY, aNONNATI, OHIO.

In presenting a paper before tlus society upon the subject which I
have chosen, I recognize full well that there is no specific remedy for
tuberculosis, which is recognized by the medical profession generally;
none which corresponds to antitoxin in diphtheria, the iodides and mer-
cury in syphilis, or quinine in malaria ; yet there are certain remedie*
which, while they have enjoyed only a limited trial by the profession,
are found to have a specific action upon tuberculous tissues wherever
found.

That the value of these products has not been recognized is due to-
a misconception of what should be expected of such remedies. Anti-
toxin is recognized as the anchor of hope in diphtheria ; yet the profes-
sion well knows that, to be efficacious, it must be used early ; and all
things being equal, the prognosis varies with the early or late admin-
istration. So it is with other diseases. The earlier the case falls into
the physician's hands the better. In surgery, we know the knife is a
specific for many troubles; yet its field of usefulness is limited, and
after a certain point in the disease has been reached this specific fails.
While the field of these specifics is limited, yet their value is recognized
and in no way impaired by the fact of this limitation. On the other
hand, the profession bends every energy to bring the cases under treat-
ment during the period when the remedies are valuable. In the case
of tuberculosis, however, the profession has not been satisfied with a
remedy of limited value. It has been unreasonable, and demanded that

a remedy to be useful and to be recognized must not only cure tub er-
■■ — ' • ^

* Read before the Los Angeles Academy of Medicine, Nov. 8, 1901.

Reprinted from the Therapeutic Gazette, Jan. 15, 1902.

141

culoeis, but remove dead and decaying tissue ; not only cure the disease,
but remove all results caused by the disease. Such demands are unfair
and preposterous. If the same test were applied to other remedies,
how many would stand ? In tuberculosis we must demand no more of
a remedy, and no less, than in other diseases. As the followers of the
healing art we should seize upon everything that will help, and apply
it to the advantage of the patient, not discard even the smallest thing
that wUl aid us to combat disease. To correctly estimate the value of
a specific remedy in tuberculosis, we must properly define our disease.
We must distinguish between tuberculosis and consumption. Tubercu-
losis in its early stages— that is, while it is pure tuberculosis— is*a very
curable disease, yielding as readily to treatment as typhoid fever or
pneumonia. But when this pure tuberculous process has changed, and
its place has been taken by ulcerations, cavities, cheesy nodules, and
these often surrounded and embedded in fibrous tissue — ^in other words,
when consumption has supervened — then the picture is different. We
have not pure tuberculosis to deal with, but the results of tuberculosis.
Tuberculosis itself will yield readily to treatment, but these results are
very difficult to combat, and a remedy for the former should not bo
expected or required to remove the latter. It would be as reasonable to
ask of a remedy for a surface ulcer to remove the resulting scar. So, if
we have a remedy at our command which can be shown to have a spe-
cific action upon tuberculous processes, we should hail it with delight,
not demand of it that it remove cavities and cheesy nodules ; but we
should improve our method of diagnosis so that we might recognize
the disease while it is in the purely tuberculous stage, and while the
remedy \b applicable.

Advances in the field of medicine, as elsewhere, are slow to be
recognized. Every new theory must force its way against the preju-
dices of preconceived ideas; and, if at all revolutionary, meets most
bitter opposition. Harvey, when he had called his confreres together
and made a thorough demonstration of the circulation of the bloody is'
reported to have said : '^ Alas, I cannot make a single man over forty-
five years of age believe it !" Although vaccination has almost driven
smallpox from civilized lands, yet we now and then meet so-called phy-
sicians who are opposed to vaccination. The germ theory of disease is
doubted by some, and the efficacy of antitoxin is not unquestioned.
Is it any wonder then that the value of culture products in tuberculosis
is not recognized?

It is unfortunate that the field of medicine is so large that we can-

142

not prove the value of new theories for ourselves. Such independent
work and thought would be wholesome, but with the cares and respon-
sibilities which are forced upon us^ we can only investigate some small
field wherein our greatest interest lies, and this in a very unsatisfac-
tory way. The greatest portion of our knowledge we are obliged to
take second-hand from men whom we recognize as authorities; and,
when we know how often they are mistaken, it behooves us to do as
much origin/il investigation as possible. Conservatism is a safeguard,
and it is praiseworthy, but it should not lead to blindness. 'New meth-
ods of combating disease should be weighed carefully and tested thor-
oughly before acceptance or rejection ; but it is hardly fair or just for
the great majority of the profession to reject a remedy, although they
have never tried it, simply because certain noted men say it is useless,
when at the same time other equally noted men are obtaining good
results by its use. In the examination of sputum, one positive evidence
of bacilli will outweigh a dozen negative results ; so in the employmeu t
of new remedies one unquestioned result should outweigh a dozen fail-
ures. By the use of the culture products in the treatment of tuber-
culosis many ciires have been made; but these have been lost from sight,
because in certain other cases cures were not effected.

In 1890 the medical world was startled by the announcement that
Professor Koch had discovered a lymph which would cure tuberculosis.
This news was received with delight. Unfortunate victims from all
parts of the world looked to Berlin for life. Physicians left their
busy practices, and went to see the great master administer his reputed
cure. Perhaps there never was a discovery made in medicine from
which such great results were expected. But, alas, how quickly theso
hopes were blasted ! Those who saw the administration of the remedy
at this time of unfortimate trial were so disappointed in not seeing
patients in the last stages of consumption restored to health that they
overlooked all good results that were obtained, and returned to their
respective homes with nothing but hostility in their hearts toward the
new lymph. They did not take into consideration that tuberculin was
a new remedy on trial for the first time, and that its limitations and
the proper mode of its administration were to be determined by clinical
experience.

It must be remembered that Professor Koch was forced to disclose
his remedy before he was ready, and before he had determined the
mode of its action, or had learned the proper method of administration. '
He was in a new field, and should have had the assistance of the med-

143

ical profession in determining the use of his vemedy. But with that^
respect for authority which is characteristic of the German race, those
who believed the remedy to be used in a faulty manner were af raidi
to say sOy lest they should offend the master ; so the improper adminis-
tration continued/ with its disastrous results to tuberculin.

A careful study of the literature of the time should convince any
fair-minded man that, whether or not the remedy possessed any virtues^
it was not used in a proper way. And when we consider it iji the light
of our present knowledge of the culture products, we are able to point
out the mistakes which then were made, and judge it according to ittw^
actual worth.

In the first place, Professor Koch recommended its use only ilk
the early stages. In this he was right, for its curative value lies ivp
its action upon the newly formed or recent tubercles. While there are-
areas of greater or less extent even in advanced cases where recent
tubercles are found corresponding to the more recent advances of the-
disease, 'yet when a remedy of such great importance is on trial it ift
wrong to cripple its usefulness by the choice of improper cases. If
used properly we can expect and often see the recent tubercles disap*
pear from a patient's lungs, in whom the disease is far advanced, and
whose vitalitv has been much reduced; but when the eves of critics
are sharpened, it is better to confine the remedy to those cases wherein
it is known to be of value. In spite of Professor Koch's recommenda-
tions, patients whose lungs were riddled with cavities, and whose con^-
stitutions were worn by the long-continued drain of suppuration, and
whose vitality was destroyed by continued high fever, were subjected
to treatment, with the only result that should have been foreseen —
disappointment. In order to Have satisfied those who were posing as
critics of tuberculin, it would have been necessary for the remedy to
have removed dead and dying tissues, to have cured suppurating foci^
to have removed all symptoms resulting from a heart long overbur-
dened, and to have restored to normal a system whose organs were all
more or less diseased. When such a remedy has been found, it will be a
specific, not only for tuberculosis, but for all diseases to which man-
kind is heir. But even in these cases, unsuitable as they were, had
the remedy been administered in the proper doses good results might
have been obtained, and at least no harm could have been done.

The second mistake which was made was the administration of too

.large doses. This dosage depended upon the erroneous view which

Professor Koch held as to the manner in which tuberculin acted. He

believed that the end desired was the destruction of the granulation

-•■^

144

tissue surrounding th6\ tubercles, thus allowing the defensive forces
of the body to attack the germs in siiu; or by liquefaction to secure
tie expulsion of the tuberculous tissue. In order to produce this resuU
doses were given which caused severe reactions, both local and gen*
eraJ. The temperature was often elevated to 104® and 105® F., and
the remedy administered at such intervals that the patient was kept
in a constant feverish condition. As a consequence the patients lost
appetite, became emaciated, and soon succumbed; and all such
results were recorded as scores against tuberculin. Instead, they
^ should have been considered as due to the improper use of tuberculin.
Strychnine is a valuable remedy and capable of producing brilliant
results when administered in doses of 1-60 to 1-20 of a grain, but when
given in 1-grain or 2-grain doses it destroys the patient. This poison-
ous effect is one of the characteristics of the drug, and is taught to the
profession ; but in no way handicaps the remedy, for the residt desired
is obtained without the poisonous effects. So it is with tuberculin. In
small doses it is capable of producing beneficial results. In large doses
it produces poisonous results. But the fact that it was administered
in poisonous doses almost exclusively in the early period of trial in
1890 and 1891 caused the poisonous symptoms to be considered as the
only ones which the remedy was capable of producing. Instead of
recognizing the brilUant results in lupus and early stage cases of pul-
monary tuberculosis, even when the remedy was used in what would
be considered to-day a faulty manner, and thus making the physician's
armamentarium richer by one valuable remedy, the hostile critics
could see nothing but harm; so they gave out the erroneous idea, from
which the medical world has not yet freed itself, that tuberculin can
produce no good results, but on the confttiry is liable to do much harm.
To show the method of administration, I will cite some examples from
the literature of that time.

January 17, 1891, a patient in von Leyden's* clinic had a paracen-
tesis made, removing a clear, serous exudate. Examination showed
rales in the right apex, relatively dull percussion note, slightly tym-
panitic, and diminished respiration. The spleen was somewhat enlarged.
Temperature 100.4® F. ; next day after the operation, 102.5® F. On
the 19th an injection of two milligrammes of tuberculin was given. By
February 12 the patient had received ten injections, the last being 50
milligrammes. During the period the patient became rapidly worse.
On February 10 the temperature reached 104® F., where it remained

^ Berliner Klin. Wochenschrift, ^891, p. 237.

145

contmuously until the patient's death on the 19th of February. Reu-
timeyer* reports a case in which he gave eleven injections in eleven
days, in spite of reactions of 104® F.

These two cases are not exceptions, but such was the method
employed generally when tuberculin was first put upon trial. Had
these patients received as an initial dose one-tenth milligramme, and
then a gradually increasing dosage, so as to avoid fever reactions,
they would have had the benefit of the specific action which the remedy
possesses over tuberculous foci ; many of them would have been bene-
fited, some would have been cured, and culture products to-day would
be warmly praised by the medical profession in the treatment of tuber-
•culosis.

Besides being held accountable for the effect produced when used
in unsuitable cases, and when administered in poisonous doses, tuber-
•cuUn was also held responsible for all post-mortem findings. Patholo-
gists who before had found so little interest in tuberculous lungs that
they had only given them a casual glance, now began to make the most
minute exaimnations. Every finding was carefully recorded and as-
cribed to the advent of tuberculin.

Perhaps the work of Virchow had more to do with the discreditiug
of tuberculin than that of all other critics combined; and, strange to
say, those who have quoted him have made his utterances much more
hostile than they really were. Virchow made the post-mortems and
recorded his findings; but much of the interpretation that has been
put upon them is not his, but that of others.

One of the commonest objections that has been urged against
tuberculin is that it is prone to produce acute miliary tuberculosis; and
^critics assign the authority for this statement to Virchow. This he did
not say. The error comes from a juggling of words. He said that in
the various organs of the body "miliary or subnuliary nodules were
observed,'' but did not ascribe them to the remedy, except in a sugges-
tive way, saying :^ "I have only shown what we have found ; I believed
— and I think there is here sufficient evidence — ^that this exhibition
wonld show the magnitude of the danger which might arise. How fre-
quently this danger arises, in what cases it arises, by what it is especially
•caused, are questions that can be definitely decided only after long
research." Krause,^ in a review of VirchoVs criticisms, says: "In

* Berliner Klin. Wochenschrift, 1898, p. 124.
^ Berliner Klin. Wochenschrift^ 1891, p. 191.

* Journal of Tuberculosis^ vol. ii, p. 246; translated from Z«/f^Ar^ y^^r
Hygiene und InfecHonskrankheiten^ vol. xxxiii, 1900.

146

order that they might account for these miliary tubercles, so frequently
observed, Virchow and his pupils, especially Hansemann, assumed that
the eruption of tubercles occurred regularly during the injections. For
this assumption both master and pupil are without a proof, because
pathological anatomy has not yet found a criterion by which one can
determine the age of a tubercle." To make tuberculin responsible for
these ^'miliary and submiliary nodules," it would be necessary at least
to show that they occurred only during its administration ; but these
same miliary nodules are found when tuberculin has not been admin-
istered. Petruschky^ reports that he has observed constantly fresh
miliary crops around old tuberculous foci in consumptives who have
died with evidences of secondary infection, but who had never received
tuberculin.

That acute miliary tuberculosis could be so frequently produced by
the injection of tuberculin as to make it one of the chief dangers of
its administration is almost too absurd to receive notice; but since it
has been so generally believed, we will examine into the supposed
danger. Acute miliary tuberculosis can only be produced in one way,
and that is by the tubercle bacilli finding their way into the general
blood stream, either "by the rupturing of a tuberculous focus directly
into a pulmonary vessd, or into the thoracic duct." How often this
happens we may judge from the investigations of Kossel,^ who together
with a number of other investigators examined the blood in 800 cases
that were treated with tuberculin, with only three positive results, and
one of these doubtful. He expressed his opinion as follows: "I am
convinced after a great number of negative results that, a dissemination
of tubercle bacilli into the general blood stream of patients treated with
tuberculin does not take place." That such an accident might occas-
ionally happen when the remedy was administered in doses sufficient to
cause high local as well as general reactions can be believed; that it
would happen during the proper admimstration of tuberculin can
scarcely be conceived. However, granting that such an accident should
occur during either the faulty or proper administration, it would carry
little evidence against the remedy, for a focus which would break down
so easily under the use of the remedy would have likely broken down
without it, and, scattering the bacilli in the blood stream, cause the
same acute miliary tuberculosis.

* Paper before Berlin Congress; quoted xn Journal of Tuberculosis vol. ii^
p. 63.

^ Berliner Klin, Wochenschrift^ i89i> P- 471-

147

Another supposed danger attending the nse of taberctdin was that
it might 'Mobilize latent foci" which were ^'apparently innocent.'^
Such a result haa never been shown ; so the burden of proof still rests
upon the critics. And^ granting that the dangerous results which
were pointed out did actually obtain under the gross misuse to which
tuberculin was subjected^ it would have absolutely no weight in the con-
sideration of the remedy when administered properly.

Virchow said :^ *T[ think that we may now with certainty say that
any process that can be brought about by tubercplin can also come
about without that remedy, but the course certainly often seems to
be extraordinarily hastened."

Even in spite of the disastrous results caused by bad selection of
cases, and improper dosage, there were a few men who could not help
seeing the true value of the remedy. These began to use it cautiously,
and with one accord determined that its proper administration coi)sisted
in beginning with small doses and gradually increasing as toleration was
established, but always avoiding marked local reactions and general
reactions entirely. Under this mode of administration, von Bardeleben,
Guttmann, Eenvers, Ehrlich, Petruschky, Comet, Goetsch, Turban,
Ejauae, and many other noted men abroad, as well as von Ruck, Whit-
taker, Denison, and others in America, report excellent results. It is
the general experience of all those men, who have carefully and pains-
takingly sought to do the remedy justice, that tuberculin is a very use-
ful remedy, that it has a specific action in tuberculous cases. Professor
Petruschiy^ says: "If in its (tuberculosis) treatment we desire to
attain success, we must bring to our resources all means which are
available to medical science, and a prominent one of these is imdoubt-
edly tuberculin. After nine years of trial of the remedy it is possible to
arrive at a conclusion of its value. Only a comparatively small number
of physicians* have used and studied this remedy continually during
this time, but it is significant that these have arrived at a favorable
judgment of its value."

Dr. Goetsch' reported his experience in one hundred and seventy-
five cases of pulmonary tuberculosis treated, with tuberculin during the
past ten years. Of the cases treated, one hundred and twenty-five, or

* Berliner Klin. Wochenschrift^ 1S91, p. 191.

* Paper before Berlin Congress ; Reported in Journal of Tuberculosis^
vol. II, p. 62.

• Deutsche Medicinische Wbchenschrift, 1901; quoted in Journal of Tu-
berculosis , vol. iii, p. 277.

148

seyenty-one per cent^ were cured. This report was made at the sug-
gestion of Professor Koch, and to it he appended a note, in which he
said: '^AU physicians who have had considerable experience with
tuberculin treatment^ and have published the same (Spengler, Turban,
Petruschky, Erause, Thomer, Heron, Bembold, Bandolier), assert that
if the treatment is restricted to purely tuberculous and not too far
advanced cases — that is to say, non-febrile cases of pulmonary tubercu-
losis — ^the influence of the remedy is favorable without exception.''
Should not the testimony of these clinicians, whose experience has
extended over the entire period from Koch's announcement in 1890 to
the present time, outweigh the doubt expressed by the hosts of physi-
cians who have never given the remedy a trial? Again, I repeat,
one positive result should outweigh a dozen failures.

I have endeavored to present in a clear light the circumstances
under which tuberculin, the first culture product used in the treatment
of tuberculosis, was given its trial by the medical world, and I have
endeavored to show why it has been held in such disrepute. Now let us
make a more caref id study of tuberculin itself, and those other culture
products which have grown out of it.

Soon after the germ theory of disease was propounded, bacterio-
logy became the most active branch of medicine. In the laboratories
the action of germs was carefully studied. In 1888 Charrin^ discovered
that the blue color sometimes seen on wounds and dressings was due
to an organism, which, when inoculated into animals, caused death by
septicemia. He found also that by inoculating the animals with steril*
ized cultures of the same bacillus they were rendered immune to the
inoculations by virulent cultures. Brieger and FrankeP found that the
filtered culture fluid of the diphtheria bacillus, when heated to 60^ or
70^, had protective properties, rendering guinea-pigs insusceptible to
inoculations with diphtheria virus. *

Such observations as these, many of which were made at that time,
led to the conclusion that pathogenic organisms produce a certain sub-
stance during their growth which is inimical to the organisms them-
selves.

The observation which led to the discovery of tuberculin was as
follows: Professor Eoch found that when healthy guinea-pigs were
injected with virulent cultures of tubercle bacilli, during the first few
days the wound healed; but after two weeks nodules formed, which

' Arch, Gen. de Med,, Paris, i88t, vol. ii.

' Untersuchungen ueber PtamcUns, dritte Thcil., «. 85, 1886.

149

broke down and continued ulcerating until death. But guinea-pigs
already tuberculous, when inoculated at the first showed the same small
wound; however, nodules did not form, only a general induration
appeared about the point of inoculation, which later became necrotic,
sloughed off, and quickly healed, without the lymph glands even
becoming infected. When, instead of virulent cultures, dead cultures
were used in healthy guinea-pigs, a local suppuration occurred ; while in
tuberculous guinea-pigs, even small doses caused death ; but if the cul-
tures were much attenuated and administered very gradually, the dis-
ease, unless too far advanced, came to a standstill. From these obser-
vations, Koch concluded that tubercle bacilli, during their growth,
produce a substance which has curative properties in tuberculosis.
After a series of experiments he produced tuberculin, which is the
culture fluid upon which bacilli have been grown, concentrated to one-
tenth, its original volume, and filtered.

Klebs found that tuberculin contained substances both beneficial
and toxic, and by certain methods of treatment produced tuberculocidin
and antiphthisin, for which he claimed the advantage of tuberculin,
without its toxic working substance.

One of the most enthusiastic workers in the field of culture pro-
ducts is our own fellow cotmtryman. Dr. Karl von Ruck, of Asheville,
N. C. When Koch made his announcement, von Euck hurried to Ber-
lin, and through his friendship with Dr. Paul Guttmann had special
opportunities offered him to study the new remedy. While he saw the
mistakes that were being made in the administration of tuberculin, he
also noted the good results that it was capable of producing.

Coming home. Dr. von Buck began experimenting in his own lab-
oratory, and as a result in a few years produced tuberculinum purifica-
tum, which was made by boiling the culture fluid containing the bacilli,
in vactto, at a temperature of 130^ F. for two or three months. By
this prolonged boiling and maceration a considerable portion of the pro-
teids from the body of the bacillus was brought into solution.

If the culture fluid contained the substance which was beneficial,
it must come from the bacillus; hence the bacillus must contain it,
either as secretion or excretion. Now, instead of using the culture fluid
alone or in part, Koch produced a new remedy by the pulverizing of
dried cultures in a mortar and mixing them in distilled water. The
mixture was then thoroughly centrifuged. This was given forth in
1897 as tuberculin K. In this preparation Koch believed that he had
obtained a true solution of the bacillus, hence obtained the most com-

150

plete remedy that could come from cultures. It wbb shown that this
preparation was an emulsion containing not only fragments of bacilli,
but entire bacilli, which were still virulent ; hence the preparation was
soon withdrawn from the market However it has since been freed
from this disadvantage, and used with marked success.

In 1896 Dr. von Buck succeeded in producing a true solution of
the tubercle bacillus, which he calls the watery extract of tubercle
bacilli. The method of producing it is as follows :*

^The tubercle bacilli are filtered out of the rapidly growing and
highly virulent culture. After washing with distilled water for the
removal of the remains of the culture fluid, they are dried in a vacuum
desicator. "Next they are powdered in an agate mortar, and then
extracted with sulphuric ether. This extraction removes the fats.
They are again dried and powdered as bef ore, and their further extrao-
tion takes place in ^erilized distilled water over a vacuum bath, with
a temperature of 120^ F. The proteids becoming dissolved in the dis-
tilled water, the fluid is then decanted and filtered through porcebun,
when finally the amount of proteids is determined and the preparaticMi
standardized to a certain per cent.''

This is entirely free from culture fluid, and is the most refined of
all the culture products, and its efficiency has proven to be superior
in the hands of aU who have used it.

Thus we can see a gradual evolution in the production of these
culture products. First, the pure culture fluid was used — tuberculin;
then a purified culture fluid — ^tuberculocidin and antiphthisin ; then a
mixture of culture fluid and proteids from the bodies of the bacilli —
tuberculinum purificatum; then an emulsion of bacilli and fragments of
same — ^tuberculin R. ; and finally a pure solution of the bacilli — ^watery
extract. That this is the end we do not know. We hope not. Yet we
have in this last a product whose value cannot be questioned by any one
who will give it a reasonable trial. All of these products are of value,
and deserve a place in the history of the combat with tuberculosis. I
have had personal experience with all of these products in treatment,
except tuberculin (my experience with it being confined to maViTig the
tuberculin test), and I have been surprised that their worth has not
been more generally recognized.

In what manner these culture products act is still debatable. Var-
ious theories have been offered. The original explanation of Koch that
tuberculin broke down the granulation tissue surrounding the tubercles

* Therapeutic Gazette ^ June, 1897.

151

and allowed the def enfiive forces of the body to attack the bacilli^ or
by this breaking-down caused the tuberculous masses to be thrown oS,
was never accepted by those who placed any value upon the remedy,
because they considered it absolutely essential to avoid the reactions
whidi would cause such a result.

Landgraf ^^ who observed the disappearance of tubercles in the
^choroid and also on the epiglottis under the use of tuberculin, gave it as
his opinion that the action of tuberculin '^is not, as was maintained, an
acute necrosis and throwing off nor a suppurating process, but an acute
cheesy degeneration of the tuberculous granulation masses followed by
their absorption.''

Krause^ says: ^^It is well known that tuberculin has no effect
upon the actually tuberculous tissue (the tubercle with its necrotic cen-
ter), but only upon the newly formed tissue, which is richly supplied
with blood-vessels and surrounds the tubercle."

Biedert' says: '^When the irritation (caused by the local reac-
tion) is moderate, an increased cell growth takes place in the encapsu-
lating wall of the tuberculous process. If the inflammation is more
intense, marked exudation occurs, while in the stage of extreme inflam-
matory irritation, cell death, necrosis results.*" Trudeau^ says it acts
^^probably by inciting the formation of fibrous tissue." .

These quotations refer to tuberculin, but since all these culture
products contain perhaps the same active principle, they will apply to
the others likewise. My experience with the culture products would
lead me to believe that they have an action which causes absorption
and removal of recent tubercles; otherwise the roughened and
enfeebled respiratory notes would not become normal when healing has
taken place.

The many opportunities offered for studying these remedies, where
the action can be watched by the naked eye, should furnish sufficient
evidence to convince the most skeptical that in culture products we have
remedies which are a specific in their action upon tuberculous lesions.
Even the earliest reports made, thoQ§ during the fated years of 1890
and 1891, are replete with such evidence. Albrant saw the complete

^ Berliner KlifUsche Wochenschrift, 1891, p. 286.

■ Zeitschrift fuer Hygiene and InfecHonskrankheiteny vol. xxxiii, 1900;
translated xn Journal of Tuberculosis y vol. ii, p. 24a.
^ Berliner KUn. Wochenschrifty 1891, p, 197.
* Transactions of the Association of American Physicians ^ 1900.

152

disappearance of a conjunctival tuberculosis ; Landgraf * that of tuber-
culous processes of the choroid and epiglottis ; Renvers* cured a patient
whose pharynx, epiglottis, and mucous membrane over the arytenoids
were covered with ulcers ; Koenigshof er and Maschke' obtained cures in
tuberculous corneal ulcerations; while it was not at all unconmion to
see cases of lupus yield to its administration. The literature of recent
years also bears much valuable testimony in such cases. Dr. von Ruck*
reports many cases of laryngeal tuberculosis in which the lesions have
disappeared.

Schmidt* insists upon the unmistakable benefit derived from tuber-
culin in the treatment of mild cases of laryngeal tuberculosis where
surgical interference is imcalled for, and cites many cases cured by
such means. Dr. Hale® reports a very interesting case of tuberculosis
of the nose, in which the triangular cartilage was entirely gone. There
was a large ulcerating surface discharging pus along the inner surface
of the left ala of the nose, also ulcerations upon the uvula. The dis-
charge showed tubercle bacilli A complete cure was effected by the
use of tuberculimmi purificatum (von Ruck). During the past winter it
was the writer's pleasure to see an ulceration of the left vocal cord in
a patient who had lesions m both Itmgs heal under the use of the watery
extract. While in many cases such as these healing has been observed,
the great field for the culture products is in the treatment of pulmonary
tuberculosis. It would be enough to make the names of the discoverers
of these products inmiortal if their field of usefulness were limited to
the cure of visible tuberculous infiltration and ulcers only, particularly
those affecting the larynx, which complicate nearly one-fifth of all pul-
monary cases, and which heretofore have almost baffled treatment. But
the results obtained in the lung are no less brilliant, as they are
observed by the ear of the trained diagnostician.

To make a fair test of culture products in pulmonary tuberculosis,
one must, in the first place, be able to interpret the pathological condi-
tion by the physical signs, so as to know what is removable and what is
not. Secondly, he must have sonie means of comparison. It is impos-

^ Berliner Klin. Wochenschrifty 189 1, p. 285.

* Deutsche Med, Wochenschrifi^ 1891, p. 512.
^ Deutsche Med, Wbchenschrifi, 1891, p. 76.

* Journal of Tuberculosis, vol. i, p. 22, and Clinical Report from Winyah
Sanitarium for the years 1899 and 1900.

* Krankheiten der Oberen Luftwege, 1898.
^ Journal of Tuberculosis y vol. iii, p. 239.

153

sible to carry in one's mind the percussion and auscultatory signs of one
ease, let alone a dozen; so, if one wishes to know whether or not his
cases are improving, he should make systematic examinations, say at
least once a month, and' record his findings upon a chart for comparison
at the next examination. Thirdly, he must remember that the remedy
must be used for a length of time. Slight results are often seen during
the first month of treatment, and during the second the change becomes
more evident. But, finally, when the recent tubercles have all disap-
peared, and one has to deal with dead and decaying tissue, he must not
become impatient because of the time that it takes to heal such lesions*

Let us next consider whether there is any ground for claiming an
advantage for culture products over the hygienic, climatic, and ordinary
medical treatment of tuberculosis. To this end we wUl bring forth the
statistics of various men who have had considerable experience in tuber-
culous work.

In 1891 Langenbuch and Wolffs reported 99 cases treated with
tuberculin, and 99 without. Of the former, 33 were cured and 40
improved ; of the latter, 9 were cured and 45 improved. Of tuberculin
cases, 78 per cent, were improved and cured ; of those treated without
it, 54 per cent, were improved and cured.

Goetsch, in a recent report, referred to above, sums up his experi-
ence since 1891, as having treated 175 patients, and cured 125, or 71
per cent. The remaining 50 patients interrupted the cure from time to
time, so the results were less favorable.

Heron^ since 1890 has treated 51 cases of pulmonary tuber-
losis with tuberculin. At the end of 1900, 17, or 33 1-3 per cent., had
been lost sight of. Of the remaining 34, 16, or 47 per cent., were well
and earning their own living. Ten of these had been discharged seven
years.

Krause* in six years had treated 27 patients of whom 12 or 44.4
per cent, are weU and 13 or 48 per cent, are improved. Deni-
son* reports 196 cases treated by culture products, including all the
various products from tuberculin to watery extract. His results
show an apparent recovery of 34 per cent., and a marked improvement
in 42 per cent. He remarks that this was not a list of easy cases, the
following complications being present : "Lupus three cases, meningitis
two, Bright's disease one, pyoneph ritis one, tuberculous kidney two,

Deutsche Med, Wochenschrift, 1891, p. 935.

* Paper before London Tuberculosis Congress, 1901.

' Cited in Heron's paper before London Tuberculosis Congress, 1901

* Journal of Tuberculosis, vol. iii, p. iii.

154

glandular cases six, joint tuberculoeis four, tabenjnioiw leBticle two,
bladder tuberculosis three, and intestinal tuberculosis two/' Of these,
49 were in the first stage; 38 second; and 109, third.

Trudeau^ makes a comparison of the incipient cases treated at the
Adirondack Sanatorium with and without tuberculin. Twenty-four
teases were treated with the remedy, of which 20, or 83 per cent., were
apparently cured; and 113 without, of which 82, or 72 per cent, were
apparently cured — a slight percentage (11 per cent.) in faror of tuber-
culin. He then chooses 50 patients discharged as apparently cured
with tuberculin since 1894, and 60 patients corresponding in lesions
and time of treatment who were cured without tuberculin, to see the
relative permanency of the cures. Three of those treated with tuber-
culin could not be traced ; so three were dropped from the list treated
without tuberculin. Of the remaining 47, 41 of the tuberculin-treated
patients remained well, l*had relapsed and was living, 4 had relapsed
and were dead, and 1 had died of insanity. Of the 47 treated without
tuberculin, 86 remained well, 6 had relapsed and were living, and 5
had relapsed and died. So we see 82 per cent, of those treated with
tuberculin remained well as against 72 per cent, of those treated with-
out it, a balance of 10 per cent, in tuberculin's favor; or, putting it in
another way, at the end of the time considered, 68 per cent, of those
treated with tuberculin remained well, and 52 per cent, of those treated
without tuberculin remained well, a balance of 16 per cent, in favor of
tuberculin. While the author says the cases treated with tuberculin
were very carefully chosen, yet he adds in another place that '^the
results in the cases classed as advanced (treated with tuberculin) were
proportionally somewhat more favorable." So, from this report, we
may say that tuberculin does imdoubtedly possess some advantages in
the treatment of pulmonary tuberculosis ; and since it is the perman-
ency of the cures that is desirable, we must find in it a valuable aid in
combating this great scourge.

Perhaps few men have had as much experience with culture pro-
ducts as Dr. von Ruck,^ who has reported 1030 cases treated with them,
with the following results: (I will insert 816 cases treated without
culture products for comparison ; as these were all treated in the same
institution, the comparis on is all the more valuable.)

' Transactions of the Association of American Physicians , 1900.
^Journal of Tuberculosis, vol. i, p. 23; Clinical Report from Winyah
Sanitarium for years 1899 and 1900; and Therapeutic Gazette, May, 1896.

155

No. of cases. Recovered. Improved

Without specific treatment 816 12.1 p. c. 31.0 p. c

Treated with Koch's tuberculin 379 3S.S 37.5

Treated with antiphthisin and tuberculo-

cidin 182 32.5 46.8

Treated with tuberculinum purificatum

(von Ruck) 166 43.4 39.2

Treated with watery extract of tubercle

bacilli (von Ruck) 303 56.1 33.7

Now, let US take statistics of cases treated without the use of cul-
ture products.

Curschmaim,* of Leipsig, says : 'TLung sanatoria give a percentage
of permanent improvement which amounts to about one-fifth of all
cases treated." This is by the ordinary sanatorium method.

Stubbert's* report of the Loomis Sanitarium for the year ending
November 1, 1899, shows 85 patients treated by ordinary sanatorium
methods, of whom 14 per cent, were apparently cured, and 62 per cent,
improved. Since the opening of the institution 456 patients have been
treated, with the result that 22.6 per cent, have been cured and 40
per cent, improved.

Hick' reports 18 per cent, as cured, 10 per cent, disease arrested,
and 26 per cent, very much improved.

Trudeau and Baldwin* report that 67 per cent, of truly incipient
cases were cured, and 11 per cent, of advanced, in a material of 800
incipient and 900 advanced cases ; 73.5 per cent, of incipient cases were
cured in 1897 and 1898.

A report of German sanatoria' recently published shows, of 5986
patients treated, an apparent cure in 7.4 per cent. Then to show the
permanency of results, statistics of 1878 patients are given, who have
been dismissed for four years. The percentage of those able to work
at the end of each y ear is noted. Of this number 424 patients were

* Address before Berlin Congress, 1899; reported in Journal of Tubercu-
losisy vol. i, p. 90. •

* Philadelphia Medical Journal^ Dec. 30, 1899.
^ Journal of Tuberculosis^ vol. iii, p. 116.

* Transactions of the Association of American Physicians^ 1900; Albany
Medical Annual^ April, 1900; The Practitioner y February, 1899.

' Results of the Open Air Treatment of Consumption, Berlin, 1901.

156

in the first stage of the disease, 863 in the second, and 373 in the third.
The results are as follows :

Patient! Able to work Plrititace. Second itaffe. Third ttaflre

at end of Percent Percent. Percent.

First year 89.1 80.3 56.5

Second year 89.1 60.7 24.1

Third year 63.7 49.2 14.3

Fourth year 44.4 16.7 0.

Among these patients the number of cures is not given; hence^
since they are to be compared with results produced with culture pro-
ducts we wiU grant that all who were able to work at the end of four
years were cured, which, of course, we know is too large a number.
Then we have 21 per cent, cured. Counting all of the remainder, who
were able to work upon dismissal as improved, we have 67 per cent.

The report of the surgeon in charge of the Army Hospital for
Consumptives at Fort Bayard, N. M.,^ shows 49 patients dismissed
prior to August 6, 1900. Of these 4, or 8 per cent., are designated aa
cured; 11, or 22.4 per cent., as convalescent; 20, or 40 per cent., as
improved.

Bowditch and Clapp,' of the Massachusetts State Sanitarium for
Consumptives, have treated 273 cases, curing 115, or 42 per cent. In
selecting these cases great care was used, 60 per cent of applicants,
being rejected.

The report for the Sailors' Consumptive Hospital at Fort Stan-
ton, IT. M.,^ to June, 1900, shows 17 discharged, of whom 4, or 23.S
per cent., were apparently cured, and 13, or 76.5 per cent, improved.

A careful comparison of these results cannot help but give one a.
favorable impression of the culture products, particularly of the more
refined culture products, in the treatment of tuberculosis. Especially
is this true of the permanency of results.

While it is diffii»alt to draw exact conclusions from a mass of sta-
tistics as given a];>ove because of the difference in classification of what
is cured and improved, and because some authors have chosen only
incipient cases and others have included all stages in their report, never-
theless I will arrange them in a table «o that it can be seen at a glance
what is being done for the tuberculous patient both with and without
the use of culture products. Those who are interested can look up the

^ Journal of the American Medical Association^ Oct. 20; 1900, p. 1003.

* New England Magazine,

^ Journal of the American Medical Association^ Oct. 20, 1900, p. loi.

loi

Apparently cured.
Per cent.

Improredi
Per cent.

33.3

40.0

71.0

29.0

44.4

48.0

47.0

32.0

40.0

33.0

40.0

44.0

CASES TRBATBD WITHOUT CULTURE PRODUCTS.

No. cases
treated

99
300
900

Langenbnch and Wolff

Trudeau, first stage

Advanced stage

Bowditch, Mass. State Sanitarium :

First stage 66

Second stage 45

Third stage 30

Clapp, Mass. State Sanitarium :

First stage 82

Second stage 40

Third stage 10

Flick

Ft. Bayard Sanitarium

Ft. Stanton Sanitarium

von Ruck

816

Apparently cured
Per cent

10.0
68.0
11.0

59.0
22.0
23.0

64.6
15.0

18.0

8.0

23.5

12.1

40.0

references and draw their own conclusions. The table comprises 12,-
669 cases in all; 1795 treated by culture products and 10,744 treated
without.

CASBS TREATED WITH CULTURE PRODUCTS.

No. cases
treated

Langenbuch and Wolff (old tuberculin) 99

Goetsch (incipient only,Koch's tuberculin) 175

Krause (Koch's tuberculin) 27

Heron (Koch's tuberculin) 34

Denlson (Koch's tuberculin) 57

Tuberculocidin and antiphthisin

(Klebs)

Tuberculinum purificatum (von

Ruck)

Various reports (watery extract of tubercle

bacilli, (von Ruck) 45

Trudeau (incipient only, Koch's tuber-
culin) ,.. 24

von Ruck (Koch's Tuberculin) 379

Antiphthisin and tuberculocidin — Klebs :

First stage 32

Second stage 74

Third stage 76

(Purified tuberculin— von Ruck) 166

(Watery extract of tubercle bacilli — von Ruck :

First stage 73

Second stage 117

Third stage 113

Various reports (watery extract of tubercle

bacilli— von Ruck) 210

49.0

83.0

35.5

37.5

81.0

19.0

35.1

56.7

9.0 •

47.3

43.4

39.2

94.5

5.5

66.6

33.3

20.3

52.2

42.0

Improved
Percent

45.0

40.0
64.0
63.0

34.0
45.0
30.0
36.0
62.4
76.5
31.0

158

Stubbert, Liberty Sanitarium :

First stage 163 58.0 36.8

Second stage 216 9.0 56.0

Third stage 77 4.0

German Sanatoria 5986 7.4 80.3

German Sanatoria* 1878 21.0 68.8

The total number of cases treated and number of apparent cnresi
both with and without the use of culture products, are set forth in the
following table for comparison:

No. cases No. of cases Apparently cored
treated Apparently cared. Per cent

With culture products 1795 806 44.9

Without culture products 10774 1486 13.8

So much that is adverse has been written on this subject that I
will add the opinions of some of the men who have tried culture pro-
ductSy and know their value.

Trudeau^ says : ^^7 experience with tuberculin treatment at the
Sanitarium thus far has led me to believe that^ when carefully applied^
in suitable cases^ it has proved apparently free from danger, and that
it has seemed to have some favorable influence in bringing about heal-
ing of the lesions, probably by inciting the formation of fibrous tissue."
Again :' ^The injections, nevertheless, seem to have had a favorable
influence in preventing the natural tendency of the disease toward
relapses, which occur in many who recover under climatic and hygienic
methods alone."

Krause* says: "The failures of the first tuberculin epoch are,
without exception, the result of the improper methods at that time
employed in the administration of the remedy. For that reason no one
is justified, on the grounds of the experience of 1891, in passing adverse
judgment upon the remedy. On the contrary, it is important that the
remedy be extensively tried anew in accordance with the now accepted
indications. For thereby entirely different results than those of 1891
will be obtained and the medical profession will be richer by one valu-
able remedy."

* In making up these percentages I counted all who were living and able
to cam a livelihood four years after dismissal from the Sanatoria as cured, as
mentioned above.

* Transactions of the Association of American Physicians^ 1900.

* The Practitioner, February, 1899.

* Zeitschrift fuer Hygiene und Infectionskrankheiten, vol. xxxiii, 1900;
translated in Journal of Tuberculosis , vol. ii, p. 255.

159

Denifion^ says: ^'Despite the charges of failure of this specific
method of treatment, made bj hasty and indiscriminating critics, it is
coming more and more to be acknowledged by those physcians who are
willing to test the matter, that there is a special and specific stimulation
of tuberculous living tissue, which is characteristic of a healing pro-

cess."

Von Buck^ says : ^The favorable and specific action of the rem-
edy becomes manifest not only in the general improvement with subsi-
dence of subjective symptoms, but in a more direct manner. • • • It
consists in the disappearance of tuberculous lesions accessible to sight
and touch, as well as of those which we recognize through percussion
aud auscultation. Tuberculous cervical, axillary, and other accessible
glands that are not caseous or fibroid, disappear under its use ; infiltra-
tions in the larynx grow less and finally disappear; and infiltrations in
the lungs revealed by slight percussion dulness, and by rough, harsh,
or broncho-vesicular respiration, with or without circumscribed catarrh,
grow perceptibly less and disappear under the treatm^it, without other
medication. These are changes which we do not note from the appU-
cation of other methods. The latter, so far as I know them, fail in
directly influencing the pathological lesions, and while they are indi-
rectly beneficial and aid in bringing about the previous condition of
latency, they do not actually cure. In this view I am confirmed by the
fact that while without specific medication subjective symptoms may
disappear, the objective evidence continues; percussion dullness over
the tuberculous areas does not clear up ; rales may disappear, but the
abnormal respiratory sounds persist in the parts which were and still
are the seat of tubercles, and the patient still reacts to the tuberculin
test ; whereas in patients that have been successfully treated with the
remedy under consideration (watery extract of tubercle bacilli) the
physical signs of recent tuberculous processes disappeared entirely, and
no reaction occurred to the tuberculin test up to the present time, even
in the earliest cases treated. . . In the cases that came under treatment
in the early stage I have seen or heard of no relapses yet. . . . That
it produces a relative degree of immunity has been shown by the animal
experiment, and clinically by the marked freedom from extension of

^ Journal of Tuberculosis y vol. iii, p. H2.

* Clinical Report of the Winyah Sanitarium of Asheville, N. C, for years
1899 and 1900.

160

tuberculous proceeses, and from relapaes of patients who are under
treatment or have been discharged."

The question is often asked, ^^Can these products do harmt" Of
course they can, the same as morphine, strychnine, or any other rem-
edy. The results of 1890 and 1891 show that they can do harm ; but it
is the experience of all those who have made a careful study of the
products, and given them a fair trial in practice, that they cannot do
harm when administered carefully. My own experience has been very
encouraging. I have made a careful study of my cases, and I have
never seen the least harm done. On the contrary, my results have
been most happy, and I do not believe that they could be duplicated
by any other treatment.

The time has certainly arrived when the medical profession should
give the culture products a fair trial. The opinions of men who have
not tried these remedies, but who have drawn their conclusions entirely
from the wrong use of tuberculin when it was first introduced, are to
be compared with the opinions of those who know from experience,
and who report the cases that have been treated and show the results
obtained. Culture products have the right to demand a trial by an
unbiased court wherein spurious evidence will be discarded, and only
positive evidence taken. All friends of these remedies will stand by the
decision.

It must be remembered, however, that the friends of culture pro-
ducts should not relax their efforts in other lines. It has been said
by the critics of men employing these remedies that they use hygienic
dietetic, and climatic treatment as well. So they do; they would be
foolish if they did not. The surgeon combines all of these with his
use of the knife, and it is considered praiseworthy in him. So those
who recognize the value of culture products find their results are much
better when their cases are properly handled, and they always endea-
vor to guide the entire life of their patients. It should be considered
as malpractice to simply inject culture products, and leave the patient
to guide his own life. With reference to this point Professor Koch is
reported to have said at the Tuberculosis Congress held in London in
1901^ that he did not wish anybody to get the idea that he himself
thought there could be any antagonism between treatment by tubercu-
lin and the outdoor treatment in or out of sanatoria. He has always
insisted that the two should go on together.

A careful review of this subject, together with practical experi-

* Reported in British Medical Journal ^ July ay, 1901, p. 214.

161

ence in the use of culture products, leads me to the following conclu-
sions:

1. Culture products do have a specific action upon tuberculous
focL

2. That this has not been recognized is due to the early unfor-
tunate experience with tuberculin: (a) When it was used in too
large and too frequent doses; (6) when it was employed in unsuit-
able cases ; (c) when it was held responsible for all post-mortem find-
ings.

3. The field of usefulness for culture products is where recent
tubercles are f ound, and this is especially in incipient cases.

4. If usea in advanced cases, culture products will help remove
areas of recent extensions, but must not be expected to remove dead,
decaying, or newly formed tissue.

5. Where culture products are used, they should be reenf orced by
every means at command. Every phase of the patient's health should
be cared for, and the proper hygienic and dietetic measures prescribed.

6. Where the case is managed properly and culture products are
used, the proportion of cures is greater than when culture products are
not used.

7. Culture products produce an inmaunity, which protects the
patient from relapses ; hence, make a permanent cure more often than
hygienic and climatic treatment alone, which fact of itself should be
enough to warrant their use in all suitable cases.

1G2

ORIGINAL TRANSLATIONS.

PULMONARY TUBERCULOSIS AND SANATORIA**

BY DR. AUFRSCHT, MAGDEBURGi PHYSiaAN-IN-CHISF TO THE INTERNAL DIVISION

or THE ALTSTADTER HOSPITAL.

My subject was not suggested to me through the highly startling
communication of Koch^ to the recent British Congress of Tubercu-
losis. On the contrary the title of my paper was announced as long
ago as last spring; but I cannot refrain, while discussing my own
subject, to express my opinion of Koch's doctrine in the consciousness
that my right to do so has been earned through long continued experi-
mental, clinical and anatomical investigations.

Koch, through his latest experiments, has brought forward evi-
dence that human tuberculosis is not communicable to cattle. He has
made injections of the sputum of consumptives and cultures of the
bacilli — subcutaneous, intra-abdominal and intravenous — and he has
also caused the animals to inhale these products ; but was never able to
induce tuberculosis by these procedures. After the experiment-ani-
mals had been slaughtered, the internal organs were invariably found
to be free from tuberculosis. The points at which the subcutaneous
injections were made were the seats of small abscesses in which were
found a few tubercle bacilli — ^the same condition in fact as that which
follows the injection of dead bacilli.

On the other hand bacilli from tuberculous cattle transmitted the
disease to healthy cattle with invariable success.

Pigs, when fed with the products of bovine tuberculosis, exhibited
the most severe lesions of the disease within a period of 3^ months.
When these animals were fed with human tuberculous sputum, they
developed no trace of the affection beyond a small nodule here and
there in the cervical lymphatics, and, in a solitary animal, a few gray
tubercles in the lungs.

Koch maintains further that, as the baciQus of human tubercu-
losis is not pathc^enic to animals, the bacillus of bovine tuberculosis
cannot produce the disease in mankind. Were the contrary true, the

*Translated for The Journal of Tuberculosis, from the Berliner KUnische
Wockenschriftf Oct. 21 and 28, 1901.

* Koch, R. The Combating of Tuberculosis in the Light of the Exper-
ience Which Has Been Gained in the Successful Combating of Other Infectious
Diseases. The British Congress of Tuberculosis, London, 1901.

163

ingestion of milk and butter which can and does often contain virulent
tubercle bacilli would produce intestinal tuberculosis, especially in
children. As a matter of fact, this lesion occurs in the latter with
great inf requency, and when present is due most probably to swallow-
ing the bacilli of human tuberculosis.

If a diagnosis of intestinal tuberculosis k to be placed beyond
doubt, the bacilli must be obtained in pure culture, and an attempt
made to inoculate cattle with them. As far as investigations have been
carried along these lines, they do not justify the assumption that bovine
tuberculosis occurs in mankind.

It therefore appears that the question of infection of human
beings through the milk, butter and meat of tuberculous cattle is of
no greater practical significance than that of hereditary transmission ;
and that in consequence it is not advisable to institute measures based
upon the contrary supposition.

I must now express a few scruples, based on my personal experi-
mental studies, against Koch's deductions. Since the publication of
my investigations upon the experimental production of tuberculosis in
rabbits in 1881^, I have carried out a considerable number of additional
experiments, and have been able thereby to establish the fact that
tuberculous substances proceeding from cows will invariably set up
miliary tuberculosis; while corresponding material from mankind
sometimes fails to transmit the disease.

When an animal so sensitive to the virus of tuberculosis as the
rabbit sometimes proves refractory to the inoculation of products of the
disease in mankind, it becomes very evident that the bacillus of the
latter affection is less virulent than that of bovine tuberculosis. What
is true of the latter does not yet hold good for the former ; or in other
words, the less virulent tubercle bacillus of mankind need not engender
bovine tuberculosis in cattle, and the much more virulent bacillus of
bovine tuberculosis may produce the disease in man.

Koch himself, however, through his own statements, gives sup-
port to such a comprehension of the matter. As already mentioned
he transmitted human tuberculosis to swine to a very slight degree.
As he states expressly that all other sources of infection may be
regarded as out of the question, the bacillus of human tuberculosis was
pathogenic here, but much less extensively and intensely so than the
germ of bovine tuberculosis. Does not this assert that the first named
microorganism is much less virulent than the latter ?

When the inf requency of occurrence of intestinal tuberculosis in

' Aufrecht, Pathologische Mittheilungen^ Heft I. Magdeburg, 1881.

164

children is adduced as proof of the absence of pathogenicity of the
bacillus of bovine tuberculosis for mankind, a territory 'is invaded
which is at present too little known to serve as a basis for deductions.
Is it necessary that the bacillus should cause a local lesion in the intes-
tine when it has qualities which enable it to infect the organism at
large ? Years ago I expressed a supposition^ that the intestinal canal
furnished the port of entry in acute miliary tuberculosis without
the production of local infection. This supposition I can now support
in a manner not to be underrated by my numerous experiments of
feeding with the products of tuberculous cattle. In not a single case
did there develop a lesion of the intestinal diucosa. But beneath the
fully intact membrane, i. e., in the mucous tissue at the site of the nor-
mal lymph follicles, exceptionally numerous caseous nodules were
found, containing bacilli. Very often these tubercles were closely
packed in the long vermiform appendix.

It is therefore shown with absolute certainty that the highly viru-
lent bacillus of bovine tuberculosis can penetrate into the tissues of the
rabbit through the mucous membrane, without causing a local lesion.
We are not justified, however, in the assumption that this fact applies
as well to the intestine of the child ; but neither is there sanction for
the claim that the inf requency of intestinal tuberculosis in the child is
evidc^nce that the bacillus of bovine tuberculosis may not penetrate the
intej^tine of the latter.

From my own experience I think we may at least infer that it is
not yet advisable to reject the quondam belief that bovine tuberculosis
is transmissible to mankind. But, however this question may be set-
tled eventually, it will not affect the subsequent portion of the present
paper.

Even before the discovery of the tubercle bacillus by Koch, I had
become convinced from my own studies that the tubercle contained
specific microorganisms. But I was unable to agree with the view that
pulmonary tuberculosis could arise from inhalation of the bacillus.
Clinical observation compelled me to deny the existence of such a mode
of origin for this affection, and to exclude the possibility that the latter
could arise from the action of the bacillus upon the healthy lung tissue.*
Consequently, upon the basis of the hitherto valid assumption, that pul-
monary tuberculosis begins with an affection of the terminal ramifica-

^ Paihologische Mittheilungen^ Heft. IV. p. 56. Die Lungenschwindsucht.
Magdeburg, 1887.

' Cf. Pathologische MiUheiiungen. Heft IV. Magdeburg, 1887 and Zur
Verhuetung und Heilung der chronischen Lungeniuberculose^ Wien : Holder.
1898.

165

tions of the air-passages, I mtist conclude that some other afiection of
the lungs precedes the deposit of tubercle bacilli.

In the meantime further histol(^cal investigation of the initial
alterations in the apices of tuberculous lungs has shown that the earlier
view in regard to the initial anatomical alterations expressed above is
erroneous. My recent studies have readily shown — and anyone at all
familiar with the use of the microscope may satisfy himself on this
point^ — ^that the changes in the lung tissue which announce the debut
of pulmonary tuberculosis have their inception in the small blood-ves-
selsy the walls of which undergo an extraordinary thickening from cell-
proliferation, while the lumen is for the most part effaced by throm-
bosis. As a result the section of lung tissue supplied by the affected
arteries is deprived of its nutriment, as in the case of an infarct. In
this manner a great number of characteristic foci, having an acinous
arrangement, are produced; the microscope showing that each acinus
is a cluster of individual berries of uniform size. Between the acini
are found areas of normal lung-parenchyma. (The more intimate his-
tological changes have been described in a previous paper).

The foregoing structural changes give us an entirely new, anat-
omical substratum for pulmonary consumption, which is bound to lead
to a complete reform in the doctrine of this affection.

The next task was to determine the relationship of the tubercle
bacillus, universally present in this affection, to the exquisite type of
vascular disease just described. With this end in view I first began
some experiments upon rabbits. Unexpectedly I encountered histolog-
ical changes in the small blood-vessels of the lungs, identical with those
already described in mankind. In the vicinity of individual cheesy
foci the vascular walls were notably thickened, and even transformed
into a deposit of granulation-tissue.

My conclusions drawn from the investigation of human tubercu-
losis were now shown to be justified. A vascular affection in foci
having an acinous distribution, precedes the tuberculous stage of the
process. When tubercle bacilli are injected into a vein of the rabbit's
ear and thence reach the pulmonary circulation, the blood-vessel is
naturally the first structure to suffer. Later the formation of acinous
foci occurs just as in man.

If, however, the bacilli in the circulation cause an affection of the
vascular wall, sufficient to convert the latter into granulation-tissue, the

* Aufrecht; Die Ursache undder oertliche Beginn der Lungenschwindsucht^
Wicn. bci Holder, 1900.

166

bacteria should be demoDBtrable in this region so attacked; and their
activity should be evidenced by something more than caseation. This
inference became a fact. In vessels thus altered the application of the
well-known double stain revealed the presence of bacilli in abundance^
both in the human and experimental tuberculosis. In the former the
demonstration was most successful in cases pursuiog a subacute course,
the lungs alone being involved.

In what manner do the bacilli reach the pulmonary vessels in
cases in which the lungs alone are infected? Inhalation according to
my anatomical findings can be excluded with even more certainty than
before, when my only evidence was clinical. Hardly anyone would
assume that the bacilli penetrate the healthy lung tissue to reach the
vessels without leaving some anatomical alteration, especially as writers
are almost imanimous in their belief that the bacilli are able to cause
initial lesions in the lung tissue.

My guiding star to illuminate the route by which the bacillus must
pass from without to reach the pulmonary vessels was the fact of the
very frequent occurrence in the human body of no other tuberculous
lesions beyond caseous lymph-nodes containing bacilli. The latter may
remain therein for years, even for decades without giving rise to tuber-
<3ulo6is. They may also cause the disease but in a self-limited form,
the original danger still persisting. My most striking case of this sort,
I have but recently seen : A girl, aged 19 years, died of volvulus, due
in turn to numerous adhesions between the intestines which produced
strangulation in the latter. I found in the mesentery of this patient
a cheesy gland, containing bacilli; the caseation of the gland, which
was as large as a pigeon's egg, was complete, and there was absolutely
no other tuberculous lesion within the body. The history of this case
disclosed the fact that at the age of four years the patient had exper-
ienced an attack of inflammation within the abdomen which terminated
in recovery only after a copious discharge of pus through the navel.
Everything here points to the probability of a tuberculous peritonitis,
and without doubt the large cheesy lymph-node dates from that period.

My observations, which agree with those of other authors in
regard to the frequent occurrence of isolated glandular tuberculosis,
lead me (with the supposition that pulmonary tuberculosis is a disease
of the blood-vessels, depending upon the penetration into the latter of
the bacilli) to the conclusion that the bacilli reach the vessels from
the bronchial glands alone. Why should not such a transfer occur from
these glands to the pulmonary arteries or their branches?

The finding of circumscribed, recent, miliary tuberculosis of the

167

lungs in children in association with a cheesj gland in the hihim in
dose relationship with the affected area, makes such an assumption
especially cogent. But the subject is no longer one of bare assumption
with me. Guided by my deductions, I caused the assistant physician
here, Dr. Goerdeler, to undertake appropriate researches into this prob-
lem. The very first experiments were rewarded by a striking degree of
success. Thus far he has investigated three cases of acute, general,
miliary tuberculosis in the following fashion: After removing the
lungs and heart in toto, he next laid open the pulmonary arteries and
veins as well as their branches; and wherever he foimd lymph-nodes
firmly adherent to the walls, he cut out such portions, which after
suitable hardening and embedding in paraffin, were cut into transverse
sections with the microtome. Each section passed through both lymph-
node and vascular wall. Proceeding thus he was able to supply clear
proof that bacilli from the lymph-node had passed into the substance
of the vascular wall without injury to the latter. Both arterial and
venous twigs were thus studded with bacilli as far as the inner surface.
One preparation showed a bacillus in an endothelial cell.

In those cases of exclusively pulmonary tuberculosis, in which
the proofs are forthcoming that a gland in the hilum can dispatch
tubercle bacilli through the wall of an arterial twig as far as the lumen,
we have plainly a faultless explanation of the method by which the
bacilli are able to produce an affection of the finer blood-vessels with
subsequent formation of an acinous focus; and if a vein is entered
by the bacillus instead of an artery we have an explanation of the
mode of origin of a general, miliary tuberculosis. Dr. Goerdeler will
make a thorough report of his investigations after a more extended
observation-period. However, we may already claim from what we
know thus far, that the mediastinal and mesenteric glands are the inter-
mediaries through which the tubercle bacillus is propagated to the vari-
ous organs of the body. The route to the parenchyma of organs is
exclusively the blood-vessels. The serous membranes are probably
attacked through the propagation of the bacilli along the lymphatic
vessels to the serous sacs, but I am not yet in position to demonstrate
the certainty of this claim.

It is almost self evident that tubercle bacilli which enter the
body after birth can do so only by penetration of the mucous mem-
branes, from which in turn they are carried to the lymph-nodes, and
chiefly to the mediastinal glands. A considerable number of observa-
tions now testify to the truth of this generalization.

168

Certain authors have shown that tubercles and tuberde-bacilli
occur in the tonsils, and in cases in which the assumption will not hold
that the patient is self -infected from his own tuberculous sputum. I
myself have seen in the tonsils of a child six months old, a caseous
focus visible to the naked eye, and have convinced myself that the
chain of cervical lymph-nodes was likewise caeous as far as the hihiin
of the lung. Death occurred in this case from general miliary tubercu-
losis; the tuberculosis of the tonsils is not to be regarded, therefore,
as secondary to pulmonary localization, but solely as the site of entry
of the bacillus.

It is probable that the exciting cause of tuberculosis finds its way
into the tonsils and thence into the lymph-nodes in early childhood^
where it may remain latent for long periods (Weigert).

The influence of an infectious disease, or of puberty may lead
to a mobilization of the bacillus, which may then traverse the wall
of some vessel to which the lymph-node adheres as a result of some
•past adenitis, and in this way gain the circulation. This penetration of
the vascular wall by the bacillus could not occur without previous
adhesion to the gland.

So far I may say, supporting myself step by step with facts, that
the sole route thus definitely demonstrated, for the entrance of the
bacillus from the external world into the lungs may be described as
follows : —

1. The tonsils are to be regarded as an undoubted port of entry
for the bacillus.

2. The tubercle bacillus is propagated from the tonsils along the
cervical lymph-nodes to the mediastinal glands.

8. When mediastinal glands containing bacilli adhere to the pul-
monary artery or to one of its larger branches, the bacillus may pass
through the intact vascular wall into the pulmonary circulation, and
then finds in the pulmonary apex favorable conditions for lesion of"
the wall of the finer vessels with subsequent production of foci.

■That the lungs show such a high percentage of severe and fatal
disease as a result of the presence of the bacillus in the pulmonary
circulation is not due alone to the presence of the tuberculous vascular
focus. It is a very rare event for the lungs to be so flooded with
tubercle bacilli that they become studded throughout with acinous foci
of disease, sufiicient in themselves to cause death. Much more fre-
quently do we flnd small, healed apex-infiltrations, which show suffici-
ently well that the organism possesses powerful aids in rendering the
bacillus harmless, even after it has penetrated into the lungs. If we-

169

bear in mind that peritoneal tubercuLoBis often heals without leaving
a trace of its presence^ we may regard it as possible that the same
result may occur in the lungs, especially in the lower lobes.

The fact that the apex of the lung is almost invariably the first
seat of the disease in chronic tuberculosis is probably explicable
through the penetration of individual bacilli into the pulmonary artery
from which they can most readily attack the apex, for the reason that
the rest of the lung can exert a better defense. A circumstance which
favors this theory is the following : As the blood is propelled to the
apex by the left ventricle the inspiratory expansion of the chest coop-
erates less satisfactorily than is the case with the rest of the lung. Dis?
tention from coughing, running, etc., also occurs with more readiness
ill the apex. Coughing is an explosive removal of the air at hand in
the bronchial ramifications, the glottis being closed at first, while the
air is forced out by the combined action of the diaphragm and intercos-
tal muscles. But when the force is first applied, the glottis then being
closed, a part of the air in the bronchial passages must be sent back-
wards into the apices, for these are bounded only by soft tissues which
can exert no active explosive force. The same mechanism is found
in certain trades, such as those of glass-blowers, players on wind instru-
ments, etc., in whom the air which cannot escape from the lungs
i^ forced back toward the apices. Forced breathing is also a dis-
advantage to the apices. During running, dancing, mountain-climbing,
bicycling, etc., the auxiliary muscles of respiration (scalenus, stemo-
cleido-mastoid) come into use, and act in a direction contrary to that
of the diaphragm and intercostal muscles, causing a distention of the
apical tissue as well as of the vessels of the latter.

The greatest danger to a patient with the small pulmonary foci
caused by the action of the bacilli upon the blood-vessels lies in the
possibility of inflammation of the lung parenchyma around and between
these primary lesions. The "disposition to phthisis" probably consists
in a proneness to develop these secondary inflanunatory changes. This
pneumonic alteration is the element upon which depends the break-
down of the lung tissue, and doubtless comprises everything which
comes under the head of etiology aside from the original bacillary
causation. At least this hypothesis alone can explain why one patient
develops a cavity, another fibrous consolidation involving perhaps
an entire lobe, while a third case does not go beyond the formation of
the original vascular lesions, the existence of which is revealed only
by autopsy after death due to some other malady.

The chief task of our therapy should lie in the direction of pre-

170

venting and antagonizing the inflammatory process which may super-
vene around the primary vascular lesions. This distinction between
primary and consecutive lesions will alone enable us to understand the
course of the disease^ and the sphere of utility of our therapeutic pro-
cedures.

What physician has failed to witness the retrogression of extensive
consolidations despite the demonstration of bacilli? What pathologist
has failed to see upon autopsy extensive, chronic, fibrous pneumonia
investing a small cheesy focus? Pneumonic consolidation must have
produced the chronic pneumonia. In many cases it unfortunately
comes about that this pneumonic focus (which represents an exudate
and to a less degree a haemorrhage from the blood-vessels) leads to the
destruction of the supporting framework of the lung-tissue through
the caseation and softening which results from the accumulation of
bacilli. It is easy to convince one's self in studying sections of these
pneumonic consolidations that in the areas most recently involved the
alveoli contain merely swollen alveolar epithelium and blood, bacilli
being absent ; while in the older lesions bacilli are found between the
cells which fill the alveoli, and the oldest of all consist of an amphorous
mass of these microorganisms.

In addition to the degrees of predisposition of these secondary
inflammatory changes another factor must be reckoned with as a prox-
imal cause of the complicating pneumonia. The much mentioned
mixed infection I do not indeed look upon as such a factor. This con-
dition becomes a reality only when individual forms of pneumonia
develop independently as a result of the coincident or subsequent pene-
tration of the blood-vessels by the tubercle bacillus, or when a section
of the lung tissue which has already broken down becomes infected
secondarily.

The factor to which I refer is rather a purely toxic cause. Any
one who has had opportunity (as in the early days of the use of tuber-
culin) to see as a result of the administration of large doses of this
remedy the supervention of extensive pneumonia with caseation of the
exudate, should be convinced that this inflammation was brought about
by the toxic substances in the tuberculin. Should not, therefore the
bacilli in the primary vascular foci in the apices be able likewise to
produce toxins which cause inflammation in the surrounding paren-
chyma?

The essential results of my investigations may now be stated in
terms of both etiology and pathologic anatomy as follows : —

The fear of infection as a result of inhalation of the tubercle

171

bacillTis is unfounded and unnecessary ; for the bacillus does not arrive
within the lung tissue through penetration of the mucous membrane
of the respiratory tract. On the contrary it ia taken by the mucosa
of the digestive tract and especially by the tonsil — ^mostly in childhood
— and borne through the lymph-nodes to the blood.

YirchoVs tubercle and caseous pneumonia retain their scientiiio
foundation as two entirely different anatomical processes, although
the former as far as it represents typical pulmonary tuberculosis^ is
not a nodular formation of cellular nature, but a terminal vascular
focus due to thickening of the vessel-wall as a result of the penetration
of bacilli ; while caseous pneumonia does not become caseous until the
bacilli have escaped from the vascular foci into the pneumonic exudate.
In regard to our therapeutic procedures I must note before all that
the same obscurity has prevailed in thia territory; because hitherto
the complicating pneumonic process has not been duly considered in its
relationship to the destruction of lung tissue. One authority would
•cure tuberculosis by antibacillary measures, another by hygienic regi-
men. The former states that hygiene cannot destroy the bacillus ; the
latter maintains that experience has sufficiently demonstrated the fact
of the curability of phthisis through hygienic resources. Both are
right. It IB unfortunate that the representatives of the antibacillary
therapy have thus far accomplished so little, for even they themselves
must admit that specific remedies do not destroy the bacillus.

The representatives of hygienic measures, however, are just as
little able to accomplish anything against the bacillus and its penetra-
tion through the vessel-wall ; but they can do a very great deal toward
the prevention and cure of the consecutive pneumonic consolidation
and are thus able to ward off the breaking down of lung tissue or in
other words, phthisis. The primary vascular foci may persist without
^danger to life (as shown by autopsies) by reason of the small number in
which they exist in chronic apex-tuberculosis.
I We must therefore hail the sanatorium-movement as a fortunate

I advance in medicine, because it offers to that wide stratum of humanity

in which tuberculosis so commonly occurs, a possibility of a sojourn

^ If tuberculous material is introduced into the subcutaneous tissues of an
•experiment animal (rabbit) in the neighborhood of a primary caseous focus
secondary miliary tubercles arise which consist only of an increase of cells in
the connective tissue, permeated by tubercle bacilli, just as the tubercles which
appear beneath the serosa in intestinal ulceration are nothing but accumula-
tions of cells in the lumen and walls of the lymph-vessels. It is worth noting
Tthat the area of these secondary tubercles is always of small extent.

172

under hygienic conditions sufficiently long to fortify the organism and
likewise to secure a retrogression of the pneumonic processes which
may be present.

That such sanatoria have been established throughout Germany
without much regard to climatic conditions appears to me to be justifi-
able throughout ; and I am of the opinion that the results will not be less
satisfactory than those in southern health-resorts^ so long as the phy-
sician in charge proceeds upon correct principles. As long ago as
1887^ I expressed the opinion : "If we had a suitably arranged sanator-
ium in the Harz, protected as much as possible by nature, I would have
no scruples against sending patients thither for the winter who for
any reason were unable to leave their homes."

To obtain favorable results in sanatoria it is however requisite
before all to refer the patient thither in the initial stage of the disease.
The fulfilment of this condition involves numerous difficulties. The
first is that the patient seldom comes to consultation in the initial
stage of the malady. The inception of the disease in the apex passes
without notice.

If ever the results of anatomical and experimental investigation
can be brought in full harmony with clinical observation it will be
through the views on the pathogeny of the disease which we have
enunciated in the present paper.

The foci of the disease do not originate in the final ramifications
of the bronchi but in the finer twigs of the pulmonary artery. The
establishment of these lesions, however, is accompanied neither by
fever nor by cough ; and the patients see no occasion to consult a physi-
cian. At this period hemoptysis is the earliest subjective symptom
referable to the lungs.

If the parenchyma between these foci undergoes consolidation, an
occasion soon arises for an objective investigation. Patients with such
foci — ^usually individuals between the ages of 15 and 26 — often com-
plain of symptoms which proceed from anaeinia.

It would be a great error to omit an investigation of the lungs
because cough is absent. The statement found in the majority of text-
books, that cough is one of the earliest symptoms of phthisis certainly
rests upon an error.

Cough occurs often enough as an intercurrent phenomenon, and I
am of opinion that the presence of the vascular foci predisposes
strongly to attacks of bronchial catarrh, which if long persistent may
lead to pneumonic alterations in the vicinity of these primary lesions.

^ Pathologische Mittheilungen^ Heft IV. p. 115. Magdeburg, 1887,

173

This would be brought about by the exteoBion of the catarrhal process
to the finer bronchi; which in turn would be a consequence of the dis-
tention of the lung tissue already described as a natural result of
coughing. These bronchial catarrhs occurring early in the disease^
have, when neglected, a great bearing upon its subsequent course.

If a patient, hitherto free from ailments, comes to the medical
man for the first time with a bronchial catarrh, it is natural to look
upon the latter as a primary manifestation. But whoever examines
a patient thoroughly will frequently be convinced that objective symp-
toms are at hand in cases of this sort and that they antedate the cough.
Auscultation and percussion may reveal a low position of one clavicle
(that is, the bone is either horizontally placed, or the acromial end is
the lower); while the resonance is more hollow, higher or at times
duller to percussion. The resonance may become deeper and more
full during and at the close of inspiration ; (in the normal apex it should
be more hollow and higher). Gentle, weakened, and even cogwheel
breathing may be present.

The foregoing signs frequently occur in youthful, anaemic indi-
viduals ; and when all or the more important of them occur together
— ^the lower lobes and heart being fully normal — we have sufficient
evidence for the diagnosis of tuberculous infiltration of the apex.
These symptoms are present long before cough occurs ; and with defect-
ive protection and bad weather a bronchial catarrh, as already men-
tioned, may be associated with the apical lesions, but may disappear
completely after appropriate treatment, to return perhaps several years
later.

In case results that are demonstrable by objective examination
only, are present in the apices, the prospect for recovery is very favor-
able. Unfortunately most patients are disinclined at this stage of their
disease to subject themselves to months of treatment. This statement
applies with the same truth to people in all walks of life. They do not
feel sufficiently ill to renounce all their activities, and they base their
refusal to obey the physician's mandate upon their good general condi-
tion. It is only after a harassing cough has developed, or tubercle
bacilli have been found in the sputum that the danger is realized, and
a strong inclination develops toward radical efforts at recovery.

In r^ard to the demonstration of bacilli, what has been said of
cough as a symptom applies here with even more force. Whoever
makes a diagnosis of tuberculosis only after the appearance of bacilli
in the sputum, often comes to this assurance at a late period of the dis-
ease. Nevertheless we must always investigate the sputum in all sus-

174

picious cases; for under these circumstances doubt often becomes cer-
tainty.

It would be unjust to regard as suitable for sanitarium-treatment
only cases of the incipient type just outlined. Recovery is possible
even after further pathological changes have taken place in the lungs^
after months of sojourn in a sanitarium. Dull resonance on percussion
with a slight tympanitic quality extending to the second rib ; with fine
or medium moist rales, speaks for the existence of a small cavity;
but when there is no striking degree of emaciation, no evidence of dysp-
noea after slowly climbing stairs and also after speaking (the latter
symptom is readily overlooked) ; when there is no elevation of the pulse-
rate while patient is at rest, the patient may be admitted into a sana-
torium. The significance of night-sweats and past hemoptysis is still
less in regard to prognosis. Only in the late stages of phthisis do
the former become resistant to treatment of every kind ; while hemop-
tysis, being an affair of the remote past, should be judged only by the
objective conditions which have remained behind.

On the other hand febrile temperatures should exclude from the
sanatoria, although this prohibition does not imply that such cases,
may not recover. The objective findings, or the extension of the infil-
tration are more of a criterion of severity than the fever, which may
finally subside. The actual reason for rejecting febrile cases is found
in the expediency — ^for the time being — of restricting the sanatoria
to patients with the best prospects for recovery; for at the present
time the sanatoritim-accommodations are too limited for even this
favorable class of cases. Furthermore, the arrangement of the sana-
toria to-day, is such that bedfast patients — and all febrile cases should
belong to this category — can be cared for only in a very limited degree.
The firmness involved in rejecting for sanatorium-treatment consump-
tive patients who are in need of care, is best known to those who are
detailed to conduct the examinations for a great body like the Magde-
burg Union. It will become necessary to find ways and means to evade
the inhuman refusal of sanatorium-privileges to bread-winners; for
such a refusal is tantamount in the patient's mind to a death sentence,
although this is not necessarily the truth. Lung-hospitals should be
erected in the vicinity of the sanatoria.

Is recovery from pulmonary tuberculosis possible through the
sanatorium, or better, through hygienic management? Neither a
simple no, nor yes will answer this question. The pneumonic consolida-
tion which appears about the vascular foci, however extensive — even
with participation of an entire lobe or more — can undergo complete

175

recovery through timely hygienic management; but the tuberculous,
vascular foci remain encapsulated by a fibrous consolidation, and after
a long interval may lead once more to inflammatory phenomena, pro-
vided suitable causal factors are at hand. As a result the patient with
the most pronouced cure is exposed to the danger of relapse for a
long period, and this peril can be averted only by living under hygienic-
ally favorable conditions. This is a hard task for the patient just
released from the sanatorium. His sphere of existence is not of the
sort calculated to avert relapses. Many of these patients have occu-
pations exactly calculated to favor relapse.

In this connection we must first see clearly that a relapse in
chronic tuberculosis does not signify a new infection with bacilli; as
the representatives of the inhalation-theory are forced to assume, but a
renewed, more or lees diffuse inflammation of the parenchyma of the
lung in the vicinity of the tuberculous vascular foci originally present,
the existence of which involves the possibility of the passage of the
bacillus into the pneumonic exudate.

As contributory causes for the appearance of an inflammation of
this sort, whether a first attack or relapse, may be enumerated a series
of factors only too frequently occurring in combination. These com-
prise overexertion, in connection with either labor or sport; drenching
of all the garments or of the foot-covering alone; frequent pass^ige
from hot rooms into the cold, especially when over-heated ; sojourn in
dusty and poorly ventilated rooms ; and excesses in alcoholics, the last
named being readily associated with any one of the preceding elements.

The effect of the foregoing factors is either a hyperaemia of the
lung-tissue or a catarrhal irritation of the bronchial mucosa. Here-
upon the parenchyma may become inflamed.

Mindful of the etiological elements which underlie the relapses of
this disease, we must endeavor before all to ward off such dangers to the
recently discharged, as hard labor, extremes of weather and frequent
passage from hot rooms to cold atmosphere.

Only when the head of a large factory or other enterprise is
informed as to these details — and this has not yet happened — ^will he
be able to accomplish something positive. The number of individuals
employed in the trades is so great that the individual pulmonary cases,
especially those which have been cured or benefited in sanatoria may
be favored as far as possible by assignment to the light duties of inspec-
tor, office-assistant and the like, in place of their original work as mold-
ers, machinists, etc., etc.

Care must be taken that these cured or improved patients do not

176

undo on Sundays what has been done for them during the week. They
must forego dancings excursions^ attendance at meetings held in close
quarters with poor ventilation, etc.

Another recommendation often made to pulmonary victims for the
betterment of their health should in this connection be correctly judged.
One often hears advice imparted that such individuals should apply
themselves to agricultural pursuits. The idea which underlies this
recommendation is certainly justifiable ; for a life of this sort insures
the presence of plenty of pure air. If all other conditions of rural life
were equally favorable, if the patient were protected from extremes of
weather, if his residence was arranged to the best advantage, the coun-
try would certainly be superior to the town. But when a farm-hand
is exposed to all fluctuations in the weather, when he must occupy a
very small room which perhaps must be shared with others, his sur-
roundings are worse than those of the town-employee, if the latter can
but have an hour or so daily in the open air when the weather is favor-
able.

The greatest success of the sanatoria will be seen in the cases of
officials of all kinds and of the better situated, independent patients
whom I would refer Hkewise to these institutions if there was room
to receive them ; because people from these classes are so situated that
after their discharge following successful treatment they are better
able, from that point of view which we have enunciated, to maintain
their improved state indefinitely.

THE TREATfXENT OF TUBERCULOSIS OF THE EPIDIDYMIS AND TES-
TICLE BY UGATURE AND DIVISION OF THE SPERMATIC CORD.*

BY DR. MAUCLAIRB, OF PARIS.

[Concluded from page 45]
ATROPHY OF THS TESTICLE BY TORSION OF THE VASCULAB PEDIOLE.

Torsion of the vascular pedicle of certain of the viscera has been
followed by atrophy and necrosis respectively. As applied to the epi-
didymis and testicle^ the principle of torsion of the cord has been studied
in animals by Chauveau^'' who finds that atrophic degeneration follows
this operation when done subcutaneously. Torsion arrests the arterial
circulation of the testicle, and eight or ten turns are sufficient to rup-
ture the cord. Gangrene of the testicle may be produced by torsion,
if the blood is first rendered septic ; hence the state of the blood plays
an extensive role when the circulation of an organ is suddenly shut off.

* Translated for the Journal of Tuberculosis,

177

When gangrene does not occur after torsion^ etc.^ histologic exam-
ination shows that the testicle has undergone atrophy, while it has
at the same time become grafted to its surrounding tunics. In the
human subject in which torsion has been performed, the testicle having
been left in place, atrophy has rapidly resulted. Moreover, cases of
spontaneous gangrene have often been placed on record ; this accident
18 probably due to orchitis, whether infectious or tuberculous, in which
torsion or infectious thrombosis of the spermatic vessels has occurred.

Our patients suffered for the most part from pulmonary lesions,
and therefore it was feared that torsion, however, slight, might pro-
voke intense pains ending in gangrene of the testicle. Such a termi-
nation has occurred, doubtless by reason of a septic condition of the
blood at the time of operation.

In one case we crushed a cord with large sequestrum forceps and
we have often performed this operation between ligatures to avert the
likelihood of haematoma. Longuet informs us that angeiotripsy has
been employed upon the cord. He has reported one case in which
this operation was followed by considerable haemorrhage and advises
.the addition of a safety ligature.

amOOtAL OONOLUSIONB.

In all records of ligatures, whether physiological or pathological,
in which all the elements of the cord were concerned it is necessary
to make a distinction, as follows : — In some cases the ligature was per-
formed aseptically, ^ile in others it was septic and infected the affer-
ent and efferent vessels of the testicle. This distinction has not always
been made, which accounts partly for the great diversity in the results
obtained. New experimental researches will be required to resolve
certain questions.

Ligature of the excretory duct of a gland having an external secre-
tion causes atrophy of that gland ; but for the most part ligature of the
vas deferens has not led to atrophy of the testicle, which is a gland hav-
ing both an external and internal secretion. Alessandri, however, finds
that ligation of the vas deferens does have a tendency to induce atrophy
of the testicle.

In tuberculous epididymitis, the author has never attempted iso-
lated division of the vas deferens.

Ligature of the arteries of a healthy organ produces atrophy of
the latter, but arterial ligature, practiced for the purpose of determin-
ing atrophy of organs attacked by tumors, benign or malignant, has
not yielded very satisfactory results.

ITS

When the testicle is healthy, ligature of the spermatic artery
causes atrophy of the testicle.

Harvey and Maunoir obtained results from this same ligature in
"sarcocele" ; but under this term very different lesions have been im^
plied. In tuberculosis of the epididymis we have not yet practiced the
isolated ligature of the spermatic artery. Upon the only occasion when
we sought to perform this operation, the artery could not be found and
distinguished from the veins.

Ligature of the veins of a healthy organ produces little or no-
atrophy of the latter. Ligature of the veins of the cord does not pro-
duce atrophy in a sound testicle. In tuberculosis we have sought to
imitate Bier's method of venous stasis by ligature. The immediate
result was almost negative in one case of suppurative tuberculosis of
the epididymis. Eventually, however, the fistula closed and the
tuberculous process appeared to be extinguished.

Division of the nerves of a healthy organ causes atrophy of the*
latter.

Division of the spermatic nerves has generally resulted in atrophy
of the testicle. We have never practiced isolated section of the nerves-
in tuberculosis of the epididymis.

Ligature of the arteries and veins of a healthy organ causes-
atrophy of the latter.

Ligature of the spermatic arteries and veins produces atrophy of
the sound testicle. The same result follows this ligature in tubercu-
losis of the epididynus and testicle. If suppuration does not coexist,,
atrophy occurs rapidly, and there remains a fibro-glandular, or fibro-^
exglandular nodule, small, but hard and free from tenderness on pres-
sure, giving the patient the illusion of a testicle. If the tuberculosis-
is suppurative, curettage, exposure to the air and centripetal cauteri-
zation with the fine point of the Paquelin, end by giving the patient
— after a prolonged interval of suppuration — a fibrous nodule which
satisfies him in his delight at having escaped castration. If a scrotal
fistula prolongs the period of suppuration, it is, perhaps for the rea-
son that grafting does not readily occur under these conditions.

We have never but once observed necrobiosis or gangrene of the
testicle after ligature of all the elements of the cord. The patient in
this case was an aged individual. Many authors and experimenters
have looked upon such a termination as inevitable after total ligation
of the cord.

We have crushed the cord with forceps but have never dared to

179

practice torsion. The latter procedurjB applied to the vascular pedicle
of a healthy organ, will produce atrophy.

Our method of ligation and section of the cord, partial or total, is
still incomplete, and we publish only immediate results of recent cases.
The end in view has been : — 1, to cause the atrophy of the tuberculous
epididymis with the conservation of a "testiculiform'^ fibrous nodule;
2, to avoid the propagation of tuberculosis to the other testicle, which
is seen in cases of purely external tuberculosis; and 8, to cause the
retrogression of preexisting lesions.

Generally speaking the various interventions to be described led
to atrophy of the testicle in the majority of cases.

In certain cases in which the fistula persisted after the operation,
we did not believe that necrobiosis had necessarily occurred, judging
by the seat of the fistula and nature of the discharge. In some cases
nodules of the tuberculous epididymis were eliminated.

As operative complications we have noted the presence of late
haematoma which suppurated, and of temporary fistulae through which
were eliminated nodules of tuberculous epididymis or sphacelated con-
nective tisffue.

Of all the methods for producing atrophy, that which has appeared
to us to yield the best results is section of aU the elements of the cord
save the vas deferens, deferential artery and the veins which accom-
pany the latter.

Finally our observations refer only to adults. The results pub-
lished herewith are inmiediate results only; later we expect to report
the ultimate outcome of these cases.

I OASES.

!
I

Case 1. Non-suppurative tvberctdosis of the epididymis: Sec-
tion of the cord en masse between the ligatures: Disappearance of tuber-
cuUms nodules: No consecutive atrophy, Retrogression of vesicular
and prostatic lesions. Patient aged 20. Swelling of testicle without
gonorrhoea in July, 1899, with partial resolution. Gonorrhoea con-
tracted shortly afterward with exacerbation of orchitis. Consultation
Oct. 16, slight hydrocele. Hard, sensitive nodules in both head and
tail of epididymis. Vas deferens seemed healthy. The prostate was
enlarged with a hard nodule in the right lobe. The left seminal vesi-
cle was irregular in shape and nodular. The genito-urinary organs
were otherwise normal. Examination of the chest revealed evidences
of apical tuberculosis.

The operation was performed Oct. 18, under cocaine. The wound,

180

which was not drained, healed promptly, and without operative seque*
lae. Two weeks later the testicle and epididymis were notably dimin-
ished in size and were much softer. The nodules in the epididymis were
still perceptible, but smaller, more supple and free frcnn pain.
Patient applied for and obtained his discharge. He was next seen
March 30, 1900. The testicle on the operation-side appeared to be
normal in every way and the vesicular and prostatic lesions had
undergone retrogression. Crural adenitis was present, with tubercles
on the opposite side.

Case 2. Suppurative tiAereuloais of (hs left epididymis: Nonsup-
purative tuberculosis of ths right epididymis: Total section of the cord
and exposure of the lesions of the left side^ followed by elimination:
Total section of the right cord, followed by atrophy.

Patient aged 40. Ko history of gonorrhoea. The genital lesions
of six months' duration. The right epididymis, nodular throughout;
testicle apparently healthy; no hydrocele. On the left side the testicle
is enlarged and hard but not irregular; the head of the epididymis
apppears normal, but the tail is of the size of a small egg, the mass
being tender, irregular in contour and adherent to the skin with pres-
ence of fistulous communication. The left vas deferens is irregular in
outline. Both prostatic lobes and both seminal vesicles are tubercu-
lous. Pulmonary lesions, not very far advanced. General condition
good ; no disturbance of urinary functions.

Operation Oct. 18, under general anaesthesia. On the right side,
cutaneous inguino-scrotal incision, with ligature of the cord, followed
by free incisions on the left side with laying bare of all tuberculous foci
Wound left open. Three days later hernia of the left testicle through
the incisions in the epididymis. Profuse suppuration followed with
gradual elimination of the testicle. The wound healed in about three
weeks. Nothing remained in the scrotum, to the left, but a hard, insen-
sitive nodule, the residue of the epididymis and testicle. On the
right side the testicle was seen to have undergone notable atrophy. The
prostatic and vesicular lesions had undergone no change. Patient
discharged at his own request.

This case should have been treated, it appears, by orchidotomy
and epididymotomy, with cauterization of the epididymal incisions,
replacement of the organs in the scrotum and lateral drainage through
the scrotal incision. Elimination of the testicle should not have
occurred.

Case S, Suppurative tuberculosis of the epididymis: Division
of the cord en m^asse between two ligatures: Atrophy.

181

Patient aged 22 years, consultation Oct. 30, 1899. Gonorrhoea
in preceding August, terminated in recovery during September. First
noticed swelling of testicle on Oct. 28. History of pleurisy at the age
of 18 ; had lost flesh thereafter.

Examination: — ^Right testicle slightly enlarged but not nodular.
Epididymis exhibits nodules in both head and tail. Vas deferens
permeated by small nodules. No abnormalities on left side. Prostate
nodulated; right seminal vesicle enlarged, hard, uneven in contour
and tender to pressure. No urinary disturbances. Lesions of pulmon-
ary tuberculosis in the period of softening. Diagnosis of genital
tuberculosis (despite the history of recent gonorrhoea).

Operation Nov. 4. Cord ligated en masse, under cocaine anaes-
thesia. Course of healing smooth. Upon his discharge Nov. 28, the
testicle and epididymis formed a mass of considerable volume, but
very soft and supple and free from sensitiveness. Condition of the
prostate and seminal vesicle unchanged.

Case i. Bilateral epididymal tvhercidoais: Total division of
the spermatic cord on both sides: Intense consecutive tumefaction.
Sclerosis and late atrophy shown by autopsy, patient having suc-
cumbed to pulmonary tvberctdosis.

Patient aged 81 years. First consultation Oct 24, 1899. Had
had syphilis and gonorrhoea in 1891 and hemoptysis in 1895 with sub-
sequent repeated attacks of bronchitis. Fresh attack of gonorrhoea
in 1898 followed by gleet. State of lungs became worse early in 1899.
Tuberculous orchitis began in right side in July, on left side in August.

Examination: — ^Left testicle enlarged and of irregular outline,
left epididymis very large, irregular and nodular. Abscess at tail of
epididymis. Yas deferens appears healthy to touch. On the right
side a cutaneous fistula which gives exit to caseous pus. Kight epididy-
mis irregular, nodular and the seat of an abscess. Vas deferens
appears sound on palpation. Prostate enlarged, irregular, nodular;
both vesicles enlarged and nodular.

Operation Nov. 1. Ligation of both cords. The abscess on the
right side opened and curetted. Tamponnade with iodoform gauze.

On the second post-operative day the supervention of marked
swelling led to the belief that a hematoma had formed. By Dec. 2, the
testicles had diminished in size by one-half. The pulmonary lesions,
however, were constantly proceeding from bad to worse, so that the
patient died on Dec. 15.

Autopsy showed the testicles reduced in size by one-half. Tuber-
culosis of the tunica vaginalis. The microscope showed that the sem-

182

inif eroiis tubules were normal in number and size. There was no
hypertrophy of the intertubular connective tissue. The epithel-
ium of the seminiferous tubes was intact.

Case 6. Bilateral fistulous tvherculosis : Division of the right
cord: Exposure of the tuberculous foci to the air: Orchidotomy and
Epididymotomy without consecutive suture: Almost total elimination
of right testicle. Ligature of the veins of the left cord according to
Bier^s method. Late amelioration.

The patient was first seen Oct. 10, 1899. The right testicle had
been swollen for six months and the left testicle for one month. Both
sides suppurated with formation of fistulae. Patient complained of
fatigue, emaciation and night-sweats. Examination: — Ulcer on right
side of scrotum opposite head of epididymis. Suppurative vaginalitis.
Testicle enlarged but not nodular* Epididymis enlarged and nodular
throughout. Vas deferens apparently normal. The left side of the
scrotum normal, but traces of an old fistula existed. Testicle enlarged
but not nodular; epididymis enlarged and nodular throughout. Vas
deferens apparently normal. Prostate contained a nodule on the
right side. Seminal vesicles normal.

Operation under general anaesthesia. On the right (fistulous)
side, the epididymal foci were laid bare and curetted. The testicle was
split. The organs were then replaced in the scrotum, and the wound
tamponned with iodoform gauze, which served to keep the testicle froia
primary hernia. The entire cord was now ligated. On the left
side ligature was applied only to the anterior and i)osterior veins of
the cord; the sheath of the latter had been dissociated and was not
included in the ligature.

The results of the intervention were as follows: — On the right
side the testicle, which had not been sutured, was unable to keep its
place within the scrotum, and was eliminated little by little, along
with the epididymal foci. Eventually nothing remained but a fibrous
nodule which gave to the patient the illusion of a testicle. On the
left side, the ligation of the veins led ultimately to a diminution in
volume of the epididymis and testicle. The prostatic lesions were not
modified in any way.

When seen again three or four months later, a varicocele was
found to be present on the right side, while to the left the fistula was
closed. The epididymis and testicle were resistant and sensitive to a
slight degree. The prostatic lesions had undergone some retrogression,

183

and the general condition was good. To sum up, ligature of the veins
gave a good, albeit a late result.

Orchidotomy ought always to be followed by suture, because a
tamponnade is insufficient to retain the testicle within the scrotum.
Our aim was to allow the lesions to be exposed to the air indefinitely,
but the patient was very intractable.

Case 6. Nonsuppurative bacillosis of the epididymis: Resec-
tion of the cord: Incision and cauterization of the tuberculous foci
and return of the organs within the scrotum: Cure through atrophy.

Patient aged 21; consultation Dec. 5. Gonorrhoea one year
before with rapid recovery. One month before consultation the left
testicle became swollen and painful, without apparent cause.

Examination : — The entire epididymis is much swollen, chiefly the
tail. Xo signs of softening. No hydrocele. Inguinal hernia of the
same side. Yas deferens enlarged and indurated as high as the inguinal
canal. The right testicle and appendages are healthy. The prostate
is enlarged, but not nodular. Seminal vesicles unchanged. No urin-
ary disturbances. General condition poor, patient emaciated, coughs;
rough breathing over both apices.

Operation Dec. 8. Mass ligature of the cord at the x)oint of exit
from the abdomen, or even higher. Anterior wall of inguinal canal
incised to perform the radical operation for inguinal hernia. Besection
of the wall of the canal and of the cord between two ligatures, and
application of the thermocautery to the stumps. Enucleation of the
testicle with its tunica vaginalis. Incisions 3 c. m. deep into the tuber-
culous epididymal foci, for the purpose of exposing the latter to the
air, the incisions being treated with the thermocautery. The testicle
and appendages were replaced within the scrotum. Complete cutan-
eous suture without drainage.

The wound appeared to be healing by first intention, but supppur-
ation imfortunately set in on the tenth day, and persisted for a fort-
night. The tuberculous mass diminished in size little by little and on
Feb. 10, was of the size of a large nut. The size of the prostate under-
went no change, while the seminal vesicles appeared to increase in vol-
ume. The general state of the patient was good at his discharge.

Case 7. Fistulous tvbercul4)sis : Total resection of the cord:
Curettage: Atrophy with fistula remaining patent for a long period.

Patient aged 24 years. First consultation Dec 10. No history of
gonorrhoea. The left epididymis had begun to swell two years before.
Abscess formed and discharged for a year.

Examination: — Postero-inferior scrotal fistula discharging pus

184

which contained caseous debris. The entire tail of the epididymis
involved. Vas deferens slightly increased in size. Considerable hydro-
cele. The right testicle is healthy. The prostate contains multiple
nodules, while the seminal vesicles are still normal. No urinary disr
turbances. General condition good, no pulmonary troubles. The
patient requested conservative treatment.

Case 8, FisUdous, genital tiAerculosiSy right-aide: Total divis-
ion of the cord: Testicle and epididymis reduced in size to the volume
of a nut: Non-fistulouSy genital tuberculosis^ left-side: Total section
and cauterization: Atrophy with persistence of fistula.

Patient aged 22. Consultation Nov. 14. History of tuberculous
cervical adenitis, suppurative in childhood. For past 4 years epididy-
mal tuberculosis, suppurative, of right side. Fistula still persists.
For the past six months tuberculous nodules in left epididymis. Inter-
mittent discharge from the urethra, which contains no gonococci.

Examination: — Bight side — ^hard nodule in the epididymis; tes-
ticle and vas deferens apparently healthy. Scrotal fistula. Left side
— the tail of the epididymis forms a large, hard mass, irregular, insen-
sitive, with adherence of the integument. No hydrocele. Yas def-
erens normal. Prostate voluminous, irregular in shape, nodular. Left
vesicle not recognizable to the touch. Bight vesicle irregular, nod-
ulated. No urinary troubles. General condition good. Lungs appar-
ently sound.

Operation Nov. 16, under general anaesthesia. The right cord
ligated and divided en masse. Lesions in epididymis laid open and
exposed to the air. Cauterization and curettage of the tuberculous
focus. Same operation practiced on the left side, where an epididymal
abscess was present. On both sides the ligature was made after first
dissociating the cord from its sheath, in order to avoid ligation of cer-
tain vessels necessary for the success of the testicular graft.

Suppuration was very abundant on the left side after the opera-
tion. After Dec. 16, the tuberculous masses began to diminish in
size, from a third to a half on the left side, but with persistence of
fistula. The tendency of the latter is towards closure. On the right
side the genital mass is normal. On March 9, a small fistula is pres-
ent on the left side. The testicle and epididymis form a soft mass the
size of a nut. To the right the testicle and epididymis form a hard
mass the size of a nut, ascending to the inguinal orifice. . The prostate
is reduced in size; the right vesicle is still palpable. Aside from the
persistence of the fistula the result may be called extremely good.

Case 9. Suppurating epididymis: Ligation en masse of the

185

cords with the exception of the posterior group of veins: Consecutive

atrophy.

Patient aged 20. First consultation Jan. 15, 1900. Had suppu-
rative right orchitis, Oct., 1898, with rapid production of fistula. After
closing it reopened in Sept., 1899, after the patient had contracted a
gonorrhoea ; while at the same time the epidiymis of the left side sup-
purated.

Examination : — On the right side, a large abscess of the epididy-
mis, with suppurative adenitis. On the left side the epididymis is
enlarged and tender to pressure. The prostate is but little enlarged
and insensitive. The left seminal vesicle is normal in contour but ten-
der to the touch. The right vesicle is enlarged and tender; pressure
applied to it causes pus to exude from the urinary meatus. Consid-
erable fever is present (39 °C).

Operation Jan. 24. General anaesthesia. Dissociation of the
sheaths of the cord. After application of the ligatures, the epididymal
nodules were cauterized with the Paquelin.

Three weeks later, (Feb. 15), the genital mass on the right side is
smaller ; a fistula persists, and the testicle is still tender to touch. To
the left there is slight suppuration and the testicle is not tender to
pressure. The prostate is large.

One month later, (Mar. 15) the right testicle is soft, smooth and
of the size of an egg. The epididymis is much reduced in size, hard,
nodular and painful, with the presence of a scrotal fistula. The left
testicle is of the size of a small nut, firm, smooth and quite insensitive.
A scrotal fistula is present, the discharge being much more abundant
than on the other side. The prostate is enlarged; the urethral dis-
charge proceeds from the prostate. Fever is gone, and the general state
is improved.

Case 10. Tuberculous epididymitis of the hypertrophic type:
Ligature of the cord with the exception of the posterior fasciculus of
veins: Cauterization of a cold abscess: Consecutive atrophy with tem-
porary secondary fistula.

Patient aged 15. Consultation Jan. 22, 1900. Emaciation for
some time past, and enlargement of right testicle for two months pre-
ceding.

Examination ; — Right epididymis much hypertrophied, hard and
nodular. The vas deferens indurated. No urethral discharge, no
urinary disturbances. Prostate and vesicles normal. Roughened
breathing at apices. General condition good.

Operation Jan. 24. Sheath of the cord isolated. Ligature of the

' ISG

entire cord excepting the posterior fasciculus of reins^ tnd division
between two ligatures. The nodules in the tail of the epididTmis wer(»
cauterized with the Paquelin; and a small, latent cold aloecess was
opened. The mass so treated was returned into the scrotum and the
skin sutured. No febrile reaction followed.

About three weeks later the genital mass was initeh smaller. The
wound had healed by first intention save at one point, which remained
tender and gave vent to a discharge. A small abscess formed later and
was opened above and below and drained.

After another month the affected testicle felt smooth and was
aot painful. The epididymis was much smaller, and uniform in con-
tour. The vas deferens was clearly increased in size. Two weeks
later the wound closed, the testicle then exhibiting normal characters.

Case 11. FiatvlouSy tuberculous epididymitis: Ligature of the
entire cord and cauterization of the foci of the disease: Consecutive
atrophy.

Patient aged 32 years. First consultation Jan. 15, 1900. Father
died of pulmonary tuberculosis. The patient has had bronchitis for the
past seven years. Orchitis began eighteen months ago, and led to
abscess and fistula.

Examination: — The tail of the right epididymis contains mul-
tiple nodules, suppurating, fistulous and adherent to the skin. No
hydrocele. The tail of the left epididymis is also nodular and adherent
to the skin and shows the recent cicatrix of a fistulous tract. The pros-
tate is enlarged and nodular but the seminal vesicles are normal. The
patient has pulmonary tuberculosis.

Operation Jan. 17, under general anaesthesia. The sheath of the
left cord was isolated, and the vessels, nerves and vas deferens ligated
en masse, between two ligatures. The citratix in the tail of the epididy-
mis was cauterized with the Paquelin. The right cord was tied en
masse, with the exception of the posterior veins, between two ligatures,
the fistula was incised, curetted and cauterized with the Paquelin.

After the operation there was some fever, with profuse suppura-
tion of the fistula. In four weeks' time, the genital structures had
undergone a very notable diminution in size on both sides. The left
testicle was insensitive, while the right was still tender to pressure.

Two months after intervention, the left testicle and epididymis
were very small, hard and insensitive ; while on the right side the cor
responding structure had undergone further diminution in size. They
were still tender and a few nodules were still present in the epididymis.

187

There was a tubercnloua formation in the scrotal integument which
required excision.
1 Case 12. Tvberculous epididymitis of the left side etc, (This

, case has already been described in a preceding section,)

In conclusion we cannot sufficiently express our obligations to Drs.
/ Humbert and Picqu6 for their courtesy in permitting us to operate on

the foregoing cases from their services in the Hopital Ricord and
Hopital Bichat.

OASES OF UGATIOK OF THB OOBD FOB TTTBBBOUIiOUS BFIDIDYMrnS SBOOBDBD

BEFOBS OUB BE8EABGHB8 WBBB UNDBBTAXEN.

I. Harvey (cited by Broca in his Traite des tumeurs) is said to
have caused the disappearance of testicular tumors by Ugating the
arteries in the cord. 11, m, IV, Maunoir reported three cases, (the
first two cases recorded in his Memoir sur le traitemeni du sarcocele
par la ligature arterielUj and the others in the Melanges de chirurgie
€tr anger e, tome 11). The first patient was a military man aged 30 who
had sustained a trauma of the testicle which led to the formation of
multiple abscesses of the scrotum. Maunoir tied the spermatic artery
And nerves. The operation was followed by prolonged suppuration
which finally ended in resolution. The testicles imderwent atrophy.

The second patient was 35 years old and had had orchitis for a year
with an extensive hydrocele which had been punctured repeatedly.
Ligation of the spermatic artery was followed by a return of the testicle
to its normal volume..

Maunoir's third patient had had multilple tumefactions of the tes-
ticles for several years. The spermatic artery was tied without any
I effect upon the testicle. The patient, who refused to submit to ligation

of the cord en masse waa subsequently castrated.

V. Lannelongue (Tumeur du testicle traite et guerie par la lig-
iiture de Tartere spermatique) Oaz. des hopiiauXy Jan. 12, 1875.

The patient, who was aged 49, was an ataxic; the tumor, which
was on the left side, had been present for about a year, and was now
oi the size of the fist and sensitive. The patient had had syphilis, but
specific remedies had no effect upon the size of the tumor. The sper-
matic artery was then ligated and the volume of the testicle reduced
to that of a nut, the sensitiveness disappearing at the same time. The
author believes the case to have been one of syphilitic testicle.

VI. Skey (Suppurative tuberculosis of the testicle: Ligature of
the spermatic cord followed by gangrene and elimination of the testicle
through the ulceration in the scrotum.) London Lancet — 1862, p. 647.

188

On account of the patient's weakness Skey regarded castration a&
out of the question. In practicing ligation of the cord^ he hoped to
cause either atrophy, or elimination of the affected organ. After pro-
fuse and protracted suppuration with gradual and complete elimination
of the testicle, the wound healed, with the cure of the local lesion.

BIBLIOGRAPHY.

' Dimitresco. De repididymectomie partielle ou totaledans latuber-
culose primitive du testicule. These de Paris ^ 1897.

* Ettlinger. Les microbes du sang. These de Paris^ 1891.

' Sappius. De la spermatog^n^se dans les testicules tuberculeux.
These de Paris ^ 1899.

^ Longuet. Traitement chirurgical de la tuberculose genitale chez
rhomme. Revue de Chirurgie^ Jan., 1900.

* Lejars. Lecons Cliniques, 1895.

* Koenig. Deutsch, Zeitschrift fuer Chirurgie^ Bd. XLVII.

* Poncct. Gaz, Hebdoni, June 12, 1898.

* Delbet. Soci^t^ de Chirurgic 1897.

* Delore. Lyon Medicate ^ 1899.

'° Duplay. International Congress at Moscow, 1897.

" Qu6nu. See. de Chirurgic, May 18, 1896 ; Chevrolle, These de
Paris ^ 1896.

" Alessandri. Les l^iuns des diff^rents ^l^ments du cordon sperma-
tique, et leurs consequences sur la glande genitale. // Policlinico^ May i ^

1895.

" Miflet. Arch,f, Klin. Chirurgie, 1879, p. 399.

" Albarran and Motz. Operations exp^rimentales pratiqufees sur
Tappareil genital pour amener Tatrophie de la prostate. X Congres d'UroU
ogie, 1897, p. 95.

" Charpy. Organes Genito-urinaireSy p. 115.

" Vouillac. Proth^se testiculaire. These de Paris, i^^^,

" Chaveau. Lyon Medic ale ^ 1873, p. 157.

189
REVIEW OF CURRENT UTERATURR

THE PREVENTION AND CURE OF PHTHISIS.

Hambleton (The Lancet, Dec. 28, 1901) refers to his "experi-
ments and observations in phthisis" which go back to 1873, comparing
tliem with the views of to-day, which of course are based on bacteri-
ology. He has always taught that the phenomena of the disease are of
toxic origin, but is inclined to regard this element as a retained excre-
tion product, the retention being due to a defective aeration-surface in
the lungs.

While this theory may not be in hartnony with the teachings of
to-day, it leads at least to practical results; since the indication in
treating the disease is to multiply the breathing-area, by increasing the
thoracic capacity up to certain standards of measurements and spir-
ometry.

The open-air treatment directly favors the interchange of gases
and elimination of the retained toxic substances. The scrupulous care
of the skin which is practiced at the present day is also in the line of
vicarious elimination. The early stages of the treatment comprise oiit
door life, care of the skin, etc., while the respiratory gymnastics come
into play after the arrest of the disease. The author cites numerous
cases of recovery, due to carrying out his hypothesis, including his
own personal one, he himself having recovered from the disease in
1876.

[Dr. Hambleton appears to be a good example of a type of scien-
tist which is rapidly becoming extinct. It does not appear that he has
ever made the slightest attempt to isolate, imitate or predicate the
characters of this unknown toxic retention-product. It is much easier
to theorize than to do hard laboratory work. Fifty or seventy-five
years ago, medical literature abounded in efforts of this sort. The men
who write thus are not visionaries, but in many cases highly competent
to express opinions upon almost any subject. They simply do not
learn that science is a matter of experiment, not of speculation.— ^Ed.]

COUGH AND EXPECTORATION.

These subjects are considered exhaustively by Striibing in the
Deutsche Klinih, 1901, No. 6.

Cough comes either from direct or reflex excitation of the cough-
centre in the medulla, and in the vast majority of cases is due to reflex

190

excitation from the respiratory apparatus (normal reflex). When
congh existfi without any evidence of central or peripheral irritation it
is styled nervous. Since coughing is a conservative phenomenon, which
has the effect of keeping the air passages clear of obstruction, a nervoiLS
cough is a superfluous act.

In some diseases cough is invariably present, while in others it
may or may not occur. Experiments on animals show that the localities
which provoke cough when irritated are the mucous membrane of the
larynx, especially of the interarytenoid area ; of the trachea, especially
its posterior wall, and finally of the bronchi. On the contrary, irrita-
tion of the lung parenchyma — the air-cells — does not provoke cough.
It is not necessary that it should, for the irritation of the terminal bron-
chi answers the purpose of clearing the lung-tissue proper. Irritation
of the pleura does not necessarily produce cough, and when the latter
accompanies pleurisy the reflex should proceed from a coincident lar-
yngitis or bronchitis. It must be confessed, however, that after the
development of traumatic pleurisy, attempts at deep inspiration some-
times cause cough-movements. After the subsidence of the pleurisy
cough can no longer be induced in this manner. Irritation of the pleura
may therefore provoke cough under certain conditions. The part
played by the larynx in the genesis of cough is similar in character to
the preceding. We seldom see this symptom produced by acute phar-
yngitis. On the contrary, it is by no means unusual to see cough accom-
pany chronic pharyngitis.

In some instances cough has a mixed origin, as when secretion
from above drains into and thereby irritates the larynx; or when nasal
stenosis leads indirectly to the same result through alteration in the
quality of the inspired air. Ear-cough is to be regarded as a physiolog-
ical reflex due to irritation of the auricular branch of the vagus (as by
foreign bodies).

Cough of central origin may be due to irritation of the cortex cer-
ebri or of the medulla itself. So called habit-cough is probably of cor-
tical origin, while direct irritation of the cough-centre occurs in inflam-
mation or injury of the bulb. The inhibitory power which the patient
possesses over his cough is of course derived from the cortex, and in
this Niemeyer is quoted with apparent approval as to his belief that
mothers should always exhort their children unceasingly to stop cough-
ing during the course of pertussis, and should even threaten them
with punishment.

What has been said of cough thus far has been confirmed by ani-

191

mal experiment. But there are other clinical varieties which cannot
be thus reproduced artificially^ and in which the irritable zone may be
in the mammae, skin, ovaries, testicles, prepuce, etc., in which localities
friction or pressure may be sufficient to arouse paroxysms of cough.
The latter may be associated with sounding the uterus, compressing an
enlarged liver or spleen, the passage of gall-stones or renal calculi, etc.
It may vary in consonance with disease of the stomach (so-called stom-
ach-^sough). There is also the so-called trigeminus-cough in which the
afferent impulse comes from some locality supplied by the fifth nerve,
especially the nasal mucosa.

In all these forms of reflex cough the supposition of a neuropathic
substratum appears justified by clinical facts, the subjects often exhib-
iting the phenomena of neurasthenia or hysteria. In cough with the
ordinary bronchial reflex, which of course occurs without predisposi-
tion, a hysterical patient will exhibit paroxysms out of all proportion
to the degree of local mischief, and in these individuals the cough per-
sists oftentimes after complete recovery from the bronchitis. This is
doubtless the rationale of some cases of so-called nervous cough.
Under these circumstances a sort of generalization of the pathological
reflex may occur so that other areas become irritable. It is perhaps in
patients thus affected that we should expect to see a uterine cough
supervene in connection with coitus or tamponing the cervix; or a
pharyngeal cough develop in connection with lateral pharyngitis, hyper-
trophy of the tonsillar ring, etc. We are therefore obliged in a given
case of cough to determine as far as possible how much of it is due to
this element.

The subject of reflex-cough is still unexhausted, but it is perhaps
sufficient in this connection to state that there is hardly any limit to its
possibilities if we consider all the elements of the source of irritation,
irritable area, etc.

The physiology of the act of coughing is sufficiently familiar, but
recently the claim has been made that the larynx is not forced open
by the air-pressure, and that the abductors of the cords contract
actively, the colimm of air then escaping with the loosened secretions.
Doubtless cough is effected by the joint action of air-pressure and active
opening of the glottis.

There are three degrees of coughing : — 1. The act of clearing the
throat ; 2, ordinary cough ; and 3, paroxysmal congh. These degrees
result from the varying part played in a given case by the amount of
local irritation and the irritability of the nervous system.

192

With time a certain amount of tolerance develops in chronic cases ;
thus many phthisical subjects have surprisingly little cough, although
a large portion of the bronchial mucosa may be in a state of irritation.

While the cough which accompanies disease of the larynx, trachea
and bronchi is associated with a pathological state the reflex is a natural
one, which should be produced at will in the healthy subject by irrita-
tion of those areas. But when the cough proceeds from the nose, phar-
ynx, liver, uterus, etc., the reflex itself is pathological, and people who
develop these types of cough undoubtedly possess a substratum of neu-
ropathy. In none of these types should we expect to see tolerance
develop.

While pertussis is the type of paroxysmal cough, it is closely
imitated in acute laryngitis, in the laryngeal crises of locomotor ataxia,
etc.

The general consequence of cough is to increase the intra-thor-
acic and intra-abdominal pressure, with tendency towards emphysema,
hernia, displacement of the uterus, abortion, vomiting, involuntary
evacuations, etc. Further the disturbance in the circulation of the
superior vena cava tends to produce cerebral congestion and haemor-
rhage, and in association with the suspension of inspiration, to cause
cyanosis.

Numerous phenomena of cough are of especial interest to the lar-
. yngologist, who, alone is able to study them.

ExpEOTOEATiON : — The sputum of a patient should be received into
a glass containing a stratum of water for the purpose of preventing des-
iccation. Its consistency, amount of contained air, color, transparency,
stratification and odor should be noted.

The old division of sputum into mucous, muco-purulent and serous
is based upon the varying proportions of mucous, cells and water pres-
ent. Mucous expectoration is the expression of the activity of the
raucous glands, and accompanies every mucous catarrh as long as the
glands remain intact. If there is much serous transudation the mucous
is liquefied to a greater or less extent, and in extreme cases can be rec-
ognized by chemical means alone. A relative excess of mucous gives
the sputum a tenacious and adhesive quality.

Pneumonic expectoration does not owe these qualities to mucin,
but to nuclein which is formed from the cells by the pathol<^cal pro-
cess. As the rusty color of this sputum may fail, the presence of tougli,
adhesive expectoration may or may not indicate pneumonia in doubtful
cases. Under these circumstances the macroscopic stain of A. Schmidt

193

will decide the diagnoeis. The reagent consists of 1 part Biondi's pow-
der to 30 parts distilled water (this test is described in detail in Volk-
mannas Samml. Klin. Vortrdge, N. F. 1898, No. 202).

To the ordinary tenacious, vitreous, colorless and transparent spu-
tum of beginning acute catarrh, pus-corpuscles are gradually added
until a yellowish or grayish yellow hue is produced, while the original
transparency is replaced by cloudiness. The serous transudation which
accompanies the pus-corpuscles renders expectoration more free.

Muco-purulent secretion accompanies chronic catarrh as long as
the mucous glands are intact. The components may be intimately
mixed or may form different strata on standing (translucent mucous,
opaque pus). The greenish tinge which is present at times is due to an
alteration of the coloring-matter of the blood, due to the intensity of
the inflammatory process.

Sputum which consists of pure pus could occur only in the case of
rupture of a pulmonary abscess or empyema into the bronchi.

A purely serous expectoration is seen only with oedema of the
lungs. It usually possesses a slight red tinge and is foamy. Thin
sputum mixes much more readily with the air, and the amoimt of the
latter varies with the consistency of the sputum as well as with the
character of the cough itself, violent paroxysmal efforts naturally pro-
ducing a higher degree of admixture.

Sputum which sinks in water is not characteristic of cavernous
affections of the lungs, although a nummular shape — which indicates
a small admixture of mucous — ogives a presumption of such oriscin. The
contents of a cavity, when forced through a small opening are identified
at times through the threadlike form acquired in this manner.

The stratification of muco-purulent sputum is as follows: The
three layers produced by allowing the expectoration to stand in water
are from above downward the foam-stratum^ which consists of air
bubbles originally derived from both the mucous and the serum of the
pus ; the middle layer which, however, is well marked only when there
is an abundance of pus-serum, since it consists entirely of the latter,
and finally the lower stratum which adheres to the bottom of the glass
and comprises all the formed or solid elements.

The color of sputum is modified chiefiy by the amount of blood-
coloring matter which is furnished by such red corpuscles as enter by
diapedesis or by haemorrhage. Diapedesis occurs in connection with
intense inflammation, stasis, infarction and haemophilia. Haemor-

104

rhage accompanies ulceration, traumatism, rupture of aneurisms and
varicose venules ; in connection with tumors and parasites, etc.

Aside from blood-coloring matter in the natural state, certain de-
rivatives of the latter play a prominent role in tingeing the sputum.
We see this exemplified in the rusty pneumonic expectoration and also
in the green tinge in the same disease from delayed lysis, and in florid
phthisis (especially the type which develops upon a pneumonic founda-
tion).

Pneumonic expectoration may also be tinged green if icterus
coexists.

When sputimi develops imusual hues upon standing, such as
bright yellow, bluish, etc., the tinctorial influence of bacteria is in evi-
dence (b. pyocyaneus, b. virescens, etc).

When siich coloration is associated with malignant disease the
source of the coloring principle is obscure. In considering the question
of the hue of expectorated matter we must always bear in mind the
possibility of the inhalation of coloring matters in connection with the
arts (English red, ultramarine, etc.). Other rare peculiarities in col-
oration are seen in chylous sputum, in oesophago-tracheal fistula (from
the food or drink), from the multiplication of fungi, etc.

The amount of sputum varies with the extent and intensity of the
pathological process. In the height of a catarrh it is greatly increased
in comparison with the beginning. If the lymphatic circulation is
impeded the amount of sputum in twenty-four hours may exceed 2
litres.

The macroscopic study of the sputum is best carried out as follows :
It should be spread out upon a saucer, and in this manner bits of necro-
tic tissue, cartilaginous or alveolar, etc., may come to light, indicating
ulceration or gangrene ; or lime-concretions from calcified tuberculous
foci ; or grayish greenish cheesy fragments in caseous tuberculosis. In
the latter products especially, do we search for tubercle-bacilli and elas-
tic fibres. Other formations, which strongly resemble the products of
tonsillar crypts, are the so-called Dittrich's plugs, which are found
especially in putrid bronchitis and consist principally of bacilli in bulk
with crystalized fatty acids. Other objects, occasionally encoimtered
are fibrin-coagula, casts of the finer bronchioles, false membrane (in
bronchitis crouposa) Curschmann spirals, parasites, foreign bodies, etc.

The microscopical examination not only follows up the study of
the objects revealed by the naked eye, but is also able to make the diag-
nosis independently. At first a smear is made of the fresh sputum

195

and the latter is thus studied microscopically as a whole. If solid par-
ticles are present on the cover-glass, they are crushed.

If the sputum is mixed witli saline solution and allowed to deposit,
the mucous sediment will be f oimd to contain leucocytes or pus-cor-
puscles in varying number with the gross amount of pus. These ele-
ments are mostly polynuclear, as shown by the addition of 1 per cent,
acetic acid. Eosinophile cells are present in various catarrhal affections
but are far more abundant in asthma where they form 60 per cent, of
the leucocytes. The proportion of eosinophiles is said to increase
greatly in tuberculosis when that affection begins to improve.

Alveolar epithelia occur in the sputimi under various circum-
stances. When there is a prolonged and abundant presence of cells
containing lung-pigment tuberculosis should be suspected. These cells
exhibit a yellowiah-brown, granular pigment in brown induration and
have therefore been termed "heart-disease cells," but occur also in
pneumonic processes, infarctions and as a sequence of hemoptysis. The
substance which colors these cells is known as hemosiderin, which
imlike hematoidiD contains iron. The alveolar epithelia also contain
myelin granules, which may find their way into the sputum. They
occur most commonly in catarrhal pneumonia.

Elastic fibres occur in connection with abscess and gangrene of the
lung and tuberculosis. The fragments of tissue which may contain
them represent portions of the frame-work of the lung parenchyma.
Their occasional absence in gangrene of the lung has been accounted
for by the solvent action exerted upon them by a trypsin-like ferment
which is formed in that disease. Isolated elastic fibres still have a diag-
nostic value in tuberculosis when bacilli cannot be found (provided of
course that abscess and gangrene can be excluded).

If there is evidence of tuberculosis without the abilitv to find el as-
tic fibres a special search should be instituted by collecting a large
amount of sputum, and treating it with weak soda-lye ; after which the
fluid is centrifugated. The process may be repeated with the sediment.
When the secretion of the lungs stagnates and is decomposed, large
amounts of needles of margaric acid are formed. More rarely choles-
terin crystals are found under these circumstances. Coffin-lid crystals
of triple phosphates may accompany the preceding forms.

The Charcot-Leyden crystal is seen especially in asthma, along
with Curschmann's spirals. It is possible that these formations are
derived from the eosinophile cells which also accompany the same affec-
tion.

196

The bacteriology of the sputum has been so thoroughly discussed
in medical literature that it will suffice to call attention to a few
huportant points. Thus the Fraenkel and Friedlander pneumococci,
the strepto- and staphylococci inhabit the nose, mouth and throat of
healthy individuals; so that the sputum after its passage through the
two latter structures should be washed repeatedly to free it from
saliva, etc.

The microorganisms just named may be regarded as the causes of
ordinary bronchitis, while influenza has a specific bacillus. In putrid
bronchitis the ordinary exciters of putrefaction are likewise present.

In enumerating some of the numerous tests for the tubercle bacil-
lus emphasis is laid upon the Spongier method according to which the
sputum is first digested with pancreatin. After digestion is under way
a small quantity of carbolic acid is added to prevent decomposition. A
sediment is present after digestion and should be investigated for the
bacillus.

The bacillus of pulmonary gangrene resembles greatly the bacillus
tuberculosis, taking the same stain. It is, however, decolorized by abso-
lute alcohol.

Pneumonia of the acute croupous type may be caused apparently
by a large number of germs, new ones being added to the list from time
to time. The same may be said of broncho-pneumonia, no less than 7
pathogenic bacteria having been identified with this affection. Natur-
ally, with such possibilities mixture of infection is sufficiently common.

In croupous pneumonia from the pneuraococcus, we may look for-
ward to a crisis with favorable termination, save in cases of special vir-
ulence as seen in old or alcoholic subjects. If streptococci are associa-
ted with pneumococci, the crisis will probably fail to develop and as a
result the patient dies or recovers very slowly.

In plague-pneumonia the bacillus pestis may be found alone or
associated with strepto- and diplococci.

Pathogenic bacteria which occasionally appear in the lungs are
those which cause anthrax, glanders and lepra.

Actinomycosis, aspergillosis and other diseases due to fungi may
affect the lungs and appear in the sputum.

ON THE RECIPROCAL RELATIONS OF SANITARIUM AND TUBERCU-
LIN TREATMENT.

Weicker (Berl, Klin. Wochenschr,, 1902, No. 4) speaks of the
credit awarded to Germany at the late British Congress of Tubercu-
losis for its initiative in compelling workingmen to insure themselves
as a step in the warfare against tuberculosis, and cites numerous statis-

197

tics calculated to show the good work which is being accomplished in
placing incipient consumptives in a condition to resume their means of
livelihood.

At the present time, there are 59 people's sanatoria in operation
ill Germany and this number will shortly be increased by 35 others.

There are also 16 private institutions which receive the same class
of patients. It is now even implied familiarly that this is the only
method by which the disease can be effectually treated (Koch appears
to have expressed this view at the London Congress).

This opinion appears to be based upon the claim that 20 per cent,
of patients lose their "bacilli-expectorating capacity" after sojourn-
ing in sanatoria. This, according to Koch, is the only actual evidence
of recovery, or at least in respect to prophylaxis to others. This can
hardly be evidence that the disappearance of the bacilli is tantamount
to recovery, for many of these patients live after the discharge in
accord with the principles of hygiene in vogue at the sanatorium, that
is they continue to disinfect their sputum, and take other measures to
protect those around them.

The original idea of Brehmer was to detain patients in sanatoria
until they were completely cured. To-day we agree with Brehmer in
placing these patients in sanatoria, but differ with him in discharging
them after 13 weeks' treatment, a period certainly too short for recov-
ery. Dettweiler has said that two things are requisite for sanatorium-
cure — money and character; and the lack of means would of course
bar out the working man as far as private treatment is concerned, and
only the aid of the State makes it possible to place the man of no means
in a position to receive the benefit of sanatorium-treatment.

While the wealthy are chiefly anxious to preserve their lives, the
laborer wishes above all things to save his ability to work. It stands
to reason that only a healthy individual is able to toil ; so that it is a
practical criterion of recovery. In other words the people's sanatorium
must do a stipulated amoimt of work within a definite time. The
average duration of treatment is 13 weeks ; which means that within
that period the institution undertakes to enable an incipient consump-
tive to earn his bread for an indefinite length of time.

The test of admission to treatment is not the technical period at
which the disease is incipient, but the ability of the case to respond to
treatment. The examining physician should be expected to determine
the eligibility of a patient along these lines.

When these individuals are discharged, the responsibility of the
sanatorium does not end, for a not inconsiderable proportion of those

198

\\ ho have been discharged will certainly become worse, even in spite of
all care. This class also becomes dangerous to its environment. Every
means has been put in operation to enable these patients to retain their
health :— <^onvalescent-hygiene, proper sanitation of dwelling-houses,
change in the kind of labor, etc. Every informed person imderstands
the gigantic size of this problem. Weicker confesses that his percent-
age of "discharged, able to work," cases which he did not feel certain
of as to recovery, and would not pronounce cured, is very large. There
is, however, no known test of cure which can be applied to suspicious
cases, unless tuberculin is such, a point which is still in dispute.

Weicker, himself, is convinced that the time will come when the
custom of trial injection of tuberculin will come into general use ; like
vaccination, however, it is bound to have opponents.

If this custom should become general, it would be possible to
determine readily whether a patient was suitable for discharge. If the
injection were followed by a negative result, he could depart, other-
wise the ability to work would not obtain his release.

The expression "able to work," does not imply that a patient is
restored to his full capacity and able to cam his regular wage. These
patients are simply supposed to be able to earn at least 33 per cent, of
the regular amount paid for their work in the districts in which they
reside. Many are unable to earn over 40 per cent. We should have a
higher aim than to expect convalescents to work ; our ambition should
be to turn out individuals able to be classed as "100 per cent, capable."

The sanatorium-movement appears to have reduced the mortality
of consumption but there may be errors at work here — cases may
simply have lingered on without a fatal termination. Such an error
would be exposed in time unless the increasing number of sanatoria
should constantly exert a contrary influence.

The isolation of incurable, indigent, bedridden consumptives in
t*pecial sanatoria is thought to have aided in lowering the mortality in
lingland.

But tuberculin, already alluded to as a diagnostic resource, has, in
the opinion of Weicker, still another future. He believes, in fact, that
it is curative in selected cases, and that it will add to the efficiency of
the usual sanatorium-treatment. The remedy should be given in the
usual manner of increasing doses with intermissions. The idea of the
combined method does not mean that the two resourcee are to be used
side by side. The purely hygienic treatment first comes into play to
increase the natural vigor of body and mind; and when the desired

199

xesulta have been obtained the patient should receive a thoiough inoc-
xdation with the tuberculin to destroy the foci of disease which may
still persist. A person thus treated ought to be so fortified as to be
termed actually cured.

THE SANATORIUM TREATMENT OF CONSUMPTION*

Drs. Dyce Duckworth and E. D. Marriott, having recently at-
tacked this method of the management of consumption, replies by
Drs. Latham and Jackson respectively, may be found in the London
Lancet, Jan. 11, 1902.

Dr. Marriott, having implied that several years appear to be neces-
sary for a sanatorium-cure. Dr. Latham replies that such a prolonged
sojourn may be advisable to secure permanent recovery, but adds that
men like Brehmer and Walther regard 4 to 6 months as the average
sojourn required for cure, as judged by records which extend back for
many years. The claim of Marriott that the expenses necessitated by
two or three years of sanatorium-life are prohibitive could not hold
if compulsory insurance were in force as in Germany.

In answer to Marriott's claim that a sanatorium for consumptives
means a concentration of infectious germs, Latham states that the pre-
cautions in vogue to destroy the germs and arrest their spread render
a sanatorium more free from bacilli than the average English dwelling.

Marriott appears to think that the best prophylaxis of plithisis is
found in increased per capita breathing space and better drainage.
This, Latham thuJcs, is one of the very best arguments for sanatoria
for the poor, who suffer from precisely those unhygienic conditions.

Marriott's plea that the consumptive requires individual attention
and not the wholesale methods supposed to obtain in sanatoria, is
answered by Latham with citations from sanatorium-physicians who
reckon among their privileges the opportimty of giving each inmate
much more personal consideration than he could possibly obtain under
any other system.

Dr. Jackson, himself a sanatorium-practitioner, also answers Mar-
riott's arguments in detail. He objects to the idea that sanatorium-
patients are necessarily crowded together, because they are inmates of
the same institution. The flocking of patients is in fact discouraged.
He knows of no evidences of reinfection or other alleged ill possibili-
ties in the history of sanatoria. Ventilation is carried out to an extent
impracticable if not impossible in home-life; so that sanatorium
patients lead a life almost tantamount to one in the open air. The

200

gain in knowledge alone which accrued to patients aa to the necessitj
and benefits of fresh air is of immense value to the community.
Nothing could be more unfortunate than Marriott's comparison be-
tween sanatoria and prisons.

Finally sanatoria do not have a monopoly of fresh air. It is pos-
sible to observe the same routine at home, especially after experience
in sanatorium-life.

Incidentally Jackson speaks of the poor teeth possessed by most
consumptives and need of fillings, etc., before treatment.

BOOK REVIEWS*

A Tbxt-Book of Physiological Chbmistry. By Charles E.Simon, M. D.,
of Baltimore. 453 Pages; cloth. Lea Brothers and Co., Philadelphia and New
York, 1901.

This book, following the author's excellent work entitled, " Clinical Diagnosis,"
covers a field which is deserving of much more attention than is generally devoted
to it. It seems to be accurate, concise, and at the same time clear and comprehensive .

All of the known facts have been pointed out and the theories deduced to
explain complex problems of metabolism will appeal to the reader as being the
most probable when reasoning from the analogy of the known.

The plan of leading up from the .probable simple origin of substances which
constitute the complex tissues of plants to the subsequent building up processes in
the formation of the still more complex substances of the animal body, affords a
clear and logical explanation of the probable syntheses of the latter. One thing,
however, which seems to the writer to have been given too little attention is the
discussion of the so-called organized ferments. The author says, " While some of
the ptomains are apparently harmless, others are exceedingly poisonous, and these
last are accordingly spoken of as toxins." That some ptomains are poisonous is
well known but to class these as toxins is not in accordance with the more advanced
classification. A ptomain is a basic substance. It unites with acids to form
salts. Its chemical structure is comparatively simple, and it is formed from the
breaking down of complex albuminous bodies. It is then an analytical product.
The most poisonous substances produced by organized ferments are not basic and
do not unite with acids to form salts. They are not simple compounds, many of them
being exceedingly complex, and, owing to this latter fact together with the exceed-
ingly small amount which can be isolated, their chemical formulae have never been
ascertained. That they are synthetic products has also been proven from the fact
that when the organisms which produce them are grown on relatively simple organic
substances, the highly complex toxic product is formed. Moreover they are not
proteins. To these substances the term toxin should be limited and should not
include ptomains, some of which at least are formed by other agencies and are not
a specific product of the action of so-called organized ferments. The toxalbnmins
which are simply mentioned, and which might also have included the toxalbu-
moses and toxo-peptones do not, in all probability, owe their poisonous properties
to their protein constituents, but simply carry down mechanically the toxin when
they are precipitated.

201

That this is probable is shown from the fact that when they are freed from
protein until they do not respond to the protein tests, they are vastly more poison-
ous than before such a separation has taken place.

A short abstract of Buchner's work on complete fermentation in the absence of
the living cell, although not accepted by all, would have been an addition of worth
to the reader.

As a whole the book offers little for criticism. It is not a mere compilation of
the work of others, but, on the contrary, embodies in it much that is original.
An excellent feature which it possesses and one which should especially commend
it to all those interested in this important subject, is that false theories have been
generally corrected while attention has been directed to many things which have
been recorded as facts in works of similar nature and which have in numerous
instances long since been disproved.

System of Physiologic Thbrapbutics. Vol. Ill 336 pages, and IV 420
pages, on Climatology, Health Resorts, Mineral Springs. By P. Parkes Weber,
M. A., M. D., P. R. C. P., (Lond.), Physician to the German Hospital. Dalston,
etc., with the collaboration for America of Guy Hinsdale, A. M., M. D., Secty.
American Climatological Association, Pros. Pennsylvania Society for Prevention of
Tuberculosis, etc. Edited by Solomon Soils Cohen, A. M., M. D.. Professor of
Medicine and Therapeutics, Philadelphia Polyclinic, Lecturer, Clinical Med., Jef-
ferson Medical College, etc. Illustrated with maps. Philadelphia: P. Blakiston's
Son & Co., 1901.

When completed this work will comprise eleven volumes of which the first and
second deal with electrotherapy exclusively. Volume III is concerned with an ac-
count of the climate and health resorts of Europe, preceded by a short introduction
upon the subject of climatology in general. In Vol. IV we find a corresponding
account of the climate and health resorts of America, Asia, Africa and Australasia,
together with a section upon climato- therapy.

The introductory section upon climatology may be characterized as a study of
what is commonly known as physical geography, including its phyisological action
upon the human organism ; this is the sort of book to inform us as to the effect
upon mankind of sunshine, altitude, humidity, extremes of temperature, etc. The
subject, however, is clearly in its infancy ; and the statistical method must be em-
ployed extensively before we can obtain the data necessary for the creation of a
science of climato-physiology and climato-pathology. Interesting studies of the
effects of the weather upon the commission of crime, of suicide, drunkenness, hos-
pital attendance and the like have been published within recent years, but we see
no reference to this sort of investigation in the present work.

Those sections of the two volumes which refer to individual health-resorts,
need only an alphabetical arrangement to constitute a geographical directory or
gazetteer. We think it would have been a much better plan to describe types of
health resorts, based upon the temperature, altitude, humidity, etc., and to indi-
cate in succession the individual resorts which belong under this or that classifica-
tion, with incidental mention of special features. Such an arrangement would be
more suitable for reference, and would be less suggestive of compilation, on the
one hand, and of padding on the other. As a mere guide-book the work does not
go into detail enough for a work of reference. There is, of course, a vast fund of
information in these chapters, but the general impression which one derives is that
for medical readers the subject of local health-resorts should be put more tersely,

202

Inore in the languag^e of science, leaving inform atios of promiacisous character, to
works of a different class.

Under the head of climato-therapehtics much space » given naturally to the
climatic treatment of phthisis. Laryngeal tuberculosis requires a dimate of itself,
a climate free from dust-storms. The patient with this affection must beware alike
of the seaboard and of Arizona and New Mexico. High altitudes are contraindi-
cated in febrile cases, and also in patients with emphysema and heart disease. The
consensus of opinion is that long sea-voyages are of benefit in phthisis of the first
and second stages.

We may state in passing that the section on climato-therapy of phthisis ap-
pears to be the work of more than one author. While a portion of the text con-
sists of a mere recital of the vogue of this or that locality for the tuberculous pa-
tient, we also encounter paragraphs which deal with general principles. Here we
find a classification of climates based on the indications respectively of protection,
Invigoration, prophylaxis, etc. Thus a protective climate is warm, equable and
sheltered, irrespective of altitude ; such a combination is found in the United
States, in San Antonio, Lakewood, Aiken, Santa Barbara. An invigorating cli-
mate must always possess a high altitude, with the exception that the summer
months may be passed at northern seaside resorts. Especially mentioned in this
connection are the Colorado Rockies, and the high ranges of Mexico and southern
California. But a combination of or rather a compromise between a soothing and
invigorating climate is indicated in a very large proportion of cases. This indica-
tion is filled by the Adirondacks, and Asheville, N. C, with Atlantic City as a
seaside equivalent.

A special classification is also given which is based upon the extent and dura-
tion of the disease. The subdivisions are as follows :

I. Little or no tendency to limitation of the disease as seen in florid phthisis,

quick consuniption, etc. Here no climate is of any avail.

II, III. Disease progressive, but liable to arrest. These cases are usually
febrile and hence require protection at first, but invigoration later.

IV. Disease progressive in time, but limited in space. Here belong cases of
fibroid phthisis, and of limitation to a single lobe. The patients are not much in-
fluencea by special climates.

Most of the cases of consumption belong to none of the above divisions.
The average case is not severe enough to be included in the first category, while
it does not possess that quality of limitation which is present in the other classes.

No general rules can be laid down, but the selection of climate will depend on
the individual case.

Atlantic City and Cape May are highly praised for scrofulous and tuberculous
children.

The general plan and intent of this system of non -medicinal therapeutics can-
not be too highly commended. The same degree of praise may be awarded to the
mechanical part of the work, the indexing being especially good.

Atlas of Clinical Mbdicinb. — Jonathan Hutchinson, P.R. S., General
Secretary of the New Sydenham Society, has requested Messrs. P. Blakiston's Son
& Co., of Philadelphia, the American agents of the,Society, to announce the publi-
cation of *' An Atlas of Clinical Medicine, Surgery and Pathology," selected and
arranged with the design to afford, in as complete a manner as possible, aids to
diagnosis in all departments of practice. It is proposed to complete the work in
five vears, in fasciculi form, eight to ten plates issued every three months in con-
nection with the regular publications of the Society. The New Sydenham Society
was established in ISSS, with the object of publishing essays, monographs and transla-
tions of works which could not be otherwise issued. The list of publications num-
bers upwards of 170 volumes of the greatest scientific value. An effort is now be-
ing made to increase the membership, in order to extend its work.

208

EDITORIAL

THE EARLY DIAGNOSIS OF PULMONARY TUBERCULOSIS.

As to just what constitutes the early stage of pulmonary tubercul-
osis there is not yet uniformity of opinion; many writers speak of a
pretuberculous stage which obviously can have no existence in fact,
for every one must necessarily be in this stage until tuberculous inva-
jsion has actually taken place. Others apply the phrase, early stage of
tuberculosis to that which in reality is the early stage of phthisis or
•consumption; for example Knight of Boston not long ago made
the statement before the American CliQ[iatological Association that,
"an early diagnosis (pulmonary tuberculosis) is not usually difficult
^ince the discovery of the tubercle bacillus." Such an expression is
unfortunate and can but lead to confusion, for it is well known to those
who are at all faiQiliar mth the pathologic alterations which occur in
tuberculous lungs that tubercle bacilli can only appear in the spu-
tum when destructive changes, resulting in the elimination of soft-
•ened, necrotic tissues, are taking place. Be the area involved large or
^mall the presence of the germ in the expectoration is not associated
with incipient alterations, but, on the contrary, with ulceration and cav-
itation.

If we are to avoid confusion we must clearly distinguish between
the early stage of tuberculosis and the early stage of phthisis or con-
sumption. In the first instance we are dealing with the formation
of tubercles, i. e., with the proliferation of active, living cellular
elements, whereas in the latter we have to deal with death and des-
truction en masse of these cellular elements and the expulsion of the
resulting detritus.

If, therefore, we are to make an early diagnosis in the true sense
of the word, we must seek to recognize the disease during the period
in which the first invasion of tubercles occurs in the lung and before
destructive changes are conditioned or impending. In this stage of the
disease the symptoms experienced by the patient, although slight and
insufficient, many times, to induce him to consult a physician, are sug-
gestive and should always be taken carefully into consideration. The

204

recurrence of winter colds and bronchitis, loss of appetite, malaise^
digestive disturbances, loss of weight and slight elevations of tempera-
ture (90^-100^ F.), particularlj' if accentuated by physical exercise,
when not accounted for in an entirely satisfactory manner by other
causes, should invariably excite the suspicion of the eruption of tubercle
and in all such instances a thorough and painstaking physical examina-
tion should at once be instituted.

At this time, however, the eruption of tubercles is not dense
enough, the proliferation of connective tissue is not sufficient and the
bronchioles and alveoli are not as yet so obstructed as to produce per-
cussion dullness. As a matter of fact the percussion note remains
unchanged, except in some instances when it will be found clear aiid
full and in quality almost resembling tympany. Indeed during th:&
period there is so little evidence, if any, to be obtained from percussion
that we can practically afford to ignore it as an aid in making a truly
early diagnosis.

Certain delicate auscultatory phenomena are nevertheless present
and audible to the ear of the practiced diagnostician. Such are weak-
ened or rough inspiration, or both, often associated with an interrupted
rhythm. At times, also an extremely delicate apical catarrh may be
detected, as evidenced by a slight sense of moisture or stickiness which
may attain the degree of very fine crepitation. The latter sign may
frequently be brought out by making the patient cough, after which
it is to be heard at the end of a deep inspiration.

If the auscultatory signs which have been enumerated are f ound^
after repeated examinations at intervals, to persist over a circumscribed
area, an apex in an adult for instance, they may be accepted as corrob-
orative evidence of the eruption of tubercles, i. e., of the early stage of
pulmonary tuberculosis. Furthermore when the history and subjec-
tive symptoms are in accord with the detection of these early physical
signs, the diagnosis becomes positive and any additional diagnostic
means, as for example the tuberculin test, are entirely superfluous.

There will, however, always be .instances in which a reasonable
doubt will arise in the mind of even the expert physical diagnostician
as to the true nature of the patient's condition. Those less experienced

205

in auscultation, will, needless to say, more often find themselves unable
to determine the diagnosis. It is just in such instances that tuberculin
is supreme in confirming or disproving suspicion, and when judiciously
and properly administered the tuberculin test will always be found
perfectly safe and reliable.

The objections urged that it is prone to excite to activity latent
tuberculous processes and thereby do harm, is wholly without founda-
tion, for on the one hand its most bitter opponents have not been able
in a single case to demonstrate that such a result has followed, while
on the other hand, those who have had the greatest experience in its
employment are unanimously agreed that when properly given, no ill
effects can occur.

It has been asserted that syphilitics as well as patients suffering
Avith other diseases, have reacted to tuberculin, and this fact has been
adduced as evidence that the test is unreliable. But all syphilitics
do not react nor do all cancerous subjects for example, and since we
know, that syphilis, cancer and many other affections are again and
again found to coexist with tuberculosis in the same individual, all those
who are not laboring under precx)nceived prejudice will see in this an
argument not against^ but for the efficacy of the test, inasmuch as in all
human probability tuberculosis, although not otherwise demonstrable,
is nevertheless concomitant in these patients.

Again the test has been found to fail in patients in whom the diag-
nosis could be made positively not only by physical examination, but
by the microscope, and this experience has caused many to lose faith
in the reliability of tuberculin as a diagnostic agent. But why resort
to tuberculin when the diagnosis is already certain ? It is quite unnec-
essary, but if for any reason it be done, the seeming failure in such
instances is readily to be explained by the fact that when the disease
has so far advanced that destructive lesions (although possibly of very
limited extent and not necessarily demonstrable on auscultation) are
present, the patient has, from the gradual absorption of specific toxins
of the germ from caseous or necrotic foci, in so far acquired a toler-
ation, that the minute amount of toxins contained in the test dose
proves inert. Just as when toleration has been established to five or

206

ten grains of morphine per day and intoxication can not be produced
with smaller doses, so it is in the case of the tubercle toxins. The more
incipient the tuberculous process existing, the less the toleration, and
the smaller will be the dose of specific toxins required to induce a
reaction, and conversely the further pathologic changes have pro-
gressed, the greater is the toleration, and the larger will be the dose
necessary to produce the typical effect.

Tuberculin diagnosis is, however, not a matter of mechanical sim-
plicity ; if it were less often so considered, by many who have failed to
apply it intelligently, and have therefore been disappointed in it, and
if such men would give to this subject the careful thought and study
which they afford as a matter of course to other subjects in medicine,
no one would have just cause to oppose a remedy which when properly
employed is capable of confirming every doubtful diagnoris of tuber-
culosis, not only with all safety, but with absolute exactness.

THE AMERICAN CONGRESS FOR TUBERCULOSIS.

The Third Annual Meeting of this Congress will take place on
May 14, 15, and 16, at the Hotel Majestic, New York City, under the
auspices of the New York Medico Legal Society.

Although having Ijad a comparatively small beginning in 1900,,
the appreciation of this movement by the profession was well attested
by the participation last year of a large number of the leaders in the
crusade against tuberculosis, and we have no doubt that the forthcom-
ing third meeting will do much to extend the influence of the Congress*
in furthering the successful prophylaxis and the establishment of State
institutions for the care and treatment of tuberculous patients.

Much credit and praise is due to the Preeidtot of the Medico Legal
Society, Mr. Clark Bell, for his devotion to and for his indefatigable
labors in connection with the previous assemblies, and we take this
opportunity to urge all interested workers to participate in the forth-
coming Congress.

207
PATHOLOGIC EXHmrr AMERICAN MEDICAL ASSOOATION*

The Committee on Pathologic Exhibits for the American Medical
Association is amdous to secure materials for the coming session at
Saratoga^ June 10th to ISth^ inclusive.

Pathologic specimens, as well as specimens illustrative of the allied
fields of bacteriology, physiology and biol<^y are desired ; also exhibits
of new apparatus, charts, etc., used by teachers of pathology and physi-
ology in medical coUeges.

This exhibit has already beconle a permanent feature of the an-
nual sessions of the Association and to enhance the value of the work
it IS suggested that as far as possible each contributor select materials
illustrative of one classification. Those lending specimens may feel
assured that good care will be afforded them, and due credit will b^
given in the published reports. They should be addressed to any one of
the committee, as follows : F. M. Jeffries, 214 £. 34th St., New York
City; W. A. Evans, 108 State St., Suite 1408, Chicago, HI.; Roger
G. Perkins, Western Reserve Medical School, Cleveland, Ohio.

A PRIZE ESSAY*

It is desired to direct the attention of the profession to the gener-
ous offer of the Maltine Company -of Brooklyn, N. Y., (see advertising
page IX), of a first prize of one thousand and a second prize of five
hundred dollars for the best essays on Preventive Medicine.

It is particularly specified in the conditions governing the competi-
tion that Maltine or any of its combinations must not be mentioned
or even indirectly alluded to in the essays.

Drs. Daniel Lewis, of New York, Charles A. L. Reed, of Cincin-
nati, and John Edwin Rhodes, of Chicago, have consented to act sa
judges.

The high professional standing of these gentlemen gives ample
assurance that the prizes will be awarded to the essays presenting the
.greatest merit.

208

SUPPLEMENT TO THE JOURNAL OF TUBERCULOSIS.

In this part the whole subject of Pulmonary Tuberculosis will be covered
by a continued series of articles written by Dr. Karl von Ruck to appear in the
following order :

Article I — The Cause of Tuberculosis, and The Conditions Which Pre-
dispose to its Acquirement. Article II. — The Prevention of Tuberculosis.
Article III. — The Pathology and Symptomatology of Pulmonary Tuberculosis.
Article IV. — The Diagnosis of Pulmonary Tuberculosis. Article V. — The
Prognosis of Pulmonary Tuberculosis. Article VI. — The Treatment of Tuber-
culosis, Dietetic, Hygienic and Symptomatic. Article VII. — The Climatic
Treatment. Article VIII. — The Specific Treatment. Article IX. — Laryngeal
Tuberculosis, its Diagnosis and Treatment. Article X. — Institutions for the
Treatment of Pulmonary Tuberculosis.

THE SYMPTOMATIC TREATMENT OF TUBERCULOSIS.

[Continued from Page 104.]

THE TREATMENT or PNEUMO-THORAX.

This is, as a rule, sjmpomatic only, especially when it occurs in
tlie closing stage of phthisis. The patient naturally assumes the most
favorable position, lying or leaning on the affected side which enables
him to obtain all the air that is possible. If the pain is severe, a hypc-
dermic injection of morphine should be given, and syptoms of collapse
should be met by diffusible stimulants, external application of heat,
etc., while great dyspnoea may be moderated by the inhalation of oxj'-
gen.

In cases where the heart becomes greatly displaced and when there
is decided bulging of the inter-costal spaces on the affected side, the
probability exists that there is no free communication between the
point of rupture and the pleural cavity, and that the air forced into
the pleural cavity with violent inspiratory efforts, cannot return
through the perforation owing to its compression, or to a valve-Uke
slit in the pleura. Under such conditions a fine trocar and canula
should be introduced, when if the theory proves correct, the pressure
will become equalized by the escape of air. After the inmiediate
danger is averted, the further treatment resolves itself into that of tbe
usually resulting acute pleurisy which eventually requires drainage,
if the exudate is purulent which is almost always the case.

20U

In circumscribed pneumo-thorax, the symptomfi are not so urgeitt,
imd many cases go nnrecc^nized upon the assumption that simple
pleural inflammation is responsible for the symptoms.

THE TBEATMENT OF NIGHT-SWEATS.

The night-sweats of phthisis occur as a rule in connection with
•caseous softening and suppuration^ and although^ especially in the
early statges^ we may fail to demonstrate such processes by physical
examination, the attendant fever and subsequent manifestations will
often confirm this view. The sweats are therefore symptomatic of
pathological changes over which we cannot exert direct control.
However, inasmuch as this symptom stands very intimately in relation
to the fever or rather to its decline, we can influence the occurrence
iind degree of the sweat by measures which moderate or control the
fever. We should therefore endeavor to diminish the fever by rest,
by open air treatment in the milder forms, by regulation of diet and
by hydropathic measures in cases in which the application of cold water
is not contraindicated by the general condition of the patient.

Nightsweats are not a troublesome symptom with my patients, and
even the far advanced cases which present those conditions under
which the sweating is most commonly observed, lose their night-sweats
soon after admission to the Institution. The necessity for prescribing
directly for them is very rare indeed, the amelioration and control of
this as of any other symptom depending primarily upon correct general

management.

When direct interference becomes necessary we may have re-
course to the administration of drugs or to applications to the skin,
and I would advise against the use of drugs until the other simpler
and more desirable measures have failed. I would recommend first a
trial of bathing the trunk with salt water, or with vinegar and water,
or of giving the patient an alcohol rub just before going to sleep, at
which time a glass of milk with brandy or whiskey may be taken. I
have occasionally had satisfactory results from the application to the
<;he8t of a compress wrung out of a strong salt solution and allowed
to remain in place all night.

If these means prove ineffectual, we may resort to internal medi-
•cation. In patients who are weak and exhausted camphoric acid may
be tried in doses of 15 to 20 grains; it should be continued for a week
or more before being discarded as inefficient.

Should this fail or cease to exert an influence agaricin may be
given, beginning with 1-10 gr. in pill-form three or four hours before

210

retiring. This dose can be slowly increased, as may become necessary,
to one grain, but like other remedies for night-sweats it gradually losea
its effect.

Much more popular is atropine, but in effective doses it so often
interferes with all other secretions, and its action is so prolonged that
even the patient wiU at times ask to be excused, preferring the sweat-
ing to the disagreeable after-effects of the drug. In occasional
instances, I have secured absolute control of the sweats with very
minute doses (1-200 gr. hypodermically).

Oxide of zinc, 2 to 3 grains in pill-form, extract of nux vomica,,
chloralamid or sulphonal have at times been found to act favorably.
A trial of the latter would naturally suggest itself in the event of
coexistant insomnia.

Ergot has also been warmly recommended by Goldendach^ whose
idea was to employ a remedy to which is attributed the ability of
exerting an influence upon the nerves and through them upon the
sweat secretion. Before going to sleep, pulv. secalis cornuti, 5 to 10
grains should be given. In consideration of the important role which
the vaso-motor nerves play in the process of secretion this seems by no
means an irrational procedure, and may be deemed worthy of a trial.

More recently H. Hirschfeld* reported favorable experiences in
night-sweats, from painting the skin with equal parts of formalin and
alcohol. In the cases in which I have so employed formalin in varying
strength, from 2 per cent, to 20 per cent., the results were not satisfac-
tory. With strong solutions the irritating vapors from the formalin
are a source of great annoyance, but Hirschfeld has met the objection
ii. his method of application which is as follows : In order to obviate
the ill-effects upon the respiratory mucosa and the eyes from the risine:
vapors, the patient^s shirt must be kept on during the procedure.
In addition, a piece of rubber cloth about a yard square is placed
around the patient's neck in such a manner that it covers the chest
and extends around the sides of the trunk, overlapping at the upper
part of the back. The rubber cloth is held tightly in place by an ordin-
ary cloth in the form of a cravat. With the patient sitting up in bed
the shirt and rubber cloth are lifted and the back is painted. Next
with the patient in the dorsal position the shirt and rubber cloth aro
reflected over the head and the application made to the chest and
abdomen. After replacing the shirt and rubber cloth over the body

* Deutsche Med, IVocA,, iSg4, S. 551.
^Berliner Klin. Woe A., No. 15, 1900.

211

of the i)atieiit the latter is covered and must remain so for an hour
before removing the rubber oloth. The author states that one painting
suffices for from 8 davs to 4 weeks. In severe cases when the sweats
return the painting miist be repeated. Some burning and itching of
the skin often results and sometimes a alight scaling of the epidermis
id said to follow. '

Instead of formalin Strassburger^ reports excellent results from
applications of tannof orm, a condensation product of tannin and form-
aldehyde. One part of tannoform is mixed with two parts of talcum
venetum, and the mixture is applied to the skin as a dusting powder.
Strassburger asserts that it is equally as effective as f ormalin, is much
simpler in application and possesses the additional advantage that the
patient himself may be entrusted with it. The effect can be augmented
by rubbing the powder into the skin.

The formalin probably owes its effect to a blocking of the gland-
ular ducts by epithelial debris consequent upon the inflammation
induced by it, and is entirely mechanical in its action. As regards
the tannoform a similar effect is produced by the contained formal-
dehyde which is increased by the astringent action of the tannin.

In some of my cases in which I have succeeded in controlling the
sweats, I have observed that the fever became more pronounced
either by reaching higher degrees or by lasting longer.

At best the treatment of night-sweats is but a temporizrog meas-
ure, and inasmuch as the loss consists almost entirely of water which
is easily replaced, the control of the symptom is more a question of
enhancing the patient's comfort than of exerting any appreciable influ-
ence upon the course of his disease. Attention has already been
directed to the fact that night-sweats are usually associated with cas-
eous softening and suppuration. When the absorption of f ever-produc-
ing substances from foci the seat of such changes, has sufficiently
diminished or has ceased, the sweats will disappear.

THE TR£ATM£irT OF ANASMIA.

Most patients who suffer from pulmonary tuberculosis in any
stage, show evidence of more or less pronounced anaemia. The haem-
oglobin is deficient in the great majority of cases owning under my
care. In 100 consecutive records of the blood state of patients on
admission into the Winyah Sanitarium there is not a single instance in
which the haemoglobin-percentage reached one hundred, even when
the count of red cells was normal or above. I find, however, that

* Therapeutische Montashefte^ March, 1901.

212

slighter deficiency is often noted in blood examinations of persons who
are in apparent good health, and I have therefore accepted as showing
normal values all those records in which the percentage approximated
85 per cent, for men, and 80 per cent, for women. In the count of
erythrocytes an approximation to five millions for men and four and
a half millions for women sufficed to exclude from the cases here
recorded as deficient. Neither were such cases subjected to any
si»ecial treatment, unless further deterioration became evident upon
subsequent examination, which rarely happened; on the contrary,
improvement occurred quite uniformly under the general dietetic and
hygienic methods and other appropriate treatment which the patients
received.

An analysis of these records shows the following results:

Approximating normal values in red cells and haemoglobin, IT
per cent.

Approximating normal values in red cells with marked deficiency
in haemoglobin, 41 per cent.

Marked deficiency in red cells and in haemoglobin, 40 per cent.

Approximating normal values in red cells and haemoglobin, 17

red cells, 2 per cent.

The lowest count in red cells was 3,048,000 and the lowest per-
centage in haemoglobin, 40.

We find therefore that haemoglobin was deficient in 81 per cent,
and that the count of erythrocytes was markedly short in 42 per cent. ;
a comparison with prior records shows that these values are practically
correct for a larger number of cases as well.

The results from treatment of these cases was satisfactory in all
those in which the stage of the disease and the attending general nutri-
tion and complications justified such an outcome. Nothing was
accomplished in instances in which extensive destructive processes
and suppuration or the presence of complications (intestinal tuber-
culosis or amyloid disease) conditioned an adverse termination.

The treatment of anaemia in tuberculosis is practically the same
as of other symptomatic forms of anaemia. In all those instances in
which the tuberculous disease had progressed to such a degree that
there was no reasonable prospect for improvement or recovery, no
treatment was attempted, the patients being returned to their respec-
tive homes. In other instances the successful removal of gastric
catarrh and atony or other gastro-intestinal complications, was alone
sufficient to improve the general nutrition and with it the anaemic

213

state, but the administratioii of ferruginous remedies contributed vis-
ibly to a more rapid increase of the haemoglobin especially. There
was, however, a large percentage of cases in which direct treatment
of the anaemia became necessary, and which showed material improve-
ment only upon its adoption, although the dietetic and hygienic
methods were systematically carried out, and increase in weight had
also occurred. The benefit of treatment was then not only apparent
from the increase of haemoglobin and erythroctyes, but also from the
improvement of the patient's strength and endurance, and by the
return of a better color of the skin and visible mucous membranes.

In the choice of the particular preparations, I have no doubt that
iron in any form will accomplish the object sought, so long as it is
given in sufficient quantity in a form that is well borne by the digestive
organs, and when the latter are normal or approximately so in their
functions. The necessity of maintaining their integrity and of adding
nothing that may in any manner increase any existing deficiency in
the digestive process demands the adoption of a preparation which shall
be free from irritating or astringent effect, and of one which conveys
the iron in an organic rather than an inorganic state. Upon this indi-
cation I have continued to use Pepto-mangan (Gude) ever since my
first investigation of it in 1894.^ This preparation has proven uniform
and satisfactory in all respects in its acceptability to the stomach, and
in the accomplishment of all that can be reasonably expected, but
especially in the increase of the haemoglobin per cent.

Since its introduction numerous preparations of a like character
have been placed upon the market, which have attained more or less
recognition and testify to the advantage of administering iron or iron
and manganese in a soluble and readily available form.

In this connection I desire to call attention to the Glycerine
Extract of Red Bone Marrow, made by Armour and Co., to whom I
suggested its preparation in the first place, in 1895, by having them
prepare it for me for experimental use. I found then and have been
able to confirm ever since, that this product has a marked influence for
augmenting the blood state, especially the red and white blood cells,
and that it is otherwise a powerful stimulant to the general nutrition.

The use of arsenic or its combination with iron I have seen no
occasion to adopt, as a general procedure in the treatment of the
symptomatic form of anaemia as we meet it in pulmonary and other

* Pepto-mangan for Anaemia in Pulmonary Tuberculosis, New York Med-
ical Jonmaly Dec. 15, 1894.

214

fciniB of tuberculosis. Its benefits in essential and pernicious forms
have been repeatedly asserted and demonstrated, and in a very few
obstinate cases it has appeared to facilitate the improvement. In such
cases, however, I prefer now a combination of Peptomangan with
Glycerine Extract of Red Bone Marrow, as much less liable to upset
the digestive organs.

Whatever form or combination of iron may be prescribed in tuber-
culous anaemia, a properly selected and adjusted diet and judicious
general management in hygiene and in securing fresh air and sunlight
are essential to the best results; they succeed in mild cases without
other aids and are indispensable in other respects as well, to the cure
of the patient.

TER WEDlCrSAJ^ TBXATiaSRT OF PULMOKABT TUBEBCULOSIS.

Under this head I propose to consider the utility of remedies which
are prescribed more particularly for their influence upon the disease
itself, remedies having for their object "the change of soil," that is,
the increase of the patient's resistance to the disease. "Change of
soil'' is aimed at by the application of dietetic and hygienic methods
which I have alreadv considered, and in a measure also bv climatic
treatment which will be discussed in a subsequent chapter.

Here I wish to deal especially with the use of certain drugs given
for the purpose of supplying supposed deficiencies in the chemical com-
position of the fluids and tissues, for their general stimulative effect
upon metabolism or again for their alterative effect.

That deficiencies in the chemical constituents of the body mani-
fest themselves in connection with disease is a well established fact;
and scurvy, rickets, osteomalacia and anaemia are familiar examples.
Further, that excesses of, or retention of certain chemical constituents
may give rise to organic and functional disturbances as in gout or the
so-called arthritic-diathesis, is not subject to dispute. When the exist-
ence of such conditions can be demonstrated by physical and chemical
examinations there is no obscurity as to the object of treatment to be
pursued. In tuberculosis, however, such physical and chemical demon-
strations are not so readily made, and in many instances they are impos-
sible. We are therefore greatly dependent upon clinical data and,
excepting the iron preparations the effect of which we can control, we
must reason backward and seek to explain the results that we observe
from more empirical medication, by the known chemic and physiologic
effects of the remedy to which the result appears to stand in relation.

The clinical value of salts of lime, iodine and iron in glandular

215

forms of tuberculosis rests upon such a f oxmdation, and in the pulmon-
ary form of the affection these remedies have also proved of value
sufficiently often and over long enough periods of time that the factor
of coincidence may be excluded.

The hypophosphites were first introduced upon the theory of sup-
plying mineral constituents, as well as phosphorus as an available nerve-
food and a stimulant to the metabolic processes, and they have often
proved their value not only in tuberculosis, but in other wasting dis-
eases also. Fellows^ Compound Syrup of the Hypophosphites, for
instance, has been before the profession for so many years and has
attained so wide a reputation in the treatment of tuberculosis in this and
in all other civilized countries, that the favor with which it is regarded
cannot be explained otherwise than upon its merits. As much may be
said of Churchill's and of McArthur's syrup, likewise of the lacto-
phosphates and wheat phosphates and of more recent products like the
glycero-phoephates, which, as they are made from glycerino-phosphoric
acid, furnish an ideal nerve-food in the form of physiologic phosphorus
at once available to the system.

While the combination with calcium, potassium, iodine, iron and
manganese, etc., can serve the organism in special ways, I believe it i^
the effect of phosphorus upon tissue-metabolism which makes these pro-
ducts most valuable in the treatment of tuberculous and scrofulous
affections. From my own experience with a large clinical material of
this class, I have reason to express my faith in the value of these prep-
arations in cases in which the disease has not induced an irreparable
state of exhaustion. It is, indeed, to be remembered with these as with
all other remedies that a trial should not be made with patients whose
condition is hopeless and in whom everything else has failed. Neither
should we expect immediate results, especially in the active and febrile
stage, during which losses are difficult and sometimes impossible to pre-
vent. My best and most convincing restdts have been in cases with
little or no fever, without complications, especially on the part of the
digestive organs, and when the patient was stationary or was losing but
slightly in his weight and strength, in spite of the fact that food in
sufficient amount or in excess was taken and was apparently digested.

Iodine in combination with chloride of gold subcutaneously, was
warmly recommended by Gibbs and Shurley^ about ten years ago,
and the pure tincture of iodine was used in like manner and by deep
injections into the tuberculous portions of the lungs years before by

* Therapeutic Gazette^ April 15, 1901.

216

various clinicians and by myself. More or less frequently recommen-
dations of the subcutaneous use of iodine preparations are found in
medical literature.

Ingraham^ oifers a formula containing iodine 1-4 gr., bromine 1-4
gr., phosphorus 1-100 gr., thymol and menthol, of each 2-3 grains, in
one drachm of sterilized oil, but reports the clinical history of only
one case to illustrate its curative effect.

Croftan^ used lodipin (10 per cent, iodine in sesame oil) as lees
irritative, and saw uniform improvement in twenty-seven cases treated.
Lawrence Flick has long insisted upon the use of iodine compounds by
Inunction, using iodoform and more recently europhen for that purpose
with satisfactory results. lodol has been rejected* by Flick* as decom-
posing too rapidly and becoming useless before the patient can apply it^
and Tyson's^ results with this preparation seem to justify Flick's views.

S. Solis Cohen^ believes iodoform innunctions to have no material
advantage over the internal administration of the drug. He recom-
mends a gradual increase in dosage to 5 gr. three times a day, especially
in the early stages before destructive processes have occurred.

Russell** in a series of 123 cases treated with iodoform internally
in doses of 15 to 30 grains per day, found that these patients gained
more in weight than did others who received the same care but were
given no iodoform.

Otis^ quotes Bansome who says that europhen is one of the best
remedies that can be given to assist in the nutrition of the patient and
to alleviate cough.

A more effective method of exhibiting iodine in the treatment of
pulmonary tuberculosis, claimed by Cavvazani and Spadoni,^ consists
of the internal administration of iodides, coincidentally with inhala-
tions of spirits of turpentine, which latter they found to cause the liber-
ation of nascent iodine in the lung wliich they say exerts a specific influ
ence iipon the tubercle bacillus and its products.

[to be continued.]

* Med, Record^ Vol. 54, page 483.

^ Journal American Medical Association, Nov. 17, 1900, page 1273.
^ Journal of Tuberculosis, Vol. Ill, page 116.

* Ibid, page 12.

^ Journal Am. Med. Association, Vbl. 36, p. 848.

* Birmingham Med. Review, June, 1898.

' Boston Med. and Surgical Journal, July 21, 1898.

* Riforma Medica, Sept. 2, 1901.

THE

Journal of Tuberculosis

VOL. IV JULY. 1902 No. 3

ORIGINAL CONTRIBUTIONS*

INTRATRACHEAL INJECTIONS IN PHTHISIS PULMONAUS.

BY WIIXIS S. ANDERSON, M. D., DETROIT, MICH.,

LARYNGOLOGIST TO THE HARPER HOSPITAL POLYCLINIC; ASSISTANT TO THE CHAIR

OF LARYNGOLOGY, DETROIT COLLEGE OF MEDIQNE.

The object of this paper is to briefly call attention to a method of
treating pulmonary phthisis that has not, in the opinion of the writer,
received the attention it deserves. Intratracheal medication in chronic
pulmonary affections does not in any way interfere with other methods
of treatment and can be employed in addition to such dietetic, climatic,
and medicinal means as may be best suited for an individual case. Like
other means at our disposal, it finds its greatest usefulness in the first
and second stages, but many of the symptoms in the advanced cases are
also relieved bv this method.

The writ;r has not always been able to confirm his diagnosis of
tuberculosis by finding the tubercle bacilli in the sputum, as many have
been seen in the early stages where the physical signs revealed but a
small involvement of the lungs, and where the amount of sputmn expec-
torated was scanty. The fact that some of the inflammatory cases, as,
for instance those following pneumonia, run their course without the
tubercle bacilli being found in the sputum during life, or in the tissues
after death, has lead competent observers to recognize a tuberculous
and a non-tuberculous form of phthisis pulmonalis. Whether we accept
this division as correct or not, the practical fact is that we find cases

218

with a clear clinical picture of beginning phthisia in which repeated
examinations fail to discover the germ. If we find a few germs once or
twice after a number of examinations we must not forget that they may
be accidentally present, as a great variety of pathogenic organisms may
be found in the mouth of a healthy subject.

We are justified in diagnosing beginning phthisis when our patient
gives a historj' of impairment of nutrition with loss of weight and a
hacking cough, .if we find evidence of involvement of one apex and a
slight rise in the afternoon temperature, even though the physical signs
are not marked. If the tubercle bacillus is found at each examination
of the sputum our diagnosis is confirmed, but unfortunately the pres-
ence of the organism is not one of the first signs.

We know that a patient may have small tuberculous foci in* the
lungs that give rise to few or no symptoms ; but let the patient catch
cold, or contract pneumonia, and the secondary infection will set up a
train of serious symptoms. This secondary infection is becoming to be
more and more recognized as an important factor in the course, prog-
nosis and treatment of pulmonary phthisis. In the treatment of the
disease these secondary infections demand our closest attention, and in
proportion as we are able to ward off bronchitis, pneumonic extensions
and the like, we are in a position to combat the tuberculous trouble. It
is in these secondary infections that intratracheal injections find their
greatest usefulness, by keeping the bronchial tract in as healthy a condi-
tion as poi^ible. The tuberculous process itself seems in many cases to
be favorably influenced by the injections.

The introduction of a considerable quantity of fluid into the
trachea, by means of a suitably curved syringe, passed between the
cords, appeals to one as a rational means of local medication. The
objection has been raised by many that it causes so much irritation and
such severe coughing as to render the procedure dangerous. The
trouble has been that too irritating fluids have been used, or unskillf ully
introduced. The writer has given hundreds of these injections, and
only in a very few instances has severe coughing, either directly or
indirectly, been caused by them. There are many in whose trachea one
or two drachms can be introduced with hardly a cough or sense of
suffocation.

Many observers who have discarded the method, because of the
irritation produced, used watery or glycerine solutions, which are
decidedly irritating when introduced into the trachea. If pure olive
oil is used as a vehicle, and reasonable care is taken to select drugs not

219

too irritatmg to the mucous membrane, no trouble will be experienced.
The Muir tracheal syringe is the one used by the writer. I will quote
the following from a former paper :^

'*The technique is similar to that of laryngeal applications. The
patient should hold his tongue out whUe the operator introduces the
cannula of the syringe, guided by the mirror, during a deep iospiration.
If the patient inhales gradually, slowly and steadily, the cannula can be
introduced between the vocal cords, and from one to two drachms in-
jected without inconvenience. The operator should introduce the fluid
gradually and steadily, not in spurts, and the whole amount must be
introduced before the end of the inspiration, otherwise choking will
take place."

This method has been used both in private and dispensary practice
with good results. It is difficult to give the precise value of the method
in any given case, as other means were employed. Many of the dis-
pensary patients were imder p<5or sanitary surroimdings and had to earn
SL living while imdergoing treatment. Some were lost sight of before
the value of the treatment could be ascertained.

In estimating the value of the method, in connection with other
ineans, one must use it in a number of cases. It is not claimed that this
is a specific in any sense of the word ; it simply relieves certain condi-
tions and places our patient in a position to better resist the inroads of
the tlisease. It would be unprofitable to give a detailed history of a
number of cases under treatment during the past two years. More can
be gained by indicating certain results obtained by its use and by illus-
trating a few by reference to certain cases.

In the early stages, where but a small area is involved and the
tem]>erature is only slightly raised above the normal, it will give relief
in many cases, gradually bring the temperature back to normal, lessen
the cough and expectoration. This has been noted in cases where the
other medication directed to the improvement of the general condition
could hardly account for the steady improvement. One case, a young
man, slender in build, came under observation with the history of a
hacking cough, loss of weight, mucous expectoration and an evening
temperature of about 100°. At the right apex was found slight dull-
ness, jerky inspiration and a prolongation of expiration with a slight
increase in pitch. Intratracheal injections were used for a number of
months, together with pulmonary exercise and tonic treatment. The

'Intratracheal Injections in Bronchial and Pulmonary Affections ; MedS'
cal News^ Sept. 28, X901.

220

temperature gradually went down to normal, the expectoration lessened,
the area of dullness diminished, and the chest expansion increased.
The hacking cough did not entirely disappear, nor did he gain much in
weight, although his appetite improved. He was confined in a store
during the whole day. On the approach of cold weather last fall he
was urged to go west, which he did. He is now in Denver, Colorado,
and has gained twenty pounds in weight and feels perfectly well. This
case is a satisfactory one when we consider that he went through a
Michigan winter without intercurrent attacks of bronchitis and that
actual improvement occurred despite unsatisfactory surroundings.

It is in the cases more advanced than this that we see the beneficial
results which we can attribute directly to the injections. Where the
cough is severe and the muco-purulent expectoration is marked, with
the hectic condition present indicative of septic poisoning, we find much
relief from the regular use of the injections. The cough lessens, the
muco-purulent matter is more easily expelled and soon decreases in
amount. As these symptoms decrease the temperature approaches
normal.

There is, occasionally, a case where the injection seems to cause
irritation, eitlier at the time of its use or several hours afterwards. As
a rule we may expect irritation in proportion as the mucous membrane is
acutely congested. This was first noticed in treating the congestive
stage of acute bronchitis. In phthisis where the mucous membrane is
acutely congested by the accompanying bronchitis or harassing cough,
we may not be able to use the injections until the cough and congestion
are controlled by other means. In these sensitive cases, if a spray of
cocaine is used before the injection less trouble will be experienced,
especiaDy if at first a small amount of the injection is used.

In those cases where larjTigeal tuberculosis complicates the pul-
monary affection much relief will result by their use, although some dif-
ficulty may be experienced on account of the sensitiveness of the parts.
Verj' little permanent benefit can be expected from the method in Inber-
culous laryngitis, although the temporary benefit is so satisfactory that
we are warranted in using it.

The dyspnoea of phthisis is greatly lessened by the injections.
This, of course, would not apply to the late stage where the lungs are
badly disorganized. The lessening of the dyspnoea seems to be due to
the sedative effect upon the nerve terminals of the bronchial mucous
membrane. The relief after an injection is noticed within a few

221

iniiinte3. aad ttsoally continuoA from twelve to twenty-four hours. A
IMitient BOW under ol)6ervati(»[i says that he is very short of breath on
his way to the elinic, but after the injection he feels an ahnost imme-
diate relief, enabling him to walk faster after having the treatment.
The beneficial effect in this ease lasts the remainder of the day. The
injections have also lessened his cough and expectoration.

The shifting pains and sense of oppression in the chest are usually
relieved by the injections. The patients report that their chests feel
easier after the injections and they welcome them if for no other reason
than for the temporary relief.

One patient came to the clinic last September with the history of
loss in weight, cough, pain across chest, afternoon fever, chills and night
sweats. Examination revealed morning temperature 100°, dullness
over both apices, with bronchial breathing and a few mucous rales.
Intratracheal injections were used every day at first, then every other
day. The cough, dyspnoea and pains in the chest graduaDy lessened,
the chills and night sweats disappeared entirely. The temperature
approached normal, but while under observation there was almost always
a slight rise. The dullness of the upper right side cleared up entirely,
but a small dull area remained at the upper left, with slight bronchial
breathing. The general condition improved and the patient often said
that she felt decided relief from the sense of oppression across the chest
after the treatments. The other medication was largely tonic in its
nature, directed towards improving her general nutrition. Creosote
was given for a short time. The latter part of last December she left
ICichigan for New Mexico, and a month after arriving reported that she
had continued to gain. The improvement in this case would seem to
be due largely to the injections, as evidenced by the improvement in the
physical signs and her own subjective sensations.

The writer has used only a limited number of drugs in these injec-
tions. Olive oil is the only vehicle used. The formula used in the
majority of the injections was liquid guaiacol, 2 per cent., and camphor-
menthol (equal parts of camphor and menthol) 5 per cent. This seldom
causes irritation, is not unpleasant, and has been the most generally
useful of the formulae tried. Ichthyol, 2 per cent, with camphor-
menthol, 5 per cent, has also been used. It seems to lessen the secre-
tions. It is not as agreeable for the patient and has not proven in the
majority of cases as useful as the first formula.

Iodoform, 1 to 2 per cent, has been used. It does not dissolve read-
ily in the oil. A little less than 2 per cent, will be taken up by the oil.

222

Iodoform is generally regarded as a valuable agent in all forms of
tuberculous disease^ so it would seem that it would be especially useful
in this connection^ but a more extended trial is necessary in order to
know its value as compared with the other combinations.

The solution should be sterilized before it is used. This can be
done easily by placing the bottle in a hot water bath for forty-five
minutes.

The usefulness of these injections in chronic pulmonary inf ectiouB
has been so evident in a number of q^ses that one is justified in giving
them a more (extended trial.

912 Chamber of Commerce.

EPIDEMIC INFLUENZA CONSIDERED IN RELATION TO QUARANTINE

AGAINST TUBERCULOSIS.

BY A. J. COMSTOCK, M. D., VENTURA, CAUFORNIA.

Most physicians in active practice realize the serious bearing of
attacks of influenza upon the subsequent development of pulmonary
tuberculosis. I have never forgotten the words of the late Dr. J. M.
Da Costa, who, as professor of the practice of medicine in the Jefferson
Medical College of Philadelphia, as early as 1882, thus began his lec-
ture upon epidemic influenza :

^'Gentlemen : I will now speak concerning the least fatal, and flt
the same time the most fatal epidemic disease at present prevalent upon
our continent. I refer to epidemic influenza. It is least fatal in its
immediate results, but most fatal in its far reaching mortality.^'

But while those words have been in my memory through eighteen
years of practice, in this paper I will only consider the relation of
epidemic influenza to the subsequent development of pulmonary tuber-
culosis. When we refer to our carefully kept records, or recall to min<i
the cases of phthisis coming to us from day to day for treatment, we
find that not less than ninety per cent, of the patients have to make
statements something like this : ''My present trouble followed an attack
of La Grippe;" — ^and this attack may have occurred, in any given
instance, one, two, or even fifteen years before.

There was a time when influenza was not the scourge that it ib
to-day. Formerly this disease, at least in epidemic form, made its
appearance in cycles, often with intervals of ten years between its

228 ;

recurrences, but now it seems ever prevalent. This may perhaps be
accounted for by the enormous increase in commerce and travel in
modem times. It is a fact that if influenza becomes epidemic in Ne\v
York, cases will surely occur at Chicago within the week, and at San
Francisco within a few weeks later, and we have all seen this epidemic
girdle the world in startlingly short time within recent years.

Now, it cannot be denied, I think, that pulmonary tuberculosis has
steadily gained ground in the United States within the past twenty
years. It is still gaining ground. Then what relation does epidemic
influenza bear to this increase in tuberculosis ? I claim that its causa-
tive relation has not been fully appreciated.

The influenza bacillus is a pioneer in a bacterial strife against
human life. It leads the way, it cuts the trails, and makes it compara-
tively easy for the tubercle bacillus to follow and firmly establish itself.
We know that the tubercle bacillus is not a specially virulent micro-
organism to the average human being, placed amidst favorable sur-
roundings. Healthy tissues fight it off for years and often conquer it
altogether, but in the system already weakened by the ravages of the
influenza bacillus it finds ready lodgment vdth lessened tissue resist-
ance.

If these things, then, are true, what is implied as to prophylaxL>
and far reaching sanitary measures ? Should we not, in the beginning,
isolate influenza patients, as far as practicable ? For the patient's own
welfare he should be confined to his room and bed from the time that
the nature of his disease is discovered, and there detained until all
active symptoms have subsided. This course \^all not only secure the
immediate welfare of the patient, but ynll tend to curtail a probable
cause for the spread of tuberculosis in years to follow, as neglect of a
case of influenza may afterwards result in the development and spread
of pulmonary tuberculosis.

In brief, the logic of the position is this : When considering thoso
infectious diseases requiring the enforcement of a quarantine in the
interest of the health of the community, should we not wisely go
back to first causes ? I do not set myself against the quarantine of any
scourge in the nature of disease, but why should we so set ourselves upon
the quarantine of the fully developed case of pulmonary tuberculosis,
which disease is after all but mildly infectious, and permit the disease
which most actively disseminates tuberculosis, epidemic infiuenza
to-wit, to go without any check whatever? Let us begin our reform at
the beginning.

224

THE RELATION OF SCROFULA TO TUBERCULOSIS.

BY CAROLXJS M. COBB, M. D., BOSTON, MASS.

The relation of scrofula to tuberculosis is a question of the utmost
importance, not alone because it is important to recognize each and every
manifestation of tuberculosis, but because it is equally important to
recognize other diseased conditions which may be included under the
general classification of scrofula. The definition of scrofula is a very
loose one, and while it does not cover as many diseases as formerly, it i»
still used to describe many conditions which evidently do not have a
common origin. It is generally accepted that scrofula is tuberculosis of
the glands, and almost every case in which the glands are the site of
chronic inflammation, especially in children, is called scrofula. This
diagnosis is confirmed if the child is anaemic, and such children gener-
ally are. The too ready acceptance of this diagnosis leads us to overlook
obvious sources of infection that are not tuberculous, and if these
sources are unrecognized and untreated the adenitis is likely to continue
and to make the typical picture of scrofula. Cervical adenitis is the
most common form of gland disease that goes under the name of
scrofula, and it is in this region that the unhealed sinuses and suppur-
ation extending over years, make the typical picture of scrofula. If all
or even a large proportion of the cases of cervical adenitis are due to
tuberculous infection, it is certainly remarkable that these patients do
not of tener suffer from general tuberculosis, and it is notable that they
do not. This is the more remarkable when we consider the vascular and
lymph system of this region and the short distance that infection has to
travel before it gains entrance to the general circulation. This is in
marked contrast to the action of tuberculous lesions in other parts of the
body, and it is a well-known fact that patients with tuberculous disease
of the long bones are in much greater danger of general tuberculosis
than are patients with cervical adenitis. Another interesting point is
that patients with typical tuberculous lesions very rarely have involve-
ment of the cervical glands. This is only one link in the chain of evi-
dence, however much it may be worth, that many of the cases of so-
called scrofula are not of tuberculous origin. But if not tuberculous
how then explain the group of symptoms which goes under the name of
scrofula? There are, evidently, several groups of diseased conditions
v.hich go under this general classification. The first of these groups,
not in relative frequency, but in clinical importance, is composed of

225

cases of inherited or intra-uterine syphilis. Every one, of oourBe, recog^
nizeB the well marked cases, but it is evident to every one who does
Dinch hospital work that there are many cases which are not distinctive
enough to attract attention during their early stages. Hereditary syph-
ilis does not cause a general adenopathy, but the glands in the tissues
surrounding any local lesion are quickly involved, and in addition to the
inhibitory effect which the disease has over general development, the
tissues as a whole offer less resistance to infection of other kinds. Syph-
ilis in its various forms offers an explanation of a large class of these
cases, but with all of its protean forms it is not so important a factor in
the production of scrofula as unhygienic surroundings which lead to all
forms of septic infection. While it is undoubtedly true that tubercu-
losis is a disease of the masses and causes more deaths than any other
one disease, it is not so prevalent among the poorer classes as septic
infection, although the sepsis is not often severe enough to cause death.
Septic infection manifests itself in affections of the skin, as skin disease,
boils, ulcers, and infected wounds, and by what is even more common,
the so-called catarrhal inflammation of the upper respiratory tract.
Enlarged tonsils, adenoid vegetations in the pharynx, and a purulent or
muoo-purulent discharge from the nose are present in almost every
child living in the unhygienic surroundings of the city. With all these
forms of infection the surrounding glands are involved, and if the
source of infection is chronic, the gland disease will run a protracted
course. That inflammation of the nose and throat is a potent cause of
enlarged cervical glands, every one can verify for himself. The climes
of the city hospitals show a large increase of these cases of cervical
adenitis during the winter and spring months, at the time when the
catarrhal conditions are more prevalent, and they also show that they
get better as the warm weather comes on, and the child gets better sur-
roundings. Yet these cases are diagnosed as scrofula and hardly any
attempt is ever made to find the source of infection. In addition to the
general catarrhal condition of the upper respiratory tract, we should
also look for local lesions in the mouth, throat, particularly in and
around the tonsils, the nose, the ears and upon the surface of the skin
in the drainage area of the glands involved. So far as my observation
goes infection takes place with the lymph current and rarely, if ever,
against it, so that we should look for the source of infection towards
the periphery of the lymph system of the glands involved. Lastly, in
relative frequency, so far as my experience goes, we find tuberculous
infection as a cause of so-called scrofula. Tuberculous disease of the

226

glands is a much more serious condition than most of the cases of scrof-
ula, and is accompanied by rather serious disturbances of the general
health. The patients, either with or without rise of temperature, suf-
fer from loss of appetite, languor, anaemia, and rapid loss of weight.
If the disease remains localized the symptoms gradually improve and
the affected glands either break down or undergo partial resolution.
Under the most favorable termination, there is often a thickened condi-
tion of the glands which can be felt for a long time after the storm has
passed. The treatment of scrofula should be based upon the nature of
the infection with which we have to deal If the infection is tubercu-
lous we should endeavor to assist nature in the effort to keep it a local
lesion. In doing this it may be necessary at times to remove infected
glands and to drain abscess cavities, but at all times it is necessary to
build up the general health, so that the system may offer as much resist-
ance as possible to further infection. To accomplish this purpose good
food and tonics are essential, but above all other things comes pure air
and hygenic surroundings. The enlarged glands which are due to other
infection require in addition to these measures, that we find the source of
infection and endeavor to heal that, if we expect to stop the continued
infection and reinfection of the diseased glands. If we apply the same
general principles to these diseased glands that the surgeon applies to
inflamed glands in other parts of the body we shall be in a position to
treat them intelligently. If the surgeon finds inflamed glands in the
axilla in connection with a septic wound of the hand, he does not devote
his whole attention to the inflamed glands and neglect the septic wound ;
further than that, if he finds inflamed glands in any other part of the
body except the neck, he at once searches for the source of infection.
Yet enlarged glands of the neck are always considered to be tuberculous,
notwithstanding the daily illustration that we have of the involvement
of these glands in practically all acute affections of the throat, and the
involvement of the glands is of shorter or longer duration, as the disease
of the throat is short or long in its course. It is hardly necessary to say
that the removal of enlarged glands caused in this way will not cure the
disease or prevent other glands from becoming involved, so long as the
source of infection still exists. We should bear in mind that the tissuies
of a child are much more liable to infection than are those of the adult
and that gland involvement occurs in many acute and chronic diseases.
The adult acquires a certain immunity to infection which furnishes a
more or less complete protection, unless the bodily resistance is reduced

227

either generaUy or locally, as by injury. An illustration of the lack of
this immunity is furnished by the virulence of any disease which is new
to a nation, or one which has not been prevalent in a country for many
years, as the measles in Mexico, syphilis in the Sandwich Islands, and
epidemic influenza in Europe and America. But to return to the sub-
ject of scrofula, the anaemic condition of these children which is such a
prominent symptom of the disease may come from a variety of causes,
among which are the vitiated tissues of the syphilitic, bad air, poor or
improper food, unhygienic surroundings, and septic infection both from
their surroundings and from the disease with which they are suffering.

A few cases will better illustrate some of the sources of infection
which may be the cause of enlarged cervical glands, than any amount of
argument.

Case 1. J. B., aged 19, was well until he had an attack of diph-
theria at the age of 15 ; following this he had a nasal discharge (sinuses
probably involved at the time of the diphtheria) and after two years the
cervical glands became involved and for the next year he underwent
several extensive oi)erations for their removal, so that when he came to
me his neck was seamed with the scars of these operations, and he had
enlarged glands beyond the site of the former operations, which had
become involved since. He was sent to me by Dr. Sopher, of Wake-
field, Mass., with the request that I examine his nose and throat to see
if there was any disease there which might act as a source of infection.
I found a chronic ethmoiditis which was treated and cured, with the
result that the remaining enlarged cervical glands underwent resolu-
tion, and no new ones have become involved for two years. There is
every reason to believe that if the former treatment had been pursued,
and no attention paid to the ethmoiditis, that he would have continued
to have a succession of new glands involved perhaps for years.

Case 2. F. L., aged 6, suffered from a latent tonsillar abscess
which caused enlarged cervical glands and one sharp attack of septic
rheumatism. After the removal of the tonsils, the glands slowly
underwent resolution. This case is interesting from the fact that the
patient had a general septic infection in addition to the adenopathy,
showiug the danger of collections of pus in or around the throat.

Case S. A. M., aged 22; his brother, a physician, brought him
to me with the history of a succession of suppurating cervical glands
which had extended over four years, being much worse during the
winter months. In fact, during the cold weather he was hardly ever

228

free from a suppurating gland. The disease was supposed to be tuber-
culous and had been treated by the usual method pursued in these cases,
with the result that one gland after another had become iuTolved, until
his neck was seamed with the scars of many battles. The removal of
a part of the middle turbinal on the same side as the enlarged glands
improved the nasal drainage and cured a purulent nasal discharge.
After the nasal discharge ceased the diseased glands began to improve
and for two years he has escaped further gland disease.

These cases might be multiplied indefinitely, but enough have
been given to illustrate the point that it is necessary to treat these cases
on the same principle that cases of gland disease in other parts of the
body are treate-d, and that it is not enough to make the diagnosis of
scrofula and practically do nothing for them until the glands have
broken down, but that we should remember that there is a large area in
the mouth, throat, and nose which is peculiarly liable to infection and
to retain infection, and that the cervical glands are in the pathway of
the lymphatic drainage and are almost certain to be involved sooner or
later. This cervical adenitis will, of course, continue as long as the
source of infection is unhealed. If I shall have directed attention to
this, to me, important subject, I shall be satisfied.

419 Boylston street.

THE DIFFERENTIATION AND DIAGNOSIS OF TUBERCULOSIS AND

PHTHISIS.

BY M.J.BROOKS, M. D., NKW CANAAN, CONN.

PHYSiaAN-IN-CHARGE, SANATOlUUlf NEW CANAAN, CONN. MEMBER OONHECTI-

CUT STATE MEDICAL SOaSTV, ETC.

For a number of years I have earnestly urged the general practi-
tioner to study the physical aspects of tuberculosis in contradistinction
to phthisis, inasmuch as therein lies the fundamental basis of all prac-
tical prophylactic measures. In this respect I am but following in the
footsteps of that incomparable master, Virchow, who has ever insisted
upon the sharp distinction between these two conditions.

The past decade has witnessed unprecedented progress in this par-
ticular field and perhaps no similar period in history has produced so
many ardent and true scientific workers. That the studies and per-
quisitions of Strauss, Chaveau, Villemin, Aufrecht, Klebs, Cohnheim,
Koch and others, have served to elucidate and exemplify the etiology

229

and pathology of phthisis cannot be gainsaid, but in the light of more
recent knowledge no small part of their labors subserves an academic
rather than a clinical value. Thus, not only the pathology of the so-
called stages of phthisis, but the very bacillus tuberculosis itself has
only a subsidiary interest at the present time.

It is to sincere, unselfish sanat<>ria-phyBicians and other coworkers
that clinicians are in the main indebted. Notably among them should
be mentioned Czaplewsky, Maragliano, Striimpell, Petruschky, Tur-
ban, Brieger, Neufeld, Ortner and especially the brilliant Japanese,
Sata. These gentlemen have given us a nosology at once simple,
obvious and effectual.

Tuberculosis is a product of a gregarious civilization with all its
concomitant deviations from the conditions essential to a healthy ani-
mal life. Crowding and insanitation, insufficiency of air, light, food,
and water are but sequential details. Tuberculosis is primarily a local
disease v^th constitutional manifestations. It has, to be sure, a specific
infectious organism, but as Baccelli affirmed long ago, the bacUlus is
only the histological e3q)onent, not the whole of the tubercle, much less
the disease. Local tuberculosis, regardless of its situation in the animal
economy, has the same characteristics — the locus minoris resistentiae —
which according to Petruschky, includes primarily all organs directly in
communication with the outside world — and the proliferation of fixed
tissue cells resulting in a sequestration of the infective irritant. Pure
local tuberculosis, whether pulmonary or articular, does not possess
the time honored and respected signs of inflammation — rvboTy dolor,
iumoTy caloTy et functio laesa. Tuberculosis per se is quite afebrile and
it is likewise without exudation. Tuberculosis is in no sense a perni-
cious process; it is a conservative one, no other disease having a greater
tendency to spontaneous recovery.

Phthisis is tuberculosis plus mixed infection. Bacteriologically it
IB a symbiosis of two or more pathogenic organisms acting in unison.
3foet frequently the staphylococcus pyogenes aureus and the strep-
tococcus pyogenes; commonly the diplococcus of Fraenkel and
PfeiflFer's bacillus play an important part; less frequently Gaffky's
inicrococcus tetragenus and Gessard's bacillus, as well as other patho-
genic and saprophytic organisms too numerous to mention.

Phthisis, then, is tuberculosis plus a pyaemia or septicaemia. The
due appreciation of this condition is of paramount importance, for
almost all the dreaded symptoms of phthisis are the result of this pyo-
genic superinfection. In other words we have but the same predomi-

280

uaBt manifestatioBB that accompany acute suppuration, acute articular
rheumatism, erysipelas, puerperal fever and the like.

To be more specific the staphylococcus pyogenes from its known
liquifying action upon connective tissue is probably in the main
responsible for the breaking down of tuberculous tissue. The diplococ-
cus lanceolatus, the influenza bacillus and, peradventure, the streptococ-
cus are almost invariably responsible for the broncho-pneumonia of
phthisis, as Ortner has shoMTi. The streptococcus pyogenes is without
doubt the sole cause of the hectic fever and night sweats. It may be
mentioned pari passu that the so-called "strepococcus curve" has
repeatedly been demonstrated in the fever charts of phthisis. The
bacillus pyocyaneus, as is well known, gives the characteristic greenish
coloring to the sputa of consumptives.

Pulmonary tuberculosis, of itself, is manifestly without expect-
oration. An exudative inflammatory bronchitis of greater or less
degree is essential to the production of sputa, and is always of pyogenic
origin.

Pure tuberculosis consists typically of closed foci and the disinte-
gration and degeneration of the tubercle with the consequent setting
free of the tubercle bacilli is likewise only the result of mixed infection.
Hemoptysis, the erosion of a radicle of the pulmonary artery,
regardless of the time of its occurence, is invariably an accompaniment
of phthisis. While pulmonary tuberculosis is not characterized by
expectoration, bacilli, fever or hemoptysis it must not be inferred that
its diagnosis is at all difiicult : Quite the contrary.

It may be stated en passant, that of the fifty-five hundred and odd
patients sent last year to the various German sanatoria over one-third
were purely tuberculous.

The following are the physical signs and symptoms of pulmonary
tuberculosis :

Inspection: — ^Deficiency, impairment or irregularity of respira-
tory movement upon affected side. Evident unilateral contraction.
Flattening or depression of the supra- or infraclavicular fossae. Amyo-
trophy of the thorax. An acceleration of respiration, more particularly
in women.

Palpation : — Slight increase in vocal fremitus.
Percussion : — ^Defective resonance upon or above a clavicle. Want
of elasticity, definite dullness, tympanitic dullness or tympany apparent
upon repeated examinations.

281

ATTSCin.TATiON : — Evident changes in the respiratory murmur; it
matters not whether it be diminished, weakened, rough, harsh, indefi-
nite, sharp, rude, puerile, interrupted or exaggerated, suffice it that
such modification in the vesicular respiration is constant over a circum-
scribed area. Most frequently the respirations are somewhat short and
slightly accelerated. Inspiration, weakened or rough, and expiration
somewhat prolonged. "An apical catarrh^^ with fine crepitaUon or a
few localized dry ronchi or sibilant rales is pathognomonic.

Symptoms: — The constitutional disturbances are, as a rule, more
pronounced than the pulmonary. There may be some dyspnoea upon
exertion. There is no true cough, rather a reflex "hack," probably due
to a small deposition upon the arytenoids or posterior wall of the
trachea. A clearing of the throat on speaking is often noted. A trans-
ient localized pain, the dry pleuritic stitch, or a neuralgic indefinite ache
in the sternal or scapular region, or a faint sense of resonance felt by
the patient in talking are usually the sole subjective symptoms attribut-
able to the lungs.

There is a slight palor, a peculiar duskiness or sallowness, a pseudo-
anaemia or chlorosis readily distinguishable from the true by the pres-
ence of a leucocytosis ; inequality of pupils ; according to some dilata-
tion ; a general dullness, weakness, or at times a disinclination to work —
symptoms frequently confounded with malaria.

A carbohydrate indigestion with eructations, acid dyspepsia, capri-
cious appetite, anorexia, gastralgia, intestinal indigestion, coated
tongue and constipation are frequently predominant symptoms A
temperature of say three-tenths to one-half degree under stimulus of
mental excitement or slight exertion and at menstrual period. Sub-
jective feeling of chilliness or a slight subnormal temperature during
early morning. There is a small loss of weight, determinable solely by
frequent weighings, not by the opinion of patient or friends. A ten-
dency to cyanosis of the extremities, less frequently of the lips or
cheeks. The pulse' is characterized by considerable instability. There
is increased rapidity upon trivial exertion or mental stimulus, particu-
larly towards evening. The pulse is often of low tension, full, soft, or
compressible. Tendency to sweats, not only nocturnal, but following
the slightest exertion. Changes in temperament, irritability, intro-
spection, sweating of the palms of the hands under excitement, in
women, palpitation of the heart and amenorrhoea, have all been noted.

In addition to the foregoing, age, occupation, environment, the

232

probability of exposure to infection, and the personal and family
history should be taken into consideration.

The physical signs and symptoms of phthisis should certainly
require no reiteration. It should not be forgotten, however, that
hemoptysis or the occurrence of bacilli in abundance, as Brieger has
well demonstrated, are evidences of cavitation. Clumps of granular
bacilli indicate progressive softening, while alternation of few and
many bacilli signifies the occasional opening of closed cavities with dis-
charge of their contents. Even in phthisis one should not rely exclu-
sively upon the presence of bacilli in the sputa, for as Neuf eld has
shown that while staphylococci and streptococci may be present in the
sputa, the tubercle bacilli may be absent for months at a time, or if
present, in so small numbers as not to be readily recognized.

The thermometer is perhaps after all the best instrument in the
diagnosis of early phthisis. If the temperature be taken every twa
hours, after midday, a rise will usually be noted proportionate to the
progress of the disease.

Again, upon examination of the chest, in phthisis, it should be
remembered, as Kingston Fowler states, that in the great majority of
cases, when the physical signs are sufficiently definite to allow of diag-
nosis, the lower lobe is already involved.

Michaelis's Diazo-reaction and Roentgen rays have proven of no
utility in the diagnosis of tuberculosis or early phthisis.

. The tuberculin reaction is too promiscuously present in other
diseases, uncertain, unacceptable to the patient and not entirely without
danger. Further, it has been repeatedly shown that the glycerin and
proteids of the culture fluid are in themselves sufficient to produce a
reaction without the tubercle bacilli extract. It may with truth be said
of many of the advocates of tuberculin : "Quod f erre libenter id quod
volunt credunt.^'

While tuberculosisy as well as a goodly nimiber of cases of phthisis,,
are eminently curable, early diagnosis is of vital importance. Success-
ful treatment must necessarily depend upon the measures taken before
the lungs are extensively involved and it goes without saying that if
ivbercvloais was generally diagnosticated there would be practically na
mortality.

It may be added, parenthetically, that even a "suspect'' has a right
to know the truth in order to protect himself ; that the physician who
fails to inform a poor consumptive of his condition commits an unpar-

donable an, emce he not only jeopardizes the life of his patient, bnt
scatters the seed of the dreaded scourge broadcast. .

I have elsewhere* gone into details apon the subject of treatment.
Soffioe it to say here that the perfection of sanatoria methods has been
the achieTement of the last ten years and emkracea modem and effect-
ual measures. A sojourn at so-called health resorts where patients are
prone to do very much as they are inclined is obviously no substitute.

In the li^t of present knowledge, however, the location of such
institations is eecondary to the ability and uncerity of the phyucian in
iduurge.

UGHT— ITS THERAPEUTIC IMPORTANCE IN TUBERCULOSIS AS
FOUNDED UPON SCIENTIFIC RESEARCHES.

BT J. UOmiT BUtynt, M. D., F. R. A., M. S., LL. D.

VICE-FKBSIDBMT AHIRICAN CONGRESS Of TUBERCULOSIS.
(Contlnned from Page 123.}
^e calorific rays are not visible to ns. If we move the bnlb of a
thermcsneter along the solar spectrum, we find that the heat begins at
the indigo, and gradually rises to acquire its maximum intensity near
the end of the visible spectrum, beyond the red. The most luminous
port of the spectrum, the yellow, is not the hottest. On the other
hand, we ascertain chemically, through the labors of Sitter and
Scheele, especially by photography, that the chemical rays begin in the

THB Son
green, acquire their maximnm in the violet and extend beyond it^
forming also an invisi ble spectrum. Figure 8 represents the relation
Ww yMt Medical Retard, Oct. 13, 1900.

234

wMch exists among the three spedes of rajs. The limunoiis rajs
extend from the red to the violet (from the \eit
of the line A to the right of the line S), and their
luminous intensity is represented bj the curve L,
of which the Tngximum occurs, as we see, be-
tween the rajB D and E. The onrre to the left,
0, represents the calorific inteneitj; and the
right curve, Ch., corresponds to the chemical
aetioD. A sixth sense is opened to the world bj
the calorific rajs, a seventh bj the chemical rajs.
(Figure S).

The accompanyinj figure, (F^ore 8 1-2)
exhibits the chemical action affected bj the var-
ious portions of the spectrum on the sensitive
mixture for one particular zenith distance of the
sun. The lines worked with the letters of the
alphabet from A to TT at the bottom of the figure,
represent the fixed dark lines which exist in the
solar spectrum, of which I shall speak as I go
along in this artacle. Thej serve as landmarks
bj which to ascertain the position of anj given
point in the spectrum. The greatest amount of
chemical action is noticed between the line in the
indigo, marked 0, and that in the violet, marked
E. In the direction of the red end of the speo-
trom, the action becomes imperoeptiUe about D
in the orange — the maximum of visible illumina-
tion — whilst towards the other end of the spec-
trmn the action was found to extend as far as the
line marked £7, or to a greater distance bejond
the line H in the violet than the total length of
the ordinary visible spectrum.

Bj waj of a conclusive illustration, this
same fact maj be shown that a photograph can
be made with these blue rajs, whereas there is
failure to produce the same effect with the red
rays.

I want to point out another important fact

right here before I go on further into my subject.

Pig. 9 viz. that the solar spectrum differs in certain

S86

respects from that beautiful apeotrum of the electrio arc light with
which much is now being done in photo-therapeutica, etc. It difiere in
this way, that the solar spectrmn oonaists, not of a continuous band
posedng without a break or interruption from the red to the violet,
through all the ahades of color which we know as the rainbow tints,
bat that in the solar q>ectrum we find, interspersed between these, cer-

tain dark lines which we may regard as shadows in the stmlight —
spaces where certain rays are absent.

What we see is nothing compared with what is constantly paamng
around us in nature.

Pig. 9}i
As early as 1816 FraiinbofeT, a Bavarian optician, studied with
care the violet spectrum and songht to discover some fized points in it

which might be independent of the nature of the prisms, and which
could be regarded aa points of reference to which the zones and colors of
the spectrum might be referred; when he perceived that, hy giving the
prism a certain special po-
sition, there suddenly ap-
peared in the spectral im-
age dark lines croeaing the
streamer tranaversel; in
the same colors, he desig-
nated the eight principal

lines by the first letters of u

the alphabet. They are I

placed as follows: — The ? .

first at the limit of the red, "^ I

the second in the middle of
that color, the third near

the orange, the fourth at !l S

the end of that tint, the l§^ S

fifth in the green, the sixth 8

in the blue, the seventh in si '^

the indigo, the eighth at ^ -a

the end of the violet. -g -t

These are, then, the piin- ^1^ e

cipal black lines which we ^ J

distinguish in the spec- ^ 1

tram. As to the total nmn- ^ S

ber of these lines, it is :»it J^

really amazing. Fraiin- ^ *■

hofer counted 600 with a
microscope ; later Brew-
ster carried this number to
2,000; now we coont 6,000
and more. (See figure

9 i-2.y

These lines of the solar
spectrum are constant and
invariable at all times when

the sepctnim studied is that of li ^t emanating from the sun ; whatever
*These lines are universally known by the letters given in figures, i^
and 9^.

S87

tliis light may be, we find them in daylight, in that form in the cloads,
ill the light reflected by moontains, buildings, and all terrestrial objects.
We find them even in the light of the moon and in that of the planets,
because these celestial bodies shine only by the light -which they receive
from the sun and reflect into space.

Thia discovery of microscopical lines whioh thus cross the solar
spectrmn was soon made fmitfol by another not less important dis-
covery. Admitting through a priam rays issuing from a luminous ter<
restrial source, such as an electric arc light, as a gas jet, a lamp, a metal
in fusion, etc., we notice at first that these artificial lights give rise to a
spectrum as well as that of the son, but that this spectrum differs from

Fig. 11
the solar spectrmn by the number and arrangement of the colors ; we
remark in the second place — and here is the important point — that the
spectrum of these lights is also crossed by lines, that the distribution of
these lines differs according to the nature of the light observed, and in
short, that they present an invariable order, characteristic of each of
them.

In order to fix our ideas, let me describe an experiment such as was
made by Kirchhoff and Bunsen, the two phyaicista to whom we owe

288

these brilliant researches. Let us place in a gas jet, a platinum wire, at
the extremity of which we pnt a small fragment of the substance which
we wish to analyse. Before the flame is placed the spectroecope, a tel-
escope expressly constructed for our analysis, and in which the rays
from the flame pass through a prism and an analysis microscope. [The
flame of our light from whatever source, is regulated and weakened so
as not to give a spectrum itself.] The moment we place in the flame
the prepared platinum wire a spectrum appears in the telescope and the
eye placed at the microscope can analyze it at its ease. This spectrum
is that of the avbatance ivhich bums. The luminous ray leaving the
point L (Fig. 11) is reflected from the little prism at the end of the
telescope, and thus appears to come irom L. Following the axis of the
telescope it is refracted successively through six prisms, Ay By G, D, E^
Hy and enters the telescope, JT, by which it is observed. In order to
compare or measure it, we should have in the little telescope, Fy an
image or a scale which serves to fix the position of the rays.

For example, we dip the platinum wire into a bottle of potash.
The moment we place it in the gas jet, a spectrum appears in the spec-
troscope ; this is the spectrum of potassium. It is composed of seven
colors — ^like the solar spectrum ; in addition, it is characterized, by two
very brilliant red rays, situated towards each of the extremities.

Similarly, if we place small crystals of soda at the point of the
platinum wire, we see a singular spectrum appear, which containa
neither red, nor orange, nor green, nor blue, nor violet, and which is
simply characterized by a splendid yellow ray corresponding to the posi-
tion of the yellow in the solar spectrum and of the line which crosses
that color. We have here the spectrum of sodium, and so on.

This method of analysis is so marvelously powerful that it reveals
the existence of substances in quantities infinitely small, and, where
any other method would be completely abortive, the presence of a mU-
lionth of a milligramme of sodium discloses itself in the flame of a

candle.

Thus every substance analyzed produces in the spectroscope an
arrangement of lines which is peculiar to it — it registers its true nat-
ural nams in hieroglyphic characters ; it reveals itself by itself and in an
incontestible form.

The black lines which are described above in the solar spectrum,
correspond precisely to certain bright lines characteristic of the spectrum
of different terrestrial substances.

On the other baud, it has been ascertained tbat metallic rapora
endowed ■with the property of emittiiig in abundance certain colored
rays absorb theee same rays when they come from a luminous source
situated behind these vapors and traversed by them. Thoa, for exam<
pie, if behind a flame in which sea salt bums we kindle a brilliant
Dmnunond light, and if we snpeipoBe the two spectra, immediately
the yellow line of sodium will disappear from the spectrum of sodium
and give place to a dark line occupying precisely the same place.

It fdlows from this double observation that the blac^ lines of the
solar spectrum prove: —

I., The extstenoe of a burning and gaseous atmosphere around that
body.

n., The presence in that atmosphere of subatancea announced by
the lines in question.

Fig. 12

There have been identified, line for line, in the sun, the 460 lines
of the apectmm of iron', the 118 of titanium, 178 of calcium, 57 of
magnesium, 83 of nickel, etc. So that we now know certainly that

'Prof. Roland has found over i,eeo lines of iron in the solar spectrum.
J.E.G.

240

there are at the surface of that dazzling Btar^ and in the gaseous state,
iron, titanium, calcium, manganese, nickel, cobalt, chromium, sodium,
barium, magnesium, copper, potassium; but we still cannot recognize
any trace of gold, silver, antimony, arsenic or mercury. Hydrogen
was discovered in 1868; oxygen must exist in this furnace, but the
oxygen lines which have been found in the solar spectrum proceed from
our own atmosphere (Jansen 1888). Amongst all the discoveries of
modern investigation none has deservedly attracted more attention
or called forth more general admiration than the result of the applica-
tion of spectrum analysis to chemistry. Nor is this to be wondered
at when we remember that such a power has thus been placed in the
hands of the chemist and allied scientists, enabling them to detect the
presence of chemical substances with a degree of delicacy and accuracy
hitherto unheard of, and thus to obtain a far more intimate knowledge
of the composition of terrestrial matter than they formerly enjoyed-
Since its discovery the sciences in their various branches of analysis
have profited much by it, in new discoveries.

HOW THE INFLUENCE OF THE SUN'S RAYS ACTS UPON THE VITAL ORGANIZATION.

The surface of our earth is rendered beautiful by the almost count-
less forms of vegetable life which adorn it, and on the bare surface of
the wind-beaten rock the mysterious lichen finds a sufficient amount of
those elements which assimilate and form its structure, to support it
through all the stages of its gro^vth; and at length, having lived its
season, it perishes, and in its decay forms a soil for plants which stand a
little higher in the scale of vegetable life. These again have their
periods of growth, of maturity and of dissolution, and, by their disinte-
gration, form a soil for others which pass through the same changes
until at length the once naked rock is covered with a garden and the
flowering shrub and the enduring tree wave in loveliness above it.

In a short time, we find the almost microscopic seed placed in a
few grains of earth, springing into life, developing its branches, unfold-
ing its leaves and producing flowers and fruit. Although it has become
a stately plant, we shall not discover much diminution of the soil from
which it grew, and from which it would at first appear it derived all
those solid matters of which its structure is composed. Experiments
have been made in the most satisfactory manner, and it has been proved
that a very small amount only, of the soluble constituents of a soil are
taken up by the roots of a plant. We have then to look to other
i^ources for the origin of the woody matter, of the acid and saccharin

241

juices, of the gums and of the resins, yielded by the vegetable world.
These are all, it will be found, formed by some mysterious modifications
of a few elementary bodies. The plant in virtue of its vitality and
under the excitement of the sun's rays, effects the assimilation of these
elements ; and these are the phenomena which it is our business to
examine thoroughly if we are going to apply photo-therapeutics.

The conditions necessary to germination are moisture, a moderate
temperature and the presence of oxygen gas. The experiments of
Ray, Boyle, Scheele, Archord, and Humboldt all show that the pres-
ence of atmospheric air is necessary. Germination cannot take place
at the freezing point of water, and at 212° all vitality is destroyed. If
seeds are kept quite dry, they will not germinate, although the other
conditions are fulfilled. All seeds do not germinate at the same
seasons, some requiring a more elevated temperature than others which
fact explains the cause of the different periods at which we find the
plants springing from the soil.

It has been remarked, that Michelloti proved light to be injurious
to germination, and Gugenhauz and Sennebier found that seeds germi-
nate more rapidly even beneath the soil in the shade than in sunshine*
This fact has been now established beyond all doubt.

Priestly's experiments* on the influence of growing plants upon
the air are most instructive ; and since tiiey are not generally known, it
is thought advisable to give an abstract of them in this space. "With-
out light," says Priestly, "it is well known that no plant can thrive and
if it do grow at all in the dark, it is always white, and is, in all other
respects, in a weak and sickly state. Healthy plants are probably in a
state similar to sleep in the' absence of lighty and do not resume their
proper functions but by the influence of light and especially the action
of the ravs of the sun.'*

Again, arguing that the green n,atter which forms in water grows
and gives off gas, bv the influence of light alone. Priestly gives the iol*
lowing experiment -—'having a large trough of water, full of recent
green matters giving air very copiously, so that all the surface of it
was covered with froth, and jars filled with it, and inverted collected
great quantities of it; and very fast. I filled a jar with it, and invert*
ing in a basin the same ; I placed it in a dark room. From that instant,
no more air was yielded by it, and in a few days it had a very offensive

'^Experiments and Observations Relating to Various Branches of Natural
Philosophy with a Continuation of the Observation on Air, By Joseph Priest-
Icy, LL. D., F. R. S., Birmingham, 1781, Vol. ii.

242

sraeD, the green vegetable matter with which it abounded being then
all dead and pntrid," Dr. Priestly then instituted a series of experi-
ments to prove that the green matter and not the water, produces the
air. Eumford imagined that any porous body, as cotton, wool, silk,
and even threads of glass would separate air from the water. Priestly's
experiments were singularly conclusive on this point.

Priestly continued his experiments with the higher order of
plants : — '^Having by this means fully satisfied myself that the pure air
I had procured was not from the water, but from the green vegetating
substance assisted by light, I concluded that then aquatic plants must
have the same effect ; and going to a piece of stagnant water, the bottom
of which was covered with such plants, I took five or six different kinds
promiscuously. Then, having put them into separate jars of the water
in which they were growing and inverted them in basins of the same, I
placed them in the sun, and I found tluU all of (hem without exception
were immediately covered with bubbles of air, which gradually detach-
ing themselves from the leaves and stalks where they had originated^
rose to the surface of the water; and this air, on being examined^
appeared to be in all the cases very pure, though not quite so pure a*
that which was before procured from the green water."

It must be remembered that carbonic acid was unknown to
Priestly and those who labored in the same field with him. Dr. Jugen-
housz^, for example, says : — "The air obtained from the leaves is by no
means air from the water, but air continuing to be produced by a
epecial operation carried on in a living leaf exposed to the daylight, and
forming bubbles, because the surrounding water prevents this air from
being diffused through the atmosphere. ♦♦♦♦♦♦

'^t is wonderful that this green matter seems never to be
exhausted of yielding dephlogisticated air, though it has no free com-
munication with the common atmosphere, from which the most part of
other plants seem to derive their stock of air. Does this vegetable
matter imbibe this air from the water, and change it into dephlogisti-
cated airl" This does not seem to me probable. I should rather
incline to believe that the wonderful power of nature, of changing one
substance into another, and of promoting perpetually the transmutation
of substances, which we may observe everywhere, is carried on in thia
green vegetable matter, in a more ample and conspicuous way.

Dr. Priestly, with his usual ingenuity, very soon determined that
the plants sepa rated some gas from the water, which they decomposed,

'Jugenhousz, Experiments 4m Vegiiabies.

243

and that, after a time, they ceased to give out air in water. He says : —
'*I put a handful of these water plants, without distinguishing their
kinds, into a receiver containing eighty ounce measures of water,
inverted in a basin of the same ; and when they had yielded between
six and seven ounce measures of air, I examined it, and found that, with
two equal quantities of nitrous air, the measures of the rest were 0.8.
BtU the air had heen diminishing about three daySy so that I believe
there had been eight ounces measured in all, or one-tenth the capacity
of the jar, and certainly purer than it was now found to be.

"It was evident, therefore, that no more air wotUd have been pro-
duced by these plants in watery though placed in the sun. ♦ ♦ ♦ ♦
It IS also a proof that the proper origin of all air produced in these cir-
cumstances is not the plant and the light, and that these are only agents
to produce that effect on something else ; that in all cases, the quantity
of air produced bears a certain general proportion to the capacity of the
vessel in which the process is made." Again, '^ have found a slower
and a less produce of air from rain water than from pump water ; owing,
I suppose, to the rain water containing less air to operate upon, and
generally also in a purer state, than that which is contained in pump
water." We now know that the latter contains more carbonic acid
than the former.

These experiments were continued by Priestly with cabbage leaves,
lettuce, the sx>onge, cucumber, potatoes^ white lilies, and many other
kinds of plants, in all of them proving the decomposition of fixed air
(carbonic acid) by the living vegetable matter in the water and the
influence of light. We find philosophers, both here and abroad, repeat-
ing Dr. Priestl/s experiments, and gradually arriving at a correct
interpretation of the observed phenomena. Cavendish, in his experi-
ments on air, wanders round the truth, but is continually drawn away
from it by the hypothesis of phlogiston. Sennebier found that plants
yielded more dephlogisticated air (oxygen) in distilled water, impreg-
nated with fixed air, than in plain distilled water. On this, Cavendish
Bays : — "For a fixed air is a principle constituent part of vegetable sub-
stances, it is reasonable to suppose that the wood of vegetation will
grow better in water containing this substance than in other water."

M. Monge, in his memoir, 8ur le Besvltat de VInflammation du
Oaz Inflammable et de Vair Dephlogistique dans des Vaisseau Clos^ also
examines this question. About this time the complete explanation
afforded by Lavoisier's annihilation of the phlogistic hypothesis led to

244

correct explanations of the facts; and we advance more steadily in our
ijiquiries.

Eobert Hunt published in the PhUoaophic Magazine for April,
1840, some very curious experiments which I, myself, followed out to
my own satisfaction. It is necessary for a correct understanding of the
results obtained, that all the conditions under which the experiments
have been made should be distinctly stated.

Six boxes were so prepared that air was freely admitted to the
plants within them, without permitting the passage of any of the solar
rays, except those which passed through the colored media with which
they were covered. These media permitted the permeation of the rays
of light in the following order :

1. A rvby glass, colored ivith oxide of gold: — ^This glass permits
the permeation of the ordinary red, and the extreme red rays only.

iS. A brovm-red glass: — The extreme red ray appeared short-
ened; the ordinary red ray and the orange ray passed freely, above
which the spectrum was sharply cut off.

5. Orange glass: — ^The spectrum was shortened by the cutting
off of the violet, indigo, and a considerable ^portion of the blue rays.
The green ray was nearly absorbed in the yellow which was consider-
ably elongated. The whole of the least refrangible portion of the spec-
trum permeated this glass fully.

^. Yellow glass, somewhat opalescent : — ^This glass shortened the
spectrum by cutting off the extreme red ray and the whole of the most
refrangible rays beyond the blue ray.

6. Cdbali Hue glass: — ^The spectrum obtained under this glass
was perfect from the extreme limits of the most refrangible rays down
to the yellow, which was wanting. The green ray was dimished, f orm^
ing merely a well defined line between the blue and the yellow rays.
The orange and red rays were partially interrupted.

6. Deep green glass : — The spectrum is cut off below the orange
and above the blue rays. Although the space on which the most lum-
inous portion of the spectrum falls, appeared as large as when it was
not subjected to the absorptive influence of the glass, there was a great
deficiency of light, and on a close examination with a powerful lens, a
dark line was seen to occupy the space usually marked by the green ray.

Robert Hunt's experiments show also by preparing a case con-
taining five flat vessels filled with different colored fluids, the fol-
lowing : —

245

^ — r^ : Sodium of carmine in super sulphate of amm^onia : — This
gives a spectrum in nearly all respects similar to that given by the ruby
glass (1)^ all the rays above the line drawn through the center of the
space occupied by the orange being cut off.

B — yeUowi A saturated solution of bichromate of potash: — ^This
beautifully transparent solution admits the permeation of the red and
yellow rays which are extended over the space occupied by the orange
ray in the nnabsorbed spectrum. The green rays are scarcely evident.

C — green : Muriate of iron and copper : — ^This medium is remark*
ably transparent ; the blue, green^ yellow, and orange rays pass f reely,
all the others being absorbed.

B — blue: Cupro-suiphate of ammonia: — ^This fluid obliterates all
the rays below the green ray, those above it permeating it freely.

E — white : — ^This is merely water rendered acid by nitric acid, for
the purpose of securing its continued transparency. It should be noted
that spaces in the boxes have been left open to the full influence of the
light in order that a fair comparison might be made between those
plants growing under ordinary circumstances, and the others under the
dissevered rays.

It will be seen from the above that the following combinations of
rays have been obtained to operate with :

1 and A. The calorific rays well insulated.

IB. A smaller portion of these rays mixed with a small amount
of those having peculiar illuminating powers.

5. The central portion of the solar spectrum well defined, and all
the rays of least ref rangiblity, thus combining the luminous and calor-
ific rays.

Jf,. The luminous rays mixed with a small portion of those having
a calorific influence.

6. llie most refrangible rays with a considerable portion of the
least so; thus combining the two extremes of chemical action, and
affording a good example of the influence of the calorific blended with
the chemical spectrum.

0. Some portion of those rays having much illuminating power,
with those in which the chemical influence is the weakest under ordi-
nary circumstances.

B. The luminous rays in a tolerably unmixed state.

C. The luminous rays combined with the least actively chemical
<me8> as in 6, but in this ease the luminous rays exert their whole
influence.

246

D. The most refrangible or chemical rays well insulated.

E. White light.

From these arrangements it will be evident that, although we do
not secure the complete isolation of the rays, as we should do with a
prism, we obtain the great preponderance of one influence over others,
which suffices to insure, to a certain extent, the decided action of that
one.

I am well aware that we only arrive at approximation to the truth
by the system adopted, but am unacquainted with any method by which
these experiments could be continued for any time otherwise than with
absorptive media.

When we look on a spectrum which has been subjected to the
influence of some absorptive medium we must not conclude, from the
colored rays which we see, that we have cut off all other influences than
those which are supposed to belong to those particular colors.

Although a blue glass or fluid may appear to absorb all the rays
except the most refrangible ones, which have usually been considered
as the least calorific of the solar rays ; yet it is certain that some princi-
ple has permeated the glass or fluid, which has a very decided thermic
influence, and so with regard to media of other colors.

The relative temperatures indicated by good thermometers placed
behind the glasses and fluid cells, which were used, will place this in a
clear light. The following results present a fair average series, and
distinctly mark the relative degrees in which these media are permeable
by the heating rays : — •

GLASSES.
Color Luminous rays not absorbed. Temperature,

1. Ruby. Ordinary red and the extreme red 87

2. Red, Ordinary red and orang^e portion of extreme red 83

3. Orange, Little blue, green, yellow, orange, red and extreme red.. 104

4. Yellow. Red, orange, green and blue 88

5. Blue, Violet, indigo, blue, little ^;reen and some red 84

6. Green, Orange, yellow, green and blue 74

FLUIDS.

A—red, Ordinary and extreme red 78 Degrees

B-— yellow. Ordinary red and yellow 80 * *

C— green. Blue, green, yellow, orange 69 **

D—blue. Green, blue, indigo, violet and trace of red 73 * '

E— white. All the rays 89 •'

In these examinations the highest temperature was not obtained
- behind the red media, but behind those which have a yellow or orange
tint.

247

Such were the arrangements adopted; these were sometimes
slightly varied, but not to an important extent.

THE FACTS THAT ARE KNOWN FROM RESEARCHES ON THE INFLUENCE OF THE

SOLAR RAYS ON THE GROWTH OF PLANTS.

Although there are still many important points which remain open
for investigation and others which although examined, require, from
the complexity of their phenomena, still more minute research. Never-
theless many important facts connected with the process of germina-
tion, and vegetable growth as affected by solar light, are known which
warrant further research into that domain and into that of animal life.

There has arisen a habit of referring all the effects observed in the
process of vegetation, etc., to the agency of light, whereas, it appear?
that some agencies which are not luminous materially influence the
phenomena of vegetable vitality.

Without entering into any discussion in this place on the probable
existence or otherwise of a principle ^distinct from light and heat in the
sun's rays, to which we refer the curious chemical changes produced by
solar influence, it will be sufficient to admit the existence of three dis-
tinct classes of phenomena which cannot, I think, be disputed.

These are luminous influence — light; calorific power — heat] and
chemical excitation — actinism.

The problem which these researches were directed to solve was
the proportion and kind of influence exerted by light, heat, and actinism
— as the principle supposed to be active in producing the chemical
phenomena of the solar rays has been called — ^in the various stages of
vegetable growth.

The means we have of separating these phenomena from each
other are not very perfect ; indeed, in the present state of our knowl-
edge, it is impossible to have evidence of the operations of either light,
heat or actinism, absolutely separate from each other. If we use the
prismatic spectrum, we have over every portion of it a mixture of
effects. Even in the mean yellow, or most luminous rays, we have a
considerable amotmt of thermic action, and, under some circumstances,
evidence of chemical power. In the violet rays which have been par-
ticularly distinguished as chemical rays, we have light and heat, and in
the calorific rays we have decided proof of both luminous and actinic
power. Experiments show with the prismatic spectrum, that we have,
in fact, no certainty, that the results due to a particular ray — ^that ray
being regarded as the representative of a particular phenomenon — are

248

not the combined effect of the three forces. The same objections apply
to absorbent media, but the amonnt of each influence is readily deter-
mined ; and we are therefore enabled to refer any particular result to a
tolerably well defind agency.

Before the British Association these facts were made very clear by
a large number of exceedingly interesting crucial experiments, and all
were embodied in a report thereon. They showed that under the
action of those radiations which have permeated variously colored
media, such as tinted glass and colored, transparent fluids, it was not
sufficient to state that a yellow, red, or blue glass or fluid was employed,
as it by no means followed that these media are permeated only by the
rays corresponding in color, or by the influences due to a given order of
refrangibility.

The difficulties which oppose themselves to experiments made with
colored media have been strongly felt by other observers.

Dr. Dauberry says in his memoir, ''On the Action of light Upon
Plants, etc.:*'* — 'The difficulty, however, of comparing the relative
intensity of the light transmitted by the variously colored media, which
were employed in my experiments, induces me to ccmtent myself with
showing that the effect of light upon plants corresponds with its illumi-
nating rather than with its chemical or calorific influence ; and to waive
the more difficult inquiry, whether its operation upon the vegetable
kingdom exactly keeps pace with the increase of its own intensity."

In 1842 and 1844 Robert Hunt again reported before the British
Asssociation the following which are the facts : — ^He stated the kind of
examination to which he then subjected each colored screen — ^''Mauy
effects which have from time to time presented themselves, have con-
vinced me of the necessity of a still more close examination of the order
in which radiant principles permeate the media employed. I have,
therefore, in every case examined with all care the illuminating, calor-
ific, and chemical effects of the solar rays which have passed the media
employed. The amount of light has been determined by measuring off,
in parts of an inch, the prismatic rays which pass the screen. This is
preferable to any system of measuring which depends upon the power
of the eye to appreciate either light or shadow. Having formed a well
defined spectrum on a white tablet, and carefully worked off the center
of the yellow ray as being the point of maximum light, and the limits
of each of the other rays, the transparent colored medium was inter-
posed and the amount of absorption observed. These exanunations,

^Philosophical TransacHans, Vol. CXXVII., 1836.

24Q

many times repeated, were made with reference to the luminous rays
only; and, in the description of my experiments, I shall, considering
the unabsorbed ray as being represented by 100, express the amount of
light actually effective by such a number as may give the sum of the
rays measured off after permeation.''

The calorific influences which escape absorption, and which have
been determined by the expansion of the mercury in a thermometer
with a blackened bulb, placed behind the colored glass or fluid, and by
the evaporation of ether from a sheet of blackened paper, as recom-
mended by Sir John Herschel, will be expressed numerically in the
same way as light, without reference to the color of any ray. I am
far from considering the thermic influences of the solar rays, as quite
independent of the color of the ray with which they may be associated ;
but in these exi)eriments on plants, it appears to me, we can only deal
satisfactorily with the total amount of radiant heat which is active
under the conditions of the experiments, the terrestrial heat being in all
comparative experimiBnts the same."

It has, indeed, been shown by Dr. James Stark* by direct experi-
ments, and indirectly by other observers, that color exerts a very power-
ful influence in the conduction, radiation and permeation of heat. Fol-
lowing up some of these experiments both from a scientific and thera-
peutic point of view myself, I found that tuberculous patients derive
the best results by either wearing white garments over the entire body
or in a perfectly nude state. This mode of treatment I have followed
since 1890 and never since then has this method depreciated in my
judgment, even one per cent.

The determination of the chemical principle of the solar rays, or
actinism, permeating the media employed, required more exact atten-
tion than the other phenomena.

The experience of many years enables me now to state that we are
not acquainted with any transparent medium which is absolutely
opaque to actinism. Although nitrate of silver, or indeed any of the
salts of silver remain unchanged behind yellow glasses and fluids, yet,
chlorophyl is deoxidized and turned yellow by the chemical principle
which is enabled to permeate them. Upon all those bodies on which
light exerts a direct and determinate influence, as upon the organized
compounds, we find that the changes due to actinic power are but
slightly interf erred T^dth, whereas upon all those inorganic bodies which
undergo a change when exposed t o the solar chemical radiations — ^that
"^ Philosophical Transactions, Vol. CXXIV, 1833.

250

change being entirely due to actinism — flight acts as a powerful inter-
fering agent. The conditions under which these antagonistic forces —
light and actinism — operate upon each other are imknown to us, but it
is certain that every combination of an inorganic salt with an organic
body presents a different scale of action.

Nitrate of silver uncombined with organic matter undergoes no
change by the influence of any portion of the solar spectrum, or of
white light ; spread it on a paper, or combine it with gum or gelatin and
all that portion of the spectrum above the green ray blackens it ; and if
we combine this salt with unstable organic compounds, the blackening
is found to take place, eventually, under every spectral ray. The other
salts of silver and metallic salts in general are affected in precisely the
same manner. From a knowledge of these facts it became evident
that some means must be devised for ascertaining, as correctly as possi-
ble, the entire quantity of this chemical principle, passing every par-
ticular medium, without which knowledge any result would be almost
valueless. In every instance, therfore, the influence of the modified
radiations was determined : firstly, upon the most sensitive silver salts ;
secondly, upon organic bodies, as the colored juices of leaves and
flowers, and on chlorophyl; and thirdly, upon combinations of the
organic and inorganic materials. In this way I have reached a degree
of correctness which has not been hitherto attained, and the results of
the experiments have consequently a higher value.

It has been repeatedly stated that seeds would not germinate under
the influence of light, deprived of that principle on which chemical
change depends. There is some difference of opinion raised on that
point by several, and those numerous exi)eriments made by Gardner
with the prismatic rays themselves have unfortunately furnished us
with no knowledge of a degree of stability which he was enabled to
ensure for the prismatic rays with his heliostat. Dr. Gardner's
reseaches corroborating those of Dr. Draper are without doubt valua-
ble; but for the reason which already is stated in this article, I must
contend that we do not secure a separate action of light and actinism
by the prism so effectually as by the use of absorbent media. It has
been shown by Mr. Hunt, after many years of practical and convincing
observation, "that light is injurious to germination and that Dr. Gard-
ner's experiments must have been deceptive." Mr. R. Harkness* in
reply to Dr. Gardner on this point says : — "We know, both from obser-
vations of Gugenhauz and Sennebier, as well as from daily experience,

-■I - —

^PhiL Magazine^ Vol. XXV, N. S., p. 340, 1844.

251

that the absence of solar light is one of the conditions almost necessary
for the germination of seed, and consequently we should not expect
that ray in which the maximum of light is found to facilitate germina-
ton, but on the contrary, as in Mr. Hunt's experiments to retard it."
There are other objections made from a physio-chemical point of view.
Many experiments toward clearing up this point were made by Mr.
Hunt, which gave satisfactory evidence that light deprived of the prin-
ciple or power of chemical action arrests the development of the plant
by preventing the vitality of the germ from manifesting itself.

Although the visible sign of germination is the process of chemical
combination of the carbon with oxygen and hydrogen, yet the power
influencing this change is of an occult character, though evidently
dependent on some external excitation which Mr. Hunt has proved not
to be light, or the principle producing the phenomena of color.

The question of importance which Mr. Hunt also raised and proved
true was to ascertain if the chemical principle of the solar rays produced
any acceleration of the germinative process. He found that the per-
iods of germination differed in each variety of seeds, under the condi-
tions to which they were exposed, yet in every instance the seeds
influenced by actinic radiations germinated in one-half the time which
those seeds placed in the dark required.

Several arrangements were made for the purpose of ascertaining if
the influence of the chemical rays was confined to the surface of the
soil, or if it extended below it. The result was, that Mr. Hunt obtained
the most satisfactory evidence that, under the influence of the rays
which passed the blue glasses, germination was set up at a depth below
the surface, at which under the ordinary conditions it did not take place.
These facts go to establish, and in addition they prove, that there exists
an influence which is always associated with light and which has the
property of accelerating the process by which the embryo swells, bursts
through its integuments, sends its radicle into the soil, and shoots its
cotyledons upwards towards the light.

The condition of the seed in this process is tolerably well under-
stood. The seed, a highly carbonized body, is placed in a position by
which its starch (O12 H^o Ojo) is changed into gum (Cjg S^ 0^) and
sugar (C12 1^14 O14). Here we have a large absorption of oxygen;
and experiment has shown that carbonic acid (CO2) is formed. The
whole process is the same in character, as the blackening of a solu-
tion of nitrate of silver, holding organic matter, in the sunshine. With-
out the organic body the silver salt remains unchanged ; with it a com-

252

bination with the oxidized carbon is effected at the eiame time as the
organic particles take the oxygen from the oxide of silver in solution.
All this is known to be entirely dependent on actinic power and inde-
pendent of luminous action, and the whole process of conversion in the
seed is of a like character.

Here is another singular fact. If the young plant continues to
grow under the influence of the rays which have permeated the blue
media employed in the experiment, it will for some time grow with
great rapidity, producing, however, succulent stalks which soon perish.
Even in the earliest stages of the growth it will be found, that the plants
grown in the full sunshine, or under the influences of yellow or red
media, repr^^^nting the luminous and calorific principles, give a larger
quanti+7 of woody fiber and less water than those grown under actinic
influence.

Another true explanation is further proved by the fact that in the
practice of planting shoots the use of blue media is highly advantageous.
It appears to increase the tendency to the development of roots, and
it is satisfactory to learn that some gardeners have, without any
knowledge of the cause, employed cobalt-blue glasses to aid in the
"striking of cuttings." Dr. LindleyS referring to the experiments of
Dr. Dauberry, seems disposed to regard the effects described as due to
the absence of light merely; it is however, evident that the chemical
principle of the solar beam materially assists in the development of new
roots from cuttings. The formation of woody fiber depending on the
secretion of carbon from the carbonic acid absorbed by the leaves, and
decomposed, by some functional power of the plant, under the influence
of external excitement, it has ever been considered important to deter-
mine if this was due to the luminous rays or to any others.

The experiments of Sennebier^ went to prove that plants decom-
posed the carbonic acid they absorbed by. the leaves much more readily
under the influence of the violet rays than any others. This power of
decomposing carbonic acid under the influence of the solar rays is a
function due to some vital principle ; which proves the position correctly
taken by Matteucci': — ^Different plants not only decompose carbonic
acid at different rates, but they exhibit greater or less sensibility to lum-
inous influence.

The conclusions from numerous experiments induced several scien-
tists to draw these facts :

^Theory of Horticulture ^ p. 215.
^Mem. de Phys, Ckim, Tom. II, p. 55.
^Supplement a la Bibliotheque Universelle de Geneve,

253

That the Ituninous principle of the sun's rays is essential to enable
the plants to effect the decomposition of the carbonic acid of the atmos-
phere and form their woody structure.

That some plants require more light than others to effect this
decomposition.

It may be inferred from all the results obtained by actual experi-
ments that the decomposition of the carbonic add by plants under the
agency of light is not a simple chemical operation, but the result of an
exertion of the vital principle of the growing plant, which requires the
external stimulus of light to call it into action.

I have made numerous experiments and have every reason to
believe that it will be found that there is as great a difference between
the effects produced on growing plants by the prismatic rays, as we
know to be the case in photographic preparations; — ^the maximum
effects altering, perhaps, for every variety of plant. It was these
known facts that led me and others to subject the various living organ-
isms in culture fluids, plates, etc., to tiie prismatic rays, so that some def-
inite conclusions could be arrived at; as to their power, individual and
combined over their growth, development, sterility, bacteriocidal valjie,
etc. To this I shall again refer in this work.

A number of comparative experiments have been made with the
unabeorbed prismatic rays, with a view to the settlement of several
points at issue. The method pursued has been to place leaves in small
tubes filled with water impregnated with carbonic acid, and to place
these tubes across the rays formed by a very excellent flint-glass prism.
The results have varied with every experiment.

If we place a small sprig covered with leaves in the tube we get the
largest quantity of gas in one ray; if we remove the leaves from the
branch, we shall then get the most gas under another ray. No two
plants as far as I am aware, gave the same quantity of oxygen in the
same time, under the influence of the same ray, and the age of the plant
most materially alters all the effects, the same plant at one age giving
evidence of being excited most readily by the blue rays, and at another
by the yellow or the red rays. Moreover, I am satisfied that by remov-
ing a member, whether a branch or a leaf, from the plant, we give a
shock to the living system which prevents our obtaining any results
which shall actually represent the true conditions of the growing plant.
On this point the experi ments of Matteucci* are most satisfactory.

^Cimento, Juillctt ct Aout, 1846.

254

In all experiments on the human being and on plants, it must be
borne in mind that we are dealing with an organized body endowed
with peculiar vital functions. As these are ever liable to derangement
from numerous causes which are almost beyond the reach of our exami-
nation, it is only by a great numebr of crucial experiments that we can
arrive at an approximation to the truth. It is, however, evident, from
careful comparison of the results obtained, that light as distinguished
from heai and actinism, is the principle on which the secretion of carbon
and the evolution of oxygen by plants depends.

De Candalle succeeded in producing the green color of the leaves
by the strong light of lamps, which we know give out a much larger
quantity of yellow rays than any others ; consequently it was inferred
that light was necessary to the production of chlorophyl. Dr. Dau-
berry, however, obtained no result from the action of incandescent lime
which emits a much purer white light, producing also chemical effects in
a marked maimer.

Dr. lindley^ refers the formation of the coloring matter of leaves
to ^^the effect of decomposed carbonic acid and exhaling oxygen" by
the agency of light, the intensity of color being in general "in propor-
tion to the decomposing cause, that is to say, to light.''

Some very interesting experiments are found recorded by numerous
men who have tried to show that to the different rays in the spectrum is
ascribed the office of different action. One important experiment was
followed up by means of a heliostat being placed outside of a window
from which was directed a pencil of light upon a flint-glass, equilateral
prism ; the prismatic spectrum was received in the dark chamber of an
ordinary photographic camera, the place of the lense being occupied by
a diaphragm which admitted the passage of the spectral image only.
It was found, however, that the spectral image did not remain under the
best conditions for more than three hours at a time. However, over
every part of the spectrum giving light, the color recognizable by the
unaided eye, the leaves of seedlings of the common cress, mustard, mig-
nonette, and peas, which were in an etiolated state, became, after a
longer or shorter time, green. In these as in other experiments, it was
found that every variety of plant appeared to be influenced by different
rays. It must be, however, observed that the influence was always
most decided between the limits of the mean orange and the mean blue
rays, and that it took much longer to green plants in the red than it did
in the blue ray.

^Theory of Horticulture^ p. 86.

265

Such are the results found recorded wherever I have hunted for
evidence to prove my position in the spectrum work. Though some
objections have been urged against the use of colored media in experi-
ments^ I am, after years of experience in the use of media, convinced
that there is no other way o:( obtaining correct results without them.
AU the colors of the spectrum are merely modifications of the intensity
of luminous power and it has been shown that light, heat and chemical
action or actinism, are conunon to every ray, the difference being only
proportional. Therefore, because an effect is produced in the yellow
ray, we have no evidence that light alone is the agent ; it may be due to
the combined influence of light and the other principles. We have the
means of analyzing with great correctness the permeability of colored
media, and we can with considerable facility, by increasing the color or
thickness of a fluid medium, produce almost any order of radiation,
which may be maintained for days or months, in a constant character.
For instance, a yellow medium does not imply the use of a yellow light
or a red one the passage of red rays only, but a well regulated, yellow
medium will give the most light with the least quantity of actinism, and
a blue one, the largest amount of actinism with the least quantity of
light. It will now be understood that I place more confidence in the
results obtained under colored media than any which can be obtained
with the prismatic spectnmi upon growing plants and other experiments
in physiological, bacteriological and photo-therapeutics, etc.

It has been shown that chlorophyl is formed under the combined
influence of light and actinism. We can easily repeat that experiment
with colored media which cut off the heat rays, but which admit the
luminous and actinic rays. It will be found that plants grow of a lively
green and the extracted green of their leaves is preserved without
change much longer than under any other conditions. To produce
chlorophyl a recombination of the elements which light assists the plant
to separate from the water and the air is necessary; and there is no
doubt that it will be proven that chlorophyl results from the combined
influences of light and actinism in exciting one of those mysterious
functions of plants which excite the admiration, but elude the curiosity
of the physiologist.

Mr. Hunt says, "that he rarely succeeded in getting plants to flower
under the influence of any of the media which cut off those rays usually
termed the calorific rays." There is something in that, where also
photo-therapeutics are applied. "For instance, under intense yellow,
deep blue, or very dark green glasses, however carefully the plants

256 ^

may have been attended to, there was seldom any evidence of the exer-
tion of their reproductive functions," This evidently arises from the
necessity of some check upon the chemical actions which depend on
light and actinism, and which exhaust the elements in the formation of
wood And vegetable juices which are ijecessary for the production of
those principles which go to the preservation of the species.

It should be again explained, that by lights I mean to express all
those rays of the spectrum which are visible to a perfectly formed
human eye; by actinic principle^ the principle to which the phenom-
enon of chemical change under solar influence or the electric arc
belongs ; and by calorific radiations, not merely those effects which are
traceable by any thermometric instruments, but also those which we can
detect by the protection change, produced by a class of rays existing
near the point of maximum heat in the spectrum.

[to BB com tin U ED.]

A STUDY OF THE DIAGNOSIS OP INC3PIBNT PULMONARY TUBERCU-
LOSIS BASED UPON THE PATHOLOGY OF THE DISEASE.

BY r. M. POTTENGER, PH. M., M. D., LOS ANGSLXS, CAL.

The great interest which has been awakened in the subject of tuber-
culosis in recent years has caused this dread disease to assume a brighter
aspect. It is not the hopeless disease that it was formerly considered
to be ; for with the awakened interest, has come a better understanding
of its nature. We have learned, as Professor Brouardel says, that it
is not only curable, but the most curable of all chronic diseases. The
curability of the disease depends, however, upon the attending circum-
stances ; such as, the earliness of diagnosis, the resisting power of the
patient, and the peculiar form that it may assume. We can not control
ihe form of the disease ; but we can increase the resisting power of the
patient and, above all, improve our ability as diagnosticians so that we
may detect the disease when it first makes its appearance.

The attitude of the medical profession towards tuberculosis has
depended very much upon and kept pace with its ability to make an
early diagnosis. Before the discovery of the bacillus tuberculosis the
disease was rarely recognized, except by expert diagnosticians until the
lung was badly involved and the clinical symptoms had become pro-
nounced ; hence, as a disease, it was of little interest to the profession ;
but, thanks to Koch's great discovery, physical diagnosis has improved
and cases with this dread malady are diagnosed much earlier than for-

267

merly. Since the discovery of the specific cause of tuberculosis^ when-
ever suspicion has existed the sputum, if present, has been examined.
In this way practitioners have learned that the earliest symptoms are
very slight. Not content here, we are now even daring to go back of
the microscope and diagnose tuberculosis before the open stage has been
reached ; and the time is not far distant when we will no longer look to
that instrument to confirm our diagnosis of incipient pulmonary tuber-
culosis.

The sanatorium movement in Germany is already causing our pro-
fessional brethren across the water to take an advanced position on the
subject of early diagnosis. In these institutions the great advantage
of detecting the disease in the initial stage is so well appreciated that
the profession is taking a stand with Brandenburg* who says : — ^''The
time is passed when it is customary to seek, for tubercle bacilli in the
sputum as evidence of beginning phthisis." And again: — ^^t is safe
to say that not over one-half the patients who have gone to Grabowsee
(a sanatorium for which he is one of the examining physicians) had
bacillus-bearing sputum when they entered." In a former paper*
when refering to early diagnosis, I quoted the experience of Weicker
of Goerbersdorf , who says that of the past fifteen hundred cases at his
sanatorium diagnosed as tuberculous by the physical signs, in about one-
third of the cases, no tubercle bacilli had yet apeared in the sputum.

The chief reason that Germany is in advance of other countries in
her skill in early diagnosis is because of the great public interest which
has been created there. The people have been educated to the fact
that the early signs of the disease are very slight ; and, also that there is
great advantage in having it recognized in its incipiency ; so, they often
present themselves for examination when the disease has made its first
appearance. Men who are thorough diagnosticians have been appointed
to examine applicants for the people's sanatoria ; and, through their con-
stant practice in examining early cases, have been able to make physical
diagnoses, for the most part, independent of the microscope.

While the physicians of Germany are diagnosing their cases before
the advent of bacilli in the sputum and are giving their patients the ben-
efit of this most favorable time for treatment, let me quote from Tru-
deau', one of our foremos t workers in this field, to show how remiss we,

^Brandenburg : Berliner Klin, Wochenschrifi, 1900, No. 16.
•Pottcngcr: " Steps in the Prevention of Tuberculosis." Journal of
Tuberculosis^ Vol. TIT, p. 228.

•Trudeau : Medical News ^ June 29, 1901, p. 1014.

258

as a profession, are in this country. He says :— " A man who has acted
M examiner for the Adirondack Cottage Sanitarium for years, in a large
city, says, that not a really incipient case of tuberculosis has ever been
referred to him for examination." And again he says:— "The his-
tones of 70 per cent, of the appUoants for admission to the Adinmdaek
Cottage Samtarium show disease of from one to three years' standing **
To show that this is no exception,.! will quote BowditehV experience
at Kutland. He says .—"The average duration of symptoms of disease
prior to entrance in aU cases was 16.7 months." This is not an unusual
experience for any man who is dealing with tuberculous patients, but
It IS a sad state^ affairs and one that should be remedied. Perhaps
tte blame for this condition of affairs should be laid to the pubKc and
«ie medical profession conjointly; to the pubUc in that those suffering
from mcipient tuberculosis rarely present themselves for examination ;
and to the medical profession, in that it has not educated the people
when to suspect the J)eginmng8 of this disease, and, furthermore, has
not treated the early symptoms, when presenting, with sufficient
respect. Wherever the bkme rests such a stete of affairs is a strong
plea for more careful study and more adequate teachings upon this
important point. The public must be informed. Tuberculosis is the
people's disease and it can be stamped out only by their intelligent aid;
so, there should be an organized united effort upon the part of both
the medical fraternity and the laity to carry an adequate knowledge of
the duease to all the people of the land. They should be taught when
to suspect it in its incipient stage, and that this is the favorable tune
for treatment. Physicians should also do their part by thoroughly mas-
tering the signs and symptoms which are essential to an early diagnosis
of the disease. Then such experiences as are detailed by Trudeau and
Bowditch could not exist. I do not believe I am wide of the mark
when I say that the time is near at hand when an early diagnosis in
tuberculosis will be only a diagnosis before tubercle bacilli have
appeared in the sputum.

One cannot expect to be able to detect the early changes in pul-
monary tuberculosis unless he understands what these changes are and
what produces them. To this end it would be well for us to freshen
our memories on the pathology of the disease; for, while we often hear
that pathology is dry, yet it is the pith and marrow of diagnosis and the
only guide for a rational therapy.

•Bowditch : J^'t/fA Annua/ Report of the Trustees of the Mass. State Sana-
torium at Rutland.

259

When bacilli have found lodgment in the pulmonary tiflsues cer-
tain phenomena take place. These are caused by the presence of the
bacilli, acting as foreign bodies, by the toxins produced, and by the mul-
tiplication of the bacilli themselves, as well as by the increase of the
local cellular elements. The effect produced is that of an irritation of
the part affected with an exudation of leucocytes and serum around the
bacilli and, also a proliferation of the local fixed tissue ceUs. These
together form the tubercle. Experiments have shown that it takes
from ten days to three weeks for the tubercle to form.

The tubercle formed, the bacilli therein may perish and resolution
take place; the cells may organize into fibroid tissue; or necrosis may
follow. Blood vessels do not form in this new tissue ; on the other hand,
those that do exist are apt to be obliterated. This necrosis is dub to
several causes, of which, perhaps, the most potent is the destructive
action of the substances produced by the germs themselves ; but it is
also thought to be partly due to the absence of bloodvessels and the
pressure due to the increased number of cells. Whatever be the cause,
this is the most common fate of tubercle; and it may take place soon
after the invasion or not until months later.

2?ot until necrosis takes place can we find bacilli in the sputum,
although tuberculosis be present ; so, if it is practicable to diagnose the
disease before this takes place, much valuable time to the patient may
be saved ; and, if proi>er treatment be instituted, the danger of reaching
the open stage of the disease will be avoided.

The orignal invasion of the bacilli may be very extensive or very
slight Gradually from this primary focus the surounding tissue
becomes infected ; but, no matter how slight or how extensive the pro-
cess may be the individual tubercles are subjected to the changes above
mentioned and the course of the disease and its outcome depend on
whether resolution, proliferation or degeneration takes place.

Before entering upon the discussion of the data furnished us by
the various methods of examination, it may be well to discuss the sub-
ject from a general standpoint.

In examining a patient for the initial lesion of tuberculosis the
chest must be bare. The day of examining through shirts, coats, and
corsets is past; for, when the examiner can detect the trouble through
the clothing, the diagnosis is of little value to the patient. The first
changes are so slight that they cannot be detected save by most careful
methods; so a bare chest is a necessity.

260

The chest must be examined systematically. It is not sufficient
to listen in one or two places over the anterior portion of the chest, but
every inch of limg tissue should be covered. After examining the apex
very carefully, the anterior portion of the chest should be examined
by beginning at the sternum and the posterior portion by beginning at
the vertebral column. Then, passing out toward the axilla, the exam-
iner should listen in three or four places in each intercostal space,
noting whether or not the respiratory murmur is as full and loud as
normal ; the relative time occupied by inspiration and expiration ; the
character of the note, whether clear, rough, interrupted or harsh ; and
whether moisture exists. Sometimes this latter shows itself only as a
' sensation of stickiness, sometimes as a click at the end of inspiration,
another times as fine crepitant rales.

The first instructions to be given a patient, presenting himself for
examination are to be perfectly natural and to breathe just as though the
examiner were not present and not to take a deep breath until he is told
to do so. The method which we often see of the examiner seating him-
self before the patient and telling him to take a deep breath can not be
condemjied t^oo strongly; for, it often changes the whole picture as
revealed through the stethoscope. If moisture be present in small
quantities, it will often times be cleared up by this deep inspiration so
that it can not be detected again until a considerable time has elapsed.
The first examination should be made during quiet respiration. If there
is a suspicion of moisture anywhere, but no distinct rales, let the patient
cough and follow it by a deep inspiration while the stethoscope is placed
over the suspicious spot. If moisture be present the ear will likely de-
tect it.

The findings of the two sides must be compared, remembering the
natural differences of the two apices — ^the vocal fremitus more intense,
percussion note duller in quality, higher in pitch, less intense, the res-
piratory note exaggerated with expiration prolonged, raised in pitch
and somewhat tubular on the right side — due to certain anatomical dif-
ferences in the lungs and their bronchi. The ability to recognize the
slight differences between the two apices is a good preparation for the
detection of incipient tuberculosis.

It must be remembered that an apical catarrh, if confined to one
side is very suggestive of tuberculosis.

The examiner should bear in mind that he is looking for the
changes caused by the presence of a few small tubercles from the size
of a millet seed to that of a pea. These may be scattered through the

261

tissue or aggregated; but, however distributed, the changes produced
by them will necessarily be slight and detected only by careful, skillful
and oftentimes repeated search. He must remember, however, that
if he has detected them he has saved a life, provided the proper treat-
ment is at once instituted.

There are certain sources of error besides the natural differences
of the apices that are likely to confuse the examiner unless he be on
his guard. Some times there is a slipping of a tendon beneath the scap-
ula with each respiratory movement of the chest, which produces
a sound not unlike a crepitation produced in the chest itself. That this
is due to the tendon, can be proven by raising and lowering the shoulder
while the patient ceases breathing. Leyden^ calls attention to a sound
simulating crepitation that is produced by the stethoscope rubbing on
the clavicle.

We hear quite a little about the "pretubercular stage." I believe
this to be a misnomer. Patients are either tuberculous or not, and as
we become better able to detect the incipient stage of the disease, we
find that the period shortly after the invasion of the bacillus, seems to
correspond with that designated as pretuberculous ; and, when by
imi)roved methods of examination, we are able to designate the pre-
b&cillary stage alone as incipient tuberculosis, the name pretvbercular
will fade from use.

With this brief review of pathology and these general remarks
upon the method of examination, let us now proceed to interpret the
pathological condition attendant upon incipient pulmonary tuberculosis
by the physical signs and clinical symptoms present.

Palpation. In the very earliest stage of tuberculosis, we would
not expect much help from this measure in detecting increased fremitus
unless the invasion were extensive and the individual tubercles were
very close together, in which case we would have an increase in the
vocal fremitus ; but, with scattered tubercles, this sign would be nega-
tive or very slight. However, by placing the hands over the affected
part we can sometimes detect a lessening of the respiratory excursion.
This defective expansion is of great importance, especially if accom-
panied by other physical or clinical s ymptoms. Anders^ says of it : —
*Leyden : Ueder die Fruehdiagnose der Lungentuberculose. Die Lungenitu
berculose in ihren Anfangstadien, Rcdigirt von Dr. Schaper, Berlin, 1900, S. 79.
"Andera : "The Diagnosis and Treatment of the Prebacillary Stage of
Pulmonary Tuberculosis," Journal of the American Med. Assn., Jan. 12,
1901, p. 74.

263

^^I regard defective expansion at or a little below one apex as pro-
f oiindlj significant, particularly if observed in the infraclavicular space,
and in some of my cases ^'lagging" was the first and for a considerable
period of time the only recognizable physical sign.''

Pebcussion. The same can be said of percussion as of palpation.
In the majority of cases, this measure gives us absolutely negative
results ; but, at times, through it, we obtain very valuable information.
Unless the crop of tubercles were quite dense there would be no marked
dullness of the percussion note in the beginning of tuberculosis although
the resonance might be somewhat impaired and the pitch of the note be
somewhat higher than normal. In fact the man who aspires to be able
to diagnose incipient tuberculosis, must learn to look only for little
things. Some times we are able to elicit a note which approaches the
tympanitic in quality. This is due to an impaired elasticity of the
underlying pulmonary tissue and caused by the deposit of tubercles,
here and there changing the normal consistency of the lung.

Auscultation. Auscultation requires the most care and the great-
est skill of all procedures in pulmonary diagnosis. Corresponding with
its diflSculty and proportionate with the skill used is the value of the
information which it gives. In incipient pulmonary tuberculosis the
slight changes are detected more readily by auscultation than by any
other procedure. When we recall the pathology of this early stage, the
slightness of the auscultatory signs is self-evident. A few scattered
tubercles produce little more than a slight local hyi)eraemia with an
encroachment on the air-conducting tubes; and, the signs heard upon
auscultation depend upon the degree of hyperaemia and encroachment
present, and will be slight or more manifest according as the lung tissue
is invaded by few or many tubercles and as they are scattered or massed
together. This hyperaemia interf ers with the normal elasticity of the
lung, causes a narrowing of the lumen of the air passages, prevents the
normal aeration of the part and thus causes the so-called 'lagging.*'
It also accounts for the diminished respiratory murmur which is one of
the earliest signs of the incipient stage. The pitch of this diminished
murmur is also slightly higher than normal because of the relative dimi-
nution of air space to solid material. It may also be accompanied by
a slight roughness due to the increased flow of blood to the part and the
constriction of the bronchioles by the projection of tubercles into their
lumina. This same outgrowth of tubercles into the lumen may inter-
fere with the simultaneous filling of the air cells and thus cause an
interrupted, jerky, breath sound which we sometimes find present.

263

Consequent upon this irritation and the increased flow of blood to the
part, there is a slight exudation of moisture into the air passages which
shows itself as a sensation of stickiness or as fine crepitations. This
sensation of stickiness or these crepitations must not be expected to be
found in large areas. They may be heard only in one small spot, and
then not until the patient has taken a deep breath preceded by a cough
as described above. Sometimes, at this early stage, a mucous click is
also heard which, perhaps, is due to mucous collecting at some point of
constriction in a bronchiole and emitting the sound as the air passes
through. While these departures from the normal sounds, heard on
auscultation, are slight; yet, they are sufficient when other possible
causes which might produce such slight local disturbances are ruled out,
such as enlarged glands and tumors, to diagnose incipient tuberculosis
as almost certain ; and, this the more certain if clinical symptoms cor-
roborate.

CiJ.^iCAL SYMPTOMS. What are the clinical symptoms attendant
upon the invasion of the organism by tubercles ? To be sure, a patho-
logical condition which would produce so few local signs would not be
expected to be accompanied by marked systemic disturbances; never-
theless, there are slight disturbances present on the part of many of the
bodily organs.

Circulatory system. Upon the part of the circulatory system we
note an increased pulse rate, which usually precedes the advent of bacilli
in the sputum ; and, when taken with other symptoms, is suggestive of
the disease. Especially is this true in young people. The character
of the pulse is also significant, being weak, indicating low blood pres-
sure. Another sign on the part of the circulatory apparatus is a mur-
mur over the subclavian or pulmonary artery as pointed out by Da
Oosta. This I have been able to detect in several incipient cases before
other physical signs were marked and before bacilli were found in the
sputum.

Bespiratory system. The respiratory system shows few clinical
symptoms in the very early stage. Cough may not be present at all or
the patient may note a tendency to a slight hack after talking or laugh-
ing. Some observers have also called attention to the inability of the
patient to take deep a breath without coughing. Bespiration may
be sligtly accelerated, but this sign is totally untrustworthy unless the
count be made without the patient's knowledge.

Digestive system. The early stage of the disease is accompanied
in many cases by disturbances upon the part of the digestive apparatus

264

either with or without the loss of weight. A capricious appetite or a
loss of appetite which may become a total repugnance to food is present
in the majority of cases. Brandenburg^ says of the cases that present
themselves for examination at the Polyclinic in Berlin^ which are
mostly from the hard-working class of laborers: — "Nearly all of the
patientp complain of loss of weight and various disturbances of nutri-
tion. They complain of being tired, and, in spite of the weariness, the
night does not bring refreshing sleep ; on the other hand, they pass very
restless nights.''

Nervous system. The patient is irritable and restless, and his sleep
is apt to be disturbed so that he awakens in the morning as tired as
when he went to bed.

Oeneral symptoms. The patient tires easily, notices that work
which he is accustomed to do tires him more than usual. There is not
only a disinclination but an inability to do accustomed tasks.

A sign which should call attention to the lungs as, possibly, being
the seat of trouble is a dilatation of the pupil. Harrington* in calling
attention to this sign says : — "I refer to a widely dilated state of the
pupils ; not a paralyzed pupil, but rather one which seems to be in a
more or less constant state of dilatation, due to some irritation along the
track of the nerve fibres in the cilio-spinal region, or perhaps an irrita-
tion of the sympathetic, brought about by some blood change associated
with very early tuberculous infection and not yet fully recognized,"
I have noted an unequal dilatation, with the wide pupil on the affected
side much of tener than the equal dilatation of Harrington.

The patient may appear anaemic. The mucous membranes are
often distinctly so, and in some cases this sign is enough to direct the
attention to the chest.

Incipient tuberculosis is accompanied by a slight rise of tempera-
ture. This rise attends the formation of tubercles and the changes
caused by their presence. The degree of rise is dependent, at least in
part, upon the magnitude of the invasion. It usually occurs in the
afternoon or after some exertion and is of great diagnostic significance ;
and, if accompanied by other physical signs and clinical symptoms, is
to be looked upon as showing the presence of tuberculosis as most prob-
able. This rise is not always constant. It may come at irregular

'Bradenburg: Die Lungentuberculose inihren Anfangstadien^ Berlin, 1900.
'Harrington: An Early Sign of Tuberculosis, /aurual of Tuberculosis^
Vol. Ill, p. 6.

265

intervaLB, or may show itself only after some exertion. It usually
amounts to one-half or one degree only, and can best be detected by a
two-hourly chart If this rise should persist for a variable time and
then the temperature return to normal^ it would not prove tuberculosis
to be absent ; f or^ after the first invasion of tubercles all reactive inflam-
mation may subside and the temperature become normal^ the disease
assuming a state of apparent quiescence.

Prom this list of physical signs and clinical symptoms one can
usually gain sufficient evidence to make the diagnosis of, at least, proba-
ble incipient pulmonary tuberculosis long before the appearance of
bacillus-bearing sputum ; and, as the ear becomes better trained, he wiU
feel less need of the microscope to confirm his diagnosis; for, it must be
remembered that the microscope is not applicable in incipient tubercu-
losis, but, only after the disease has been present sufficiently long, it
may be a few weeks or a few months, to cause breaking down of tuber-
cles with outward discharge into a bronchiole. It would not be consid-
ered an early diagnosis of an abcess, when it had broken and the prod-
ucts of discharge had been found to contain the pyogenic cocci by micro-
ecopical examination ; yet many are content to call it an early diagnosis
in pulmonary tuberculosis, when the tubercles have broken down and
afforded us bacillus-bearing sputum. Why should a patient come to a
physician for a chest examination if the existence of incipient tubercu-*
losis can only be detected by finding bacilli in the sputum ? It would
be a means of economy to the patient when he suspects the disease to
take a specimen of his sputum to the bacteriologist and find out the
result for himself.

Those who are devoting themselves to the study of early diagnosis
to-day are much like the child who is learning to walk, and who still
clings to a chair or table or some other thing for support. They are try-
ing to become independent of the microscope as a necessity in recog-
nizing the presence of the disease ; and, as they cease to rely on it, they
gain more and more confidence in themselves. By improving their
methods of diagnosis, cultivating their powers of hearing and paying
more attention to clinical symptoms, they have become able to stand
alone much of the time ; for, a careful physical examination, made by
one who is able to detect the delicate changes produced by the presence
of early tubercles, together with painstaking observation and inquiry
into clinical symptoms, will either detect or exclude tuberculosis in the
majority of cases before the advent of the open stage of the disease with
its bacillus-bearing sputum.

266

TuBSBOuuN TEST. It 18 verj fortunate for those afflicted with
incipient tuberculosis thaty in case their disease can not be detected bj
physical examination with the corroboration of clinical symptoms, we
have other methods of examination which still make it possible to defi-
nitely decide as to the presence or absence of the disease before the
advent of bacilli in the sputum. The tuberculin test is one of the most
valuable methods at our command in the diagnosis of incipient tubercu-
losis ; and, if given intelligentlj^ will prove accurate in nearly all cases.
This is not and should not be made a substitute for thorough physical
examination, but should be used only when the examiner is in doubt as
to the diagnosis. And while I plead for a better understanding and
more extended use of the tuberculin test, it is not without the warning
that it should not take the place of careful physical and clinical exami-
nation. If the value of this test were to be recognized and it were to
come into general use, there is a danger that physical diagnosis might
suffer as it did by the introduction of microscopical examination of the
sputum. But, while the profession as a whole has not deemed it neces-
sary to perfect its powers in physical examination, but preferred to rely
upon the microscope to detect tuberculosis ; nevertheless, those who are
most interested have been able to improve immeasurably in ability to
intelligently examine chests since its use became common. So it is
with the tuberculin test. It has shown us how delicate the first changes
in the lungs are, and, after detecting these fine changes and having the
tuberculin test verify our diagnosis repeatedly, we have learned that
by perfecting our powers of making physical examinations we can
detect incipient tuberculosis in that stage in which Turban says 97 per
cent, should be cured. Since learning the value of thils test I have been
able to detect several cases of incipient tuberculosis before sputum was
present; and, by appropriate treatment they were cured without ever
reaching the open stage.

There is stiU fear on the part of many physicians that the tubercu-
lin test is harmful. This is based upon the unfortunate misuse of
tuberculin as a therapeutic agent when first introduced. In a previous
paper^, I have endeavored to show the cause of this fear, and how
unwarranted it is when tuberculin is used correctly. Why are not
strychnia and morphia tabooed ; for, do not they sometimes cause death t
Does not chloroform kill one person in every three thousand on whom
it is used ? Did not Professor Henoch's own son die from an injection

*Pottenger: ''Culture Products in the Treatment of Tuberculosis/*
Therapeutic Gazette, Jan., 1902, p. 13.

26Y

of antitoxm? Do not antivaccinationifits have some groiuid for fearing
vaccinationy if an occasional accident is sufficient to cause fear ? Physi-
cians are obliged to look at things in a rational manner. They know
that there are certain idiosyncrasies on the part of some patients to the
action of certain drugs ; they know that at times accidents will happen
which can not be foreseen; but yet these unfortunate occurrences
should not so blind them that they can not see the value of these reme-
dies. We ask no more for tuberculin than we do for other measures^
yet we insist that it should have equal consideration.

Those who array themselves against the tuberculin test do not
seem to be able to rid themselves of this fear of harm no matter how
much proof is offered ; yet, if these same men were to allign themselves
as opposed to the use of chloroform or ether narcosis for more perfect
examination or exploratory incisionSy they would be laughed out of
court; yet we know that there is always some danger attendant upon
such procedures. There is practically no danger connected with the
tuberculin test if intelligently given.

I wish here to mention the names of a few eminent physicians
whose words should carry weight on this subject, for they speak from
experience: Trudeau*, von Kuck^, WhittakeP*, Otis*, Anders*, Osier*,
Heron^, McAll Anderson®, Bemheim®, and Petruschky*^ are all earnest
advocates of the test, and show from their experiences that it is harm-
less when carefxdly given.

Anders^ ^ collected 3,638 cases in which the test had been given
and states : — ^^t is worthy of note that in not a single series of cases
among the many included in the tables which I have prepared is men-
tion made of any ill effects. At all events, I have not met a single
authentic report of a case in which the disease has been disseminated to
distant parts of the economy with ensuing acute tuberculosis."

*Trudeau : Medical News, June 29, 1 90 1 , p. i o 1 3 .

'von Ruck : Journal of Tuberculosis ^ Vol. I, p. 35.

'Whittaker : Cincinnati Lancet Clinic ^ 1897.

*Otis : Medical News y July i, 1898.

* Anders : Transactions of American Climatological Association^ 1900.

•Osier: Transactions of London Tuberculosis Congress^ 1901.

^Heron: Transactions of London Tuberculosis Congress , 1901.

•Me All Anderson : Transactions London Tuberculosis Congress, 1901.

•Bemheim : Medical News ^ Sept. i, 1900, p. 351.

'•Petruschky : Die Experimentelle Fruehdiagnose der Tuberculosa

"Anders : Transactions of American Climatological Association^ 1900.

268

The test is made after keeping a two-hourly chart of the tempera-
ture for two or three days. It is best given either in the early morning
or upon retiring. The patient's mode of life during the test should be
the same as when the control chart of the preceding days was taken,
the temperature should then be taken every two hours beginning five
or six hours after the injection. The reaction usually appears from
twelve to sixteen hours after the test is given^ but is sometimes delayed
several hours. In one of my cases it was delayed until thirty-three
hours after the injection, when a typical reaction, with malaise, chill and
a temperature of 103 degrees, appeared. Although this reaction waa
much more violent than is usual, yet no evil results followed.

A reaction consists of two different manifestations; one on the part
of the general system which is characterized by general malaise with
depression of spirits, loss of appetite, nausea, headache, pain in back
and legs and a rise of temperature two or more degrees above that of
the preceding days; and, a local reaction, which shows itself by an
increase of all the local symptoms.

The dosage and method of administration has been described so
often that it is scarcely necessary to repeat it here; suffice it to say that
the value of the test will depend upon the manner in which it is given.
The first requisite is a standardized solution of tuberculin; for, unless
we have this we do not know what we are giving; and the dose that
would give a reaction one time would be inactive another. Again the
test should not be given when fever is present ; for under such circum-
stances there would be some doubt, in case of a rise in temperature, as
to what had caused it. Then, finally, the test should only be given
when it is impossible to make a diagnosis otherwise.

It must be remembered that, in administering the test, that a ques*
tion of great moment is to be decided, so every precaution should be
used to obtain the truth. If there is tuberculosis present the earlier
found the better. If it is not present it is worth a great deal for the
patient to know it. As the reliability of the test depends upon the care
with which it is given every precaution should be taken to make the test
conclusive.

EoEovTOEir BAYS. The Boentgen rays and the fluoroscope are of
value in early diagnosis; some observers claiming that they will Bhofw
changes in the lung before any physical signs are present, others that
their principal value is in corroboration of other methods and that they
will not show evidences of change until it can be detected by other

269

means. It may be that this discrepancy in the opinions of different
observers is due to each being better skilled in his own method. How-
ever, we must consider the rays an important aid to early diagnosis.
Aside from the hazy condition over tuberculons nodules, a limited
excursion of the diaphragm on the affected side has been noted. Beale
and Walsh^ in a recent contribution to this subject say, in regard to the
limits of Boentgen diagnosis in tuberculosis — ^^We know that the
earliest deposits of the disease are not recognizable; a certain number
of tubercles must be aggregated before a shadow is noticeable. It is a
conservative claim that in some cases the rays are our earliest diagnostic
measure. It is equally true that when a shadow is cast the disease is
no longer in the incipient stage." It would certainly seem, remember-
ing our pathology, that, for the disease to be sufficiently evident to be
detected by the rays, we would certainly find a lagging of the chest wall
and a diminished respiratory murmur, perhaps of a roughened char-
acter, either with or without crepitation.

ExAHmrATiON OP SPUTUM. I simply mention this procedure
because of the great importance it has assumed in the minds of the med-
ical profession, not to recognize it as a measure of value in detecting
incipient pulmonary tuberculosis. It will certainly give us a compara-
tively early diagnosis but it must not be relied upon to show anything
in the initial stage of tubercle formation ; for, as shown above, we do not
find bacilli in the sputum until the tubercle bacilli have found lodgment
in the tissues and tubercles have formed, broken down and discharged
into a bronchus. The sputum of supposed early cases is usually exam-
ined in all too careless a manner. It is a long careful process to search
a specimen or several specimens of sputum for bacilli when they are
present only in small numbers. Often we are rewarded by their discov-
ery just as we are about to give up the search. If we are depending
upon the finding of them for diagnosis, we should never be hasty in
telling a patient that they are not present if we have reason to believe
that they might be. Better is it to take other methods to prove or dis-
prove our diagnosis and withhold our opinion for the time.

I can conceive of the microscope being able to detect tuberculosis
before other methods of examination, but it would not imply an early
diagnosis, but rather a late diagnosis of a very small invasion. Such
might be the case where the lung was invaded by a very few tubercles,
60 few as to cause almost no disturbance at all, and these should break
down and discharge into a bronchiole ; but such cases are not common.

*Bcale and Walsh : Practitioner ^ July, 1901.

270

When we consider the prevalence of pulmonary tuberculosis, the
successf ulness of early treatment and the comparative hopelessness of
treatment in the advanced stage, we are forced to the conclusion that
early diagnosis is one of the most important subjects in the whole
domain of medicine. Before we are able to make rapid strides in the
prevention of tuberculosis, we must become more thorough masters of
diagnosis. It is not a simple thing to make a diagnosis in incipient pul-
monary tuberculosis ; on the other hand, it is very difficult of accomplish-
ment. It requires close observation, a well-trained ear and a mastery
of physical diagnosis; but, this is something that anyone, who has
determination and acute powers of hearing can attain.

Bradbury Block.

271
ORIGINAL TRANSLATIONS.

VmV-PQINTS AND PROBLEMS IN THE STUDY OF TUBERCULOSIS,*

BY FERDINAND HUSPPX.

Gentlemen : — In opening the present session of the Tubercnlosia
Commission my first undertaking will be to review critically some of
the causal elements of the disease in question. Interest therein is con*
siderably augmented at the present moment by the impression which
has been called forth by Koch's paper at the recent London Congress.
The resolution of this body of men to discuss at the next international
meeting the subject of the predisposition to tuberculoeisy is another doc*
ument to the fact that our view-points in regard to this affection are
undergoing a radical transformation which is everywhere in evidence.

Koch's paper has again brought home to us, and in a most astonish-
ing fashion, the fact that deep rooted misconceptions are in force
despite twenty years of labor ; and that bacteriological orthodoxy, under
Eoch's lead, has not yet arrived at a lucid presentation of a subject
which dates back to 1882, the year of the discovery of the bacillus.
One might almost say that nothing has been learned during this period,
while much which had been carefully elaborated before the bacteriol<^-
icalerahas now been forgotten. From any other point of view it
would be impossible to understand why Koch has sawed off the limb
upon which he has been sitting.

Hygiene and bacteriology in their intimate reciprocal relations
are ripe for a scientific treatment of these problems in etiology. They
have claimed new view-points for the warfare against tuberculosis
while older ones have been rehabilitated.

These points of view are of the sort that no man capable of form-
ing a judgment can afford to ignore in warfare with our greatest pesti-
lence. To desire to construct the etiology of tuberculosis out of the
biology of the bacillus and animal experiment is a hopeless undertaking,
because false in its premises. Whoever thinks of nothing but bacilli in
this warfare has already missed the connection between the latter and
the social problems of hygiene. Other circles besides our own have
come to a clear understanding that one must consider the tuberculous
individual himself along with a study of the bacteria in the case. This

♦Address of the Presiding Officer of the Tuberculosis Commission of the
Deutsche Naturforscherversammlung. 73rd session. Hamburg.

Translated for The Journal of Tuberculosis itom the Wien, Med. Wocken-
schrift, 1902, Nos. i to 3.

272

is well shown in our present meeting by the fact that the Pathological
Section has two papers upon the histology of tubercle.

Baumgarten still looks at matters from the purely bacteriological
standpoint; for he regards the differences in the histological structure
of tubercle as dependent exclusively upon the virulence of the bacteria,
and looks upon slight virulence as equalizable only through an increase
in the number of bacilli. This factor certainly cooperates in a marked
degreee, but we must not lose sight of the fact that this reasoning is
based somewhat upon analogy — ^f or example, with that of the behavior
of the anthrax bacillus. Thus far we possess no means of fashioning
the virulence of the tubercle bacillus at pleasure, and can neither
increase nor diminish it. On the other hand, we often obtain our first
idea of virulence from the histological findings.

A count of living bacilli has as yet never been made. Our quanti*
tative appreciation of the germ has been in connection with dried
bacilli, only partly controlled. We do not know how many of the latter
are dead or non-virulent, l^or can we determine how many are alive
and infectious. The sole method of coimting living and virident bacilli
which is known to-day has been recently worked out in my laboratory
by Welemmsky, and has not yet been published.

We must further consider that as far as testing the vimlence is
eonoemed, we have no tertium camparationis. Even our little exper-
iment animals — guinea pigs and rabbits — often show marked individual
variations. By passing tl^e bacillus through animals it may be made
extremely infectious for a particular species — ^the hen for example —
but it has meanwhile lost its virulnce for the rabbit. The fact is often
overlooked that virulence is only a relative term and does not comprise
all the factors which are of importance for an act of infection. The
infectiousness of a pathogenic microorganism depends upon its entire
metabolism in relation to the species of its host. One sided emphasis of
virulence can, imder certain circumstances, lead to erroneous conclu-
sions. Virulence and amount of poison alone do not explain why we
have in one case pure phthisis without local findings, in another pure
tubercle, and in a third — and without associate infection — ^that solution
of tissue which may amount to the formation of cavities. Baumgarten
has produced the latter experimentally in rabbits and I, myself, once in
the dog.

These early findings in tuberculosis were illuminated further by
observations on the part of Behring who found that solutions of diph-
theritic vims with a unit of volume sufficient to kill an equivalent by

[

2Y3

weight of the mouse, exhibited an entirely difiFerent degree of toxicity
toward the same amount of weight of pigeons, rabbits, goats and horses.
Thus the same conditions are seen to obtain in diphtheria and tubercu-
losis, and the action is not due alone to virulence and to the amount of
determinable free virus, but also to other substances which may raise or
lower the virulence and toxicity.

Orth has, in my opinion, done better in some respects, for after
duly considering the virulence and number of germs he recognizes the
presence of an unknown residue which can be explained only by pecu-
liarities in the tissues themselves. Without considering the local pre-
<lispoeition we cannot explain those cases in which the bacilli are viru-
lent and invasive and able to set in motion the phenomena of disease.

In order to make this great difference clear it is not necessary,
.as Virchow has done, to contrast human tuberctUosis with the perlsucht
of cattle ; it is sufScient merely to study the different phases of the dis-
ease in man. According to the tissue m which the bacillus produces its
lesions, we see either submiliary or miliary nodules, or a more diffuse
infiltration. We see, for example, cutaneous tuberculosis and lupus
«ide by side ; we also see scrofula and fungous arthritis. In the lungs
we observe miliary nodules and infiltration. Occasionally we see in
man the lesions of the perlsucht of cattle — as in a case reported by
l£eltzer under the designation '^perlsucht of the pericardium." The his-
tological elements — ^miliary tubercles, round cells, epithelioid cells,
giant cells, vary notably and their retrograde changes likewise exhibit
much variation.

While diptheria is to be regarded as an infectious disease and diph-
theritis as a local necrotic process, we 'understand by tuberculosis a
specific infectious disease, and by tubercle an anatomical nodule which
can be produced by the most heterogeneous irritants and which demon-
strates nothing beyond the fact that the mechanical make-up of the
tissue is especially adapted for the formation of nodules. The virus
of Buhl and Cohnheim has been replaced since 1882 by Koch's bacillus.

The anatomical conception of tubercle of Virchow is either too
narrow or too broad, and in no wise satisfies our necessities; and in
this comprehension of the matter, Orth's views meet those of the
hygienists. The conception is too narrow if one is led to believe that
he can pass directly from the morphology of the lesion to its etiology
and thereby isolate a disease. On the other hand the conception is
too broad if one is led to overlook the fact that these nodular lesions
are produced by the greatest variety of infectious and non-infectious

274

diseases. One cannot see in tubercnlosis more exquisite submiliaiy
tubercles than those which are produced in the inoculated type of
glanders in guinea-pigs. The perl-node is also a genuine tubercle of the
same class as the submiliary variety ; with Ijmpho-sarcoma it has naught
in common, despite VirchoVs assertion to the contrary. The typical
feature of the perl-node is not its structure, but its retn^rade 'meta-
morphosiB, its calcification. This is the rule in cattle, in the pleura,
pericardium and peritonetmi, but not in other localities; but even in
mankind we may exceptionally meet with genuine perl-nodes.

The statement of Koch that the bacillus of bovine tuberculosis,
does not attack man has nothing whatever to do with the question of the
nature of the perl-node. Different exciters of disease may produce-
the same histological formations ; and vice versa one bacillus, acting in
different hosts or even in different tissues of the same host, may
engender entirely different histological lesions.

But the subject of tubercles does not exhaust tuberculosis; nor
do retrograde metamorphosis, caseation and calcification; for in the
same lung, along with tubercles, caseation and calcification there occur
superficial exudative, inflammatory processes, as Orth in particular has.
told us. The extraordinary multiformity of the histological picture of
tuberculosis even in man alone — ^which is hardly less than the multi-
formity seen in syphilis — shows most strikingly that the local predispo-
sition must play the decisive role in infection with the tubercle bacillus-
It is a source of great joy to me personally that a pathologist like Orth,.
sustained by a rich histological material, should represent the view
which I first promulgated in 1889 and presented more comprehensively
in 1898.

VirchoVs distinction between tuberculosis and caseous pneumonia
was always highly unsatisfactory from the clinical standpoint and did.
not even suffice for an anatomical differentiation, when we bear in mind
the multiformity of the phenomena. The physician who has to treat
living individuals and who regards the results of autopsy as but a single-
criterion desires etiological unity along with anatomical multiformity,
for otherwise he cannot comprehend the disease. In this sense we have-
through Klencke, Villemin, Buhl, Cohnheim and Salomonsen and
above all, by Koch, attained the old conception of the unity of tubercu-
losis which Eokitansky upheld, but which we can now understand a&
dependent upon the existence of a specific disease.

It is not without interest to note the manner in which the orthodox
bacteriologists seek to evade certain of these facts. Thus Koch will see^

275

nothing which has happened in the last twenty years ; he does not or
will not know anything beyond the bacillus. The bacillus is every-
thing! But Koch had much clearer views between 1882 and 1884
than he has to-day ; for originally he recogmzed a predisposition^ while
now that is a thing of the past since Comet's labors. Baumgarten has
confessed that the resistance of the organism is of significance along
with the virulence and number of the germs.

Por Fliigge the predisposition which had once vanished is now
dowly returning. In his most recent work he defends the bacteriolo-
gists from the reproach that they do not recognize a predisposition : —
"They have always recognized the predisposition as the. second f actor.'*"
This view, however, shows, in itself, that I^iigge has never really taken
cognizance of the nucleus of the matter ; and Fliigge of all Koch's dis-
ciples is probably the most devoid of prejudice.

Such transformations in the representation of a subject must show
that no one can hereafter dispense with the scientific consideration of
the problen[is of etiology which must be established in the interest of
the development and continuity of our science. This is shown by the
universal antagonism which greeted Koch's announcement of his views
in London, and this, in despite of his authority. The facts were not
denied, but the interpretation vouchsafed by Koch was a complete
failure.

In a problem as complicated as that of the etiology of and warfare
against tuberculosis, where the course of the disease must be mapped
out by the clinician and the status at the time* of death by the patholo-
gist, and where by the side of the purely medical element the most com-
plicated social relations have importance, it appears to us frivolous to
seek the etiology and extermination of phthisis through animal experi-
ment.

Even the evolution of bacteriology should warn us to be cautious.
At first lioch denied statements to the effect that other bacilli than
his possessed the same tinctorial qualities, and asserted that such find-
ings were due to imperfect technique. We know now that the former
statements are true.

Upon the etiological side of the question Koch was more cautious.
Even in 1884 he discussed the probability that differences would be
revealed between the bacilli of human tuberculosis and perhuchtj
although he had first thought them identical. However, he thought
at that time, that if several species of his bacillus did exist, we must
still regard the bacillus of perlaucht as highly suspicious. He then

[

276

continues : — ^Trom the standpoint of hygiene the same measures must
be adopted as in human tuberculosis, as long as it is not proven that
man cannot be inoculated by the contact of perlsucht bacilli mth cutan«
cous woimdSy or cannot contract the disease by inhalation or ingestion."

Now the possibility of wound infection from the bacilli of bovine
tuberculosis is assured beyond doubt; and this sort of transmission has
all the force of an animal experiment. A few days ago in Hamburg
an action at law revealed the fact that a man had inoculated his right
arm with tuberculosis while slaughtering a consumptive cow. Prof.
Heller will report at the present meeting an analogous case witnessed
by himself, and others are to be found in literature. In 1900, Birch
Hirschf eld demonstrated in Prof. Suttler's ophthalmologic clinic a case
of tuberculosis of the conjuctiva in a man who had long milked a con-
sumptive cow. The possibility of such transmission, disputed by Koch,
has now been completely demonstrated ; and even as far back as 1888
Weisser investigated a case of inoculation of a veterinary surgeon with
bovine tuberculosi3, and utilized Koch's own laboratory for the demon-
stration. This case is mentioned by L. Pfeiffer m the Zeitshrift fur
Eygieney 1888, III. p. 209. The bacilli of bovine tuberculosis are
therefore able to attack adult human beings, and the cases cited have
all the vigor of animal experiments. As in localized cutaneous tuber-
culosis from bacilli of human origin, the lesions are accessible to treat*
ment, so in these cases of inoculation from cattle, the disease yielded
readily to local therapy.

Unintentional exepriments in inhalation of the bacilli of bovine
tuberculosis are not yet Imown among human beings ; at least I can find
nothing of the sort in literature.

On the other hand there has been plenty of observation of the
ingestion of food-products from infected animals. In this connection
cautiously compiled statistics are available. Recently I called atten-
tion to the fact that a great difference exists in this respect between
children and adults.

We know that tuberculosis in the child differs much from the same
affection in the adult in regard to the organs iraplicaed ; thus the intes-
tinal localization is relatively infrequent in the adult and extremely
common in children. My personal material shows that from 25 per
cent, to 30 per cent, of all deaths from infantile tuberculosis are due to
the intestinal localization. Prof. Heller will inform you later that
carefully compiled statistics in Kiel show that 80 per cent, of intestinal
tuberculosis occurs in children, and but 2 per cent, in adult life.

277

It appears to me that we overlook the fact that the primary f ocua
of the disease does not necessarily represent the locality at which the
virus entered the body; this focus may simply mean a locus minoris
resistentiae. It is therefore quite possible for infection to occur by
way of the nourishment without the production of a local lesion in the
intestine. Tubercle bacilli may possibly be taken up in the tonsils and
borne by way of the blood and lymph streams to the lungs and pleura^
there to cause the initial lesion, which is then set down falsely as due to
inhalation. Such possibilities have been shown by careful experiments
and cases to be facts.

Koch's own researches are conclusive on this point. He fed bacilli-
bearing sputum to pigs and after an interval of ^. 1-2 months, 5 out
of 6 aninialH showed tubercles in the cervical lymph nodes, while .in
one case the same lesions were found in the lungs. He then fed &
other pigs with material containing bovine tubercle baciUL Three of
the animals died and the others became very ilL

Cases of primary intestinal tuberculosis occur in minimal figures,
because the point of entry of the virus does not coincide with that of the
primary lesion. Even if certain of these cases are due to ingestion
of tuberculous sputum from the mother or nurse accidentally mixed
with the nourishment, in by far the greater number of cases the infec-
tion must proceed from the milk of tuberculous cows. Hence just as
the bovine disease may be inoculated in the human skin, so may it also
affect the human intestine. There can be no question of immunity, of
a natural resistance of man towards the bacilli of bovine tuberculosis —
neither in childhood nor adult life.

In regard to the reception of bacilli in the air passages, it is cer-
tain that there exists a primary inhalation-tuberculosis. We must
acknowledge as a result of Koch's old and Flligge's recent experi-
ments with droplet-inhalation that primary tuberculosis may develop
in the air pasages; and we must seek to protect ourselves from thia
source of danger. We must likewise reckon upon the possibility that
inhalation-tuberculosis may not begin in the air passages, but in the
intestine. A consideration of all the factors, however, would appear to
show that such a mode of infection would hardly be the rule in children
(A. Gottstein).

It appears to me in regard to protection from spray-infection that
^ugge has allowed a healthy human understanding to assert itself
once more. The handkerchief must again be brought into play, for
the pocket spittoon cannot answer all the demands. No one should

278

cough without a handkerchief before his f ace, as a matter of common
decency. Some sputum must adhere to the lips and beard and be wiped
off by the handkerchief^ but Comet's crusade against the latter appears
to be overdone.

On the other hand we must admit from experiments made in my
laboratory and from the communications of Auf recht and Bibbert that
primary foci of tuberculosis may occur in the lungs.

I have but recently known of Baumgarten's success in causing
primary hematogenous tuberculosis by infection through the urinary
bladder. Neither inhalation nor mechanical conditions in the apex, but
a specific weakness of the tissues in that locality was the determining
factor in this phenomenon. From this experiment Baumgarten must
at Jast admit the existence of a sequence which I have recognized since
1889, but which he has hitherto denied.

In regard to natural immunity we now know as a result of the
study of hemolysis that the active fluids of man and the ape behave
in a very similar fashion. Tuberculosis of the anthropoid apes, in fact,
constitutes a connecting link and Mr. Griinbaum will demonstrate
before this meeting pathologic specimens from a chimpanzee which was
infected from the milk of a cow with bovine tuberculosis. If recent
studies appear to show that bovine tuberculosis is transmitted to man
with difficulty — or not at all if Koch is right — ^while the human form of
the disease infects cattle with the same reluctance (other experiments
of Bollinger and Chauveau contradict Koch's findings), the explanation
should lie chieflv in the substratum of tissue which becomes infected.
Every kind of organism has acquired a certain degree of resistance,
upon which depends the reaction awakened by the disease-germ. This
substratum then determines the type of disease and not the dose of
virus, or the difference in site of inoculation as Koch claimed in 1884.
These last named factors will not of course be neglected, for we see
daily that the guinea-pig which almost never develops tuberculosis spon-
taneously may be infected artificially at pleasure.

We repeat that the substratxun, the soil, is by far the most import^
ant factor; this has been shown by Karlinski, who exposed cattle to
the bacillus of human tuberculosis in 25 experiments, 10 of which gave
positive results. He established thereby the fact that Bosnian cattle
exhibit a peculiar stisceptibility to the disease. Koch has paid too little
attention to the element of breed in his animal experiments.

The nucleus of a scientific conception of the disease is variability
of resistance, which depends upon many factors, such as social relations,

279

foody education^ inheritance^ etc. Certain disease germs^ especiallj
adapted for the purpose, are able to engender maladies through arous-
ing the resistance, congenital, or acquired, of the tissues. Koch who
has failed to keep in touch with the work of the last twenty years still
looks upon the bacillus as the disease itself.

One bacillus is pathogenic to man, another to cattle, a third to the
pig. This relative constancy doubtless comprises differences. We
have known this of avian tuberculosis for years. Kschel and myself
described it in 1891 to 1898 ; Arloing, Oourmont, and Dor in 1891, and
more recently Nocard. Differences in the virulence of the bacillus
of bovine tuberculosis were recognized by Frothingham in 1S97 and
Th. Smith in- 1898. The latter found that the virulence of the bacillua
differed in different mammals. Baumgarten and Gaiser, myself,
Arloing and Nocard have demonstrated the different behavior of the
bacilli in different nutrient media. The view that the bacillus is purely
active and the tissue passive has been refuted. In cattle the bacillus
is made to change its shape and to become more pointed. Both myself
and Smith have noted the resemblance in sections to the lepra bacillus.

Every observer must have noted in sowing cultures of the human
bacillus that differences assert themselves. The same germs kill a
£uinea-pig rapidly, but cause only a local lesion in rabbits. Bacilli
from human lupus cause a local lesion only in the rabbit ; while bacilli
from pulmonary lesions quickly destroy the same animal.

I attach little value to the fact that a positive tuberculin reaction
is obtained in both man and cattle ; for with Buchner and Bomer I do
not regard the phenomenon as specific, in the sense that the bacteria
produce specific poisons. Under these circumstances the question of
the existence of a predisposition to tuberculosis is permanently settled.
There is such a disposition, not only in the racial but also in the indi-
vidual sense, and the great differences in the histological findings are
the key to the demonstration of the validity of these assertions. This
phase of tuberculosis I regard as of such importance that I have pro-
posed it for discussion at the present meeting of our Comnussion.

As the Pathological Section of the Society is to discuss the histol-
^ogy of tubercle, 1 have made an agreement with Prof. Martins, that on
account of the great extent of the subject matter it would be best to
limit ourselves to a single feature, viz : — ^heredity.

What is usually regarded under this term may be characterized
^th few exceptions as useless rubbish. Koch denies the influence of

280

heredity, while Baumgarten is equaUy positiye that heredity is every-
thing. One sees in heredity the substratum which is formed after the
union of the spermatozoon and OTum; another the direct transmission
of the disease-germ; a third sees only intra-uterine infection. These
different views illustrate the necessity of bringing some approach to
order in the entire subject of predisposition. Everything depends upon
a proper statement of the problem, given in a concise form.

But how many things must be first considered 1 Strictly speaking
but one condition, one peculiarity can be inherited. A bacillus thus,
propagated is not a disease, and a disease is not a condition but a pro-
cess. A disease can be congenital, but not inherited.

In a given family every child as it attains a given age — ^the same
in each instance — ^becomes tuberculous. In another family the child-
ren develop the disease at widely different ages, and some escape alto-
gether although the parents are tuberculous. The question thus
answers itself falsely. In compiling statistics we usually note the
extension of family disease from the parents to the children, but we
make thereby very little headway in the problem of the heredity of
tuberculosis.

If we consider etiological factors in association with histological
findings we recognize the existence of a particular weakness in certain
cell-areas, tissues and organs. We know, however, that various germs
can set up disease in such debilitated tissues, so that we have to take
account of all other affections in a consideration of heredity.

Hitherto, we have considered diseases like influenza, whooping
cough, and measles solely from the standpoint of nosoparasitism. lie-
breich has recently given us a definition of this latter term which makes
it perfectly clear. All of us formerly understood it to mean that upon.
a noses, i e. an anatomo-elemental type of disease, a second disease,
especially tuberculosis, is grafted. Liebreich, however, succinctly
states that the nasoa i& an unnecessary conception, that it representa
nothing more than the disposition to disease. Therefore the word
nosoparasitism should be eliminated form pathology.

In a certain sense, however, the expression is just. There is no
doubt that tuberculosis often develops after previous acute or chronic
affections, catarrhal and otherwise. This nosos when parasitic is an
example of metabiosis, but it need not be an infectious disease. Thus
tuberculosis may also develop after persistent inhalation of dust has
produced lesions. This is genuine nosoparasitism, i. e. actual infection
with tubercle bacilli as a sequel of previous injury to the tissues. In

281

this sense a number of conditions must be brought in connection with
tubercle bacilli. The same is true of mixed infection — symbiosis —
which plays a great part in the destructive phenomena of lung disease*

But there is still a third group which has almost escaped obserya-
tion. Thus I observed in 1887 a certain vicariousness among the infec^
tious diseases. Thus one contagious affection appeared to give way to
another. Beger has called attention to the same phenomenon. Biffe)
in the course of extraordinarily painstaking investigations has estab-
lished the fact that the disposition to tuberculosis must be understood
more in the vicarious sense. In addition to the infectious diseases men*
tioned above we should consider diabetes, arthritiSi carcinoma, heart*
diseases, and alcoholism — affections which while they enhance the dispo*
sition to tuberculosis also act vicariously with it. Thus Beibmayr speaks
of ^'transf ormed" tuberculosis in pointing out that in England heart dis»*
ease and cancer have increased in almost the same ratio that ttiberculo»-
sis has diminished. At first sight cancer does not seem to belcmg to
this group of diseases ; but the middle germinal layer must sustain some
alteration before the epithelia can proliferate into it in a pathological
sense.

In the transmission of the substratum of disease it is not necessary
that every child who is threatened with tuberculosis should actually
develop the disease. He can contract some other affection through the
vulnerability of his tissues and either die from it or be immunized
against further attack from the tubercle bacillus. It is probable that
we can give to this vulnerable soil a second nature through hygiene
and education and thereby protect a threatened chUd. As Hirsch says^
we can seek to relieve an individual of his hereditary burden and at tiie
same time antagonize paralyzing pessimism in therapeutics.

In short, when we deal with the heredity of tuberculosis we must
do more than ask if the child's father was tuberculous, or if he used to
cough. We must go into details along the lines of research which we
have just enumerated.

This subject of heredity does not of course exhaust the duties of
our Commission. Tuberculosis is a veritable endemic pestilence, and„
in its extension, a social evil of the gravest kind. The old contrast
between city and country, accentuated more than ever to-day, leads the
rural dweller to the town, and not only the more energetic and ambitious
but those who are physically vulnerable. Some of the latter although
they look healthy often succumb quickly to tuberculosis as a result of
inability to become accustomed to town life. This is in no wise due to

282

incireafle in the possibilities of infection. There are plenty of ways to
contract the disease amid the careless life of farmers. It would be
i^iposcdble to acquire suddenly the disposition to tuberculosis after
moving to the city and leading an urban life. The exodus to town even
favors the weaker rural dweller by removing him from the hard strug-
gle for existence^ which often destroys both parents and children at
early ages. Individuals doomed thus to perish if they remain in the
coimtry come to town and enter upon a different kind of struggle for
existence. They are naturally ailing and ultimately fall a prey to
tuberculosis^ a very slow but certain method of weeding out these weak-
lings. Herein lies one phase of the social peril of tuberculosis.

We must combat the indifference, the want of cleanliness, the
imperfect comprehension of the benefits of air and light on the part of
the masses. The notion of hygienic education of the people is the
eiitering wedge in the warfare against the disease. Patriarchial benev-
olence is not our watchword ; we must teach the units of society their
duty to the community as a whole.

HISTORY OF THE DEVELOPMENT OF JOINT-TUBERCULOSIS.*

BY F. K5nIG, BERLIN.

Gentlemen: — ^Tuberculosis of the bones and joints was as good as
unknown during the first two-thirds of the past century ; and even those
from whom one had the right to expect exact knowledge upon these sub-
jects were in complete obscurity as to the affections which have since
been recognized as bone- and joint-tuberculosis. When I, a young sur-
geon, inquired of the old surgical masters as to why operations for white
swelling of the knee healed so badly or not at all, they could give me no
aziswer. The idea of "scrofula" was paramount at the time, and such
joint-affections as fungus, tumor albus, etc., could be explained upon
no other supposition. To-day there is hardly a surgical affection which
is so well understood in regard to its origin and course as joint-tubercu-
losis.

I shall endeavor to illustrate to you by means of specimens a pic-
ture of disease which could hardly be duplicated by any other surgical
affection.

The first glimpse of light in regard to the nature of white swelling
was due to a seemingly very unapparent discovery by Koster of Bonn,

♦Translated for Th€ Journal of Tuberculosis from Deutsche Klimik, Bd.
VIIL Lief. 32-24, p. 67.

283

wbo found tubercle in the granulatioiis produced by this affection. To
this finding, repeated shortly on all sides (and incidentally by myself)
were added the results of further investigations which were made in
Yolkmann's clinic at HaUe, and which gradually established the fact
that an entire series of timiors and ulcers formerly regarded as "scrof-
ulous'' or "dyscrasic" presented the same anatomical qualities and that
tubercle was to be found here as well as in lupus. At first sight it
appeared as if a special group of affections had been evolved— a so-called
'^^bereuloid" which stood in close connection with genuine tuberculosis
•^for the picture which had obtained in regard to the latter did not
:fleem tobe identioal with that of the new i^up. In due time, however,
the ^'tuberculoid" affections became recognized as actually tuberculous
processes.

Eichard Volkmann established a h^hly important truth in joint-
pathology when he showed that certain peculiar foci of disease already
•described by other observers — ^particularly French surgeons — ^were
especially common in joint-tuberculosis. These foci which are seated
in the osseous portion of the articulations and to which we shall allude
from time to time, develop at times in such a fashion that they do not
-come in direct contact with the joint; While again — ^aiid here lies their
great significance in the development of joint-tuberculosis — ^they may
enter the articulation either by breaking through the cartilaginous
lamella of the articular stirface or the insertion of the capsule of the
joint In this Way the infectious substance of the disease enters the
articulation which thereupon becomes tuberculous; while the original
osseous foci of the disease are Iflcewise examples of tuberculosis.

If we review all that has just been said we see that proofs are sup-
plied of the presence of tubercle-granulations in very many cases prev-
iously described as scrofulous joints, white swelling, etc., and of the
^x>&dstence in the great majority of cases of osseous foci with the joint
lesions which are not only tuberculous in themselves, but'from which the
joint lesions become evolved. At this stage in the advance of our knowl-
edge of the subject I was able to show in a series of papers that tubercu-
losis of the synovial membranes was a regular and inevitable lesion in
the joint-disease, and not a mere chance occurrence. I further estab-
lished the tuberculous nature tod relative f requ^hcy of the osseous foci
jcnd^how often primary synovial tuberculosis might occur with previous
lesion of bone. Thenceforth a distinction became inevitable between
prim&ry synovial and primary osseous tuberculosis.

284

I proceeded from the special to the general and demonstrated by
nmneroufl autopsies that joint-tuberculosis might occur as a primary and
isolated lesion in 20 per cent of cases ; which number is perhaps some-
what too highy for we now know that, as a rule, the disease is present
elsewhere in the body and that some of our early autopsies must have
been defective. Tuberculoses of the lungs, bronchial glands, kidneys,
etc., usually coexist and the joints become involved secondarily thereto*
Sustained by these facts, I argued long by word of mouth and in my
writings that scrofulous joints must be tuberculous, but much time went
by before the truth of my contention was admittedi And although the
entire doctrine was elaborated in all its details, demonstrating both the
nature of the joint-disease and its connection with tuberculosis aa a
whole, the discovery of the bacillus was required to dinch the matter.
After this event all oppposition was withdrawn, and the joint-disease
long known as white swelling, strumous arthritis, etc, was recognieed aa
tuberculous.

I will now proceed to sketch the picture of tubexeuloiis of the syn*
oml membranes and articular ends of the bones in the most concise
manner possible, paying no attention to tubereuloais of other oeseoua
structures. In the great majority of cases the bones and synovial tie*
sues are involved jointiy.

White swelling, fungus arthritis or whatever name we may choose
to give it has to-day a very transparent history, which enables us to
understand why this disease appears in such a definite form (which con-
stancy of type once gave it the clinical term of ^'scrofulous joint")^
This clinical condition became intelligible only after we had learned
that the characteristic spindle-shaped joint without effusion must have
once passed through a period in which effusion hctd occurred.

Even in my earliest communications on tuberculosis of bones and
joints, I had isolated a group of affections under the term tuberculoua
hydarthrosis. Only the most marked forms of dropsy were thus design
nated — ^f orms which from the extent of effusion had not originally been
reckoned as tuberculous, but simply as chronic dropsy of the jcnnt with
gradual origin and evolution. It was known of this condition that it
sometimes ended in resolution while in other cases it became a scrofu-
lous joint Later studies and especially some of my own in looking
over pathological specimens led me to the recognition of the fact that
every case of joint-tuberculosis is preceded by a stage of effusion or, in
other words, by a tuberculous hydrops. Persistent effusion, however^
is seen only in a TniTiiTnnTn of cases.

285

From the initial sero-fibrinous synovitb the various stages of white
swelling are developed for us to-day in a perfectly intelligible manner ;
the disease becomes dear to us only through the knowledge that at the
outset of every synovial tuberculosis^ there is an exudation into the sac
— in other words, a sero-fibrinous synovitis.

I shall first consider synovial tuberculosis, the course of which is
the same whether or not there is a coincidence of osseous tuberculosis*

The entire course of the affecti<»i is such as to indicate that the
inflammation evoked by the bacillus is exudative, sero-fibrinous in type.
But the proportion of the fluid and eoagulable element (fibrin) is not
constant for difiFerent ]<Hnts ; for sometimes we see much fluid and but
little fibrin, and on other occasions the reverse. The changes in the
affected joint appear to depend solely upon the amount and behavior of
of the fibrin which is responsible for the greater part of the destruction;
since the processes of cicatrization and healing are effected through this
substance.

By the term fibrin^ as used in this connection, we understand a
precipitation which occurs in the effusion, and which may appear as
flocculi or in definite f ormi, such as rice-grains, melon seeds, amylaceous
bodies or even in the most varied polypoid formations (tongue, cock's
comb, etc.). This precipitate either adheres to the articular surface or
becomes organized after a time into polypoid tumors. This collection
shows how manifold is the picture which may be constructed from the
grayish*white eoagulable substance.

The type of exudate which becomes organized possesses the great-
est significance for the synovial membrane, and as we shall see later,
many of the characteristic local phenomena are developed from this
source.

The development of synovial tuberculosis may be studied of course
in any joint of the body ; but the process first became clear to me from
the study of the knee. I am therefore of opinion that whosoever desires
to investigate this subject should have specimens of knee-joint tubercu-
losis at hand. The anatomical and physiological conditions of the
patella tend to render study of the knee-joint especially instructive.

The conditions which I shall demonstrate to you are not present
in the same degree in every case. There is a certain number of joints
in which the liquid exudate preponderates over the fibrin — ^f or example
when the joint is simply attacked as a local manifestation of acute, gen-
eral, miliary tuberculosis. Here we see tubercle deposited in the
unchanged synovial membrane although under ordinary circumstances

386

it is not common to see this early deposition into the membrane itself,
tor this phenomenon takes place in t)ie layer of organizing fibrin.

Thk sort, of precipitation^ however, is not peculiar to tuberculous
joints^ for it occurs likewise under other circumstances in which a fibrin-
ous exudate takes place. It is rare, however, for any other affection to
produce such quantities of oi^;ani£able fibrin as occur in tuberculosis.

This may occur, however, in gonorrhoeal and other forms of acute-
and subacute inflammations of the joints, and especially in haemarthro-
sis, where repeated recurrence of the haemorrhage adds to the amount
of fibrin poured into the joint. Although the conditions in haemarthrD-
618 differ somewhat from those of simple inflammation — since the blood-
coloring matter plays a role in the alterations of the joint — they are
sufficiently similar as far as the deposition of fibrin is concerned.

The tuberculous joint differs from all others as follows: — ^Wlule
tlie fibrin is being deposited layer by layer upon the cartilage and
synovial membrane and is there undergoing organization, tubercle
appears in the latter, upon the margin of the joint cartilage. To this
rule there are but few exceptions. At first we see round-cell tubercle,
which appears coincidently with and in connection with the newly
formed vessels. In this deposit of tubercle we see the germ of those
special alterations which characteriEe the tuberculous joint, such as
caseation.

The mere precipitation and organization of fibrin with the result-
ing alterations in the subjacent tissues are not dependent upon the form-
atipn of tubercle.

Let us now consider what takes place in the knee-joint in synovial
tuberculosis. Here the fibrin is always deposited in quite definite local-
ities. The femoral surface mav be selected as the most characteristic.

Smooth layers of fibrin begin to appear upon the patella at either side
which unite in the middle; while, at the same time a similar deposit
takes place at the i>eriphery of the cartilaginous surface of the condyles*
The fibrin layers increase in breadth and depth, spreading over the var-
ious articulating surfaces until but minimal portions of the latter remain
uncovered. In regard to individual details, which have much signifi-
cance for the knee-joint in particular, we must forego further discussion
and must likewise omit the description of the deposit of fibrin upon the
articular surfaces of the tibia. A general idea of the process is what
we wish to suggest in tins connection. It is only necessary to add that
the organzation of the fibrin, as well as the tuberculizaticn, likewise*
takes place from the periphery inward*

287

At tliifl period, moreover, the organizmg substance exerts its most
deleterious action upon the subjacent tissues. As long as the tubercu*
lous process is active, and the deposition of fibrin continues, a pernicious
action is exerted upon the cartilage which becomes eroded, and subse*
quentlj, as a result of the destruction of the cartilage, upon the bone
itsdf.

If we scrape o£F these fibrinous deposits, the subjacent cartilage is
found to be uneven. It has lost its smoothness and presents depressioBS
of various degrees of depth, into which the newly formed tissue has
grown. By this process the cartilage becomes progressively eroded.
The losses of substance increase in depth and width, leaving islets of
cartilaginous substance intact, until the newly formed tissue has reached
the level of the bone, into which tissue analogous loss of susbstanee
begins to occur. If a tuberculous focus had preexisted in the bony
tissue it is naturally exposed, so that the corresponding portion of tiie
joint is relatively destroyed. Further discussion of this interesting
phase of our subject must be neglected here as it is without special bear*
ing upon the general principles involved.

If the deposit of fibrin upon the cartilage and its subsequent organ-
ization are capable of accounting for the various changes which affect
the thickness of the articular ends of the. bones, they are not less equal
to the task of explaining the changes in the synovial membrane. The
granulation-process which occurs in the joint capsule is not a direct
product of the synovial membrane, but is the result of the precipitation
and organization of fibrin. The synovitis is therefore not synovial at
first but parasjrnovial, and the first formation of tubercle occurs likewise
ID these superficial strata. Only at a later period do the conditions of
irritation and proliferation occur in the synovial membranes proper,
and the deposition of tubercle then takes place in the same structure.
This fact is of great importance in the prognosis of arthrectomy and
resection, and accounts for the failure of the synovial membrane to dis*
integrate and degenerate, although thick masses of tuberculous granu*
lation-tissue can be detached therefrom.

If the process just described is arrested, the site of the progressive
destruction is indicated by a contracting scar. That is true of course,
only for the synovial membrane, for the lost cartilage and bone are not
replaced.

When these joints, as already studied by us, assume at the onset
the characters of an '^hydrops tuberculosis" by reason of the volume of
the liquid exudate, they become altered in form and characteristics, as a

— -t.

y 288 . -• .

TeBult of the depoeition which thickens the capsule. Fluctuation is th^K
still apparent, although the sac which contains the fluid is thus thick-
ened The effusion gradually disappears until at last, only the thickened
sac remains behind The character of the swelling changes and the
joint dropsy becomes a white swelling with its spindle-shape. It is of
course self-evident that this course of disease may be modified by local
irregularities^ such as the amount of disintegration, cicatrixationi inter-
current suppuration, coincidence of primary osseous foci and the like.

When everything is taken into account, we can understand the
characters of the deviative forms of this affection, and also the points of
similarity between the tuberculous joint and gonorrheal synovitis, which
has a stage in its evolution suggestive of the former malady* We are
also in position to understand why haemarthrosiB is so readily con-
founded with the tuberculous joint that the surgeon is sometimes influ-
enced to the performance of a fatal resection.

Now for bone-tuberculosiB proper I The relation of the diseases
of the bones to those of the joints is simple; they were understood
before we acquired our knowledge of synovial tuberculosis. We know
from y olkmann that tuberculous foci in bone occur in the neighborhood
of the joints. These focal lesions develop essentially in two forms : —

1. A more or less rounded or tubular osseous defect which is filled
with caseating tuberde-granulations, and perhaps with small tubercu-
lous sequestra. Such defects occur throughout the spongy tissue of the
articular ends of the bones. They need not communicate with the
joints, but may become fully encapsulated, and remain thus for years.
As a rule, however, they do communicate with the joints, either by
primary extension or because they have been exposed by the destructLve
action of the synovial tuberculosis. A certain number of these primary
osseous foci rupture externally and set up para-articular abscesses which
may in turn extend into the joints.

2. The tuberculous infarct: The broad side of this lesion ia
tamed toward the cartilaginous surface (in childhood we sometimes
see the base of the wedge turned toward the epiphyseal cartilage).

The joint infarcts chiefly interest us here. They are distinguished
by a triangular form and by a peculiar grayish-white or yellowish qual-
ity of the surface produced by the saw, from which in characteristic
cases small quantities of cheesy pus are evacuated. The osseous infarct,
as a rule, is not softened and hardly altered in its gross outline ; even at
Ae periphery there is hardly any liquefaction and solution. In manj

289

cases it is indeed possible to pry it out wth an eleyator poshed in at its
margin* Otherwise it remains fimii intimately united to the surround-
ing tissues; so far from being a sequestrum of the type found in acute
osteomyelitis, it is united thereto by many osseous trabeculae and blood
vessels. Differing much in edze and shape, it does not lend itself readily
to BSntgen photography, and at most a dark shadow of the periphery
of the infarct is obtainable.

8. To the two preoeeding^^rpcs we may add the infiltrating fornix
in which the morbid process extends into the bony tissues by means of
the Haversian canals. In its most exquisite type it extends from the
diaphyses of the long bones to the einphyses. This type represents a
highly metastatic tuberculous infection, and as distinguished from the
two precediDg may spread without limitation. Many cases of this sort
which attack the vicinity of the articular surfaces remain entirely super-
fidaL The graver type sometimes gives a bad prognosis in cases of
resection.

Generally speaking, the development of tuberculosis in bone is not
necessarily associated with joint-tttberculosis, but is dependent upon the
nutrient vessels. Types 1 and 2 already described may be produced
artificially in ammals by injecting tuberculous material in such manner
that it enters the nutrient vessels of the articular ends of the bones.

My former scholar and assistant, Dr. Miiller of Aachen, has shown
that both these forms may be imitated by injecting tubercle bacilli into
the bone-arteries. In an osseous focus thus produced the localization
determines whether or not the joint is likely to be involved.

I have shown repeatedly that Volkmann's original axiom has been
confirmed. Synovial tuberculosis arises in these cases when the osseous
focus breaks into the joint, distributing thereby caseous masses and
tubercle bacilli.

A few brief general remarks, now remain to be added. I have
found, as already stated, that in 20 per cent, of autopsies the joint-tuber-
culosis was isolated. It may, nevertheless, be objected that in such
cases the coincident foci of disease were overlooked. In any case, sec-
ondary foci must be far more common than primary.

Aside from those forms in which the joint-lesion is an incident in
the evolution of general miliary tuberculosis, primary foci in the lungs
and bronchial glands are usually at fault Other organs are sometimes
fbrst involved, for example in caseous d^eneration of the kidney. In
the latter case the joint-tuberculosis may be multiple, so that clinically
a renal affection is followed by an apparent polyarticular rheumatism.

2»0

Any other gland, and espeeiallj the granular structures of the abdomi*
nal cavity, may occasionally be primary to joint-tubercvloeis.

When the bone is affected primarily, infection must have oocorred
by way of the arteries. I muJBt admit, moreover, that I can conceive of
a primary synovial tuberculosis only as having been derived from the
terminal arteries of bone.

In conclusion, I have given my views of the evolution of the ana-
tomical conditions of joint tuberciulods in a somewhat broad manner in
order that you might not forget what severe and hardly reparable dis-
turbances of the joints are thus caused. Conclusions may readily be
drawn as to the course of these affections if definite conditions are postu-
lated A large infarct is hardly curable, while small lesions may disap-
pear of themselves, heal with scarrinjg or simply remain encapsulated.
For the resulting deformity too much dependence must not be reposed
in orthopedics. It is for the surgeon to decide as to whether bloody or
bloodless methods are indicated in a given case.

391

REVIEW op CURRB^T UTERATUttE.

STATISTICS ON THE SPBEAD OF TUBEROJLOaS.

Gottsl^in (MiinfJi^ M.^. WM^tsmchrift^ Oct. 8^ 1901.) didcus^^ the
truth of Koch's doctrine of the nonidezLtit^ pf humaJiL and bovine tuber-
culpeis from the standpoint of stati$tLCs^ and the compariaon of the
mortality perccintages, of breast-fed ajud bottle-fed children. He admi^
that four spurc^ of error hftvp tp be e?(pluded ij^ making thoae compari-
fiNons.: viz, defective autopsy reports^ defective registration, of caue^p. of
death, latency of tuberculosis, actually contracted, and variability in
resistance to inf pctipn«

Despite these very great hindrances to the application, pf the statis-
tical method to this question, the temptation to test the material of the
city of Berlin — where these sources of error act with miniTyial f prep — ^is
too great to be disregarded. The second source of errpr, which has to,
do with the actual cause of death, is the principle stumbli^-block in the
Berlin material, since numerous deaths sugjgesting a tuberculous origin
are doubtiess due to other causes. Thus one classification of mortality
in nurslings is ^^meningitis,'' presumably, but npt necessarily, tuber*
culouB.

If Koch's doctrine is trap the mortality of breast- and hand-fed
children from tuberculosis should be thp same. The actual number of
deaths of nurslings from tuberculosia during 1803 to 1898 was 4,091,
and of these 444 occurred in breast-fed children, leaving 3,647 deaths
in the bottle-fed. The ratjo tl^en between the two classes is 1,000 to
108, nearly ten times. as. much mprtality occurring in children exposed
to the action of cow's milk.

Gottstein now proceeds tp compare this ratio with that which
accrues id the mortality from noa-tuberculous diseases under the same
circumstances. Thus from acul^e gastric and enteric affections there
were 1,000 deaths, among the bottie-f ed to 43 deaths in breast children.
Such a preponderance of deaths has, a direct dependence upon the.
method of feeding and should clearly be excluded from statistical cal-
culations. Leaving out the deaths from this classification, we find that
the mortality from all other diflC^^^ including tuberculosis, stands at
1,000 deaths in the bpttle-fed to 181 dpaths in breast children. Hence
the expectation of death from tuberculosis in the bottle-fed is not much
over one-half that to be apprehended from mortality in general (6 :10)
if we exclude the gastro-enteric classification.

292

Inddentallj the statistics show that very few deaths oooor
from acute gastro-enteric disease or tabercnlosis in children who are
wet-nursed.

Oottstein admits that the above figures have but a limited value
in themselves, and seeks to give them added weight He cites the dif •
f erences which obtain in the rate of increase during the past two
decades between the nursling mortality and the death rate in the older
periods of life, while the mortality from tuberculosis above the nursling
age has apparently diminished (this reduction being attributed chiefly
to general sanitation), the mortality in the nursling period has been
stated to be on the increase, or in other words, infants are not profiting
by the alleged salutory effects of general hygiene. The allied
increased nursling mortality might, however, it is admitted, be attrib-
uted to improved diagnosiB and better registration.

Gottstein's statistics do not agree with these calculations. From
tables calculated by the author it appears that if we call the total mor-
tality in 28 large cities of Prussia 100 in 1876, the corresponding figure
for 1897 is 66.S, there having been an almost uniform decline of the
death rate during these 22 years. The death rate in nurslings appears
to have increased from 1876 to 1881; after which it, too, has shown a
decline. Thus if we represent the death rate in 1881 by 100, the figure
to represent the mortality of 1897 would be 78.3. The decline is not
so extensive or so uniform as in the higher ages, and compared with
some of the figures before 1881 is no decline at all, but a considerable
increase.

There is, however, a special improvement since 1893, including a
very sudden fall between 1898 and 1894, to be discussed later. But
these calculations are incomplete if we take no account of the mortality
from tuberculosis in special periods of life other than the nursling age ;
and the author succeeds in bringing out the fact that the essential differ-
ences in mortality do not lie between the nursling period on one hand
and all the superior ages on the other, but that the true line of demarca-
tion is between the entire period of childhood and the superior age.
Thus the ratio of diminution in the mortality of the first 15 years of life
is 10 :9 ; while for the second 15 years it is 10 :7.

We should bear in mind the great improvement in the management
of tuberculosis in children during the past two decades; the benefit
here should at least offset that which adults have derived from improved
sanitation.

298

If, now we compare the apparently irrelevant figures and facts
already adduced, we can have no doubt that there is a deep-seated dif-
ference from the etiological standpoint between tuberculosis in the child
and in the adult. The former is open to some source of infection, which
the latter escapes. The best evidence that at least one of these sources
is infected milk is a rapid decline in the nursling mortality of 1894 as
compared with that of 1893. The fonner year was marked by the
introduction of an improved milk supply (with reference to minimiriTig
tuberculous infection); this decline has since persisted. We find no
sudden slump in the adult figures between 1898-1894.

Gottstein's statistics were collected before Eoch promulgated his
doctrine of dualism, and are given simply for what they are worth. In
the ordinary course of events, he would have published them as Vloeu*
mentary evidence of the pemiciousness to nurslings of milk from tuber-
culous cows.

ON THE WARFARE AGAINST TUBEROJLOSIS IN DENMARK

DURING S90S*

Saugman (Tuberctdasisy VoL I, No. 1.) states that the past year
has been of great significance in the crusade against tuberculosis in
Denmark. Public aid was refused in order to' stimulate private
endeavor, with the result that a National League was founded with a
membership of 20,000 patrons.

The Government appointed a commission to support this private
movement, with the President of the National League as its head.

Up to this period there were but two hospitals for tuberculosis in
existence in this country. One, for scrofulous children, at Bef snaes,
dated back for 26 j^ears, while the other, a modem institution for the
care of phthisis was already filled to ovei^owing. This was the Vejle-
f jord Sanatorium, a pay institution of which Dr. Saugman is the head.
The results obtained therein were so encouraging that in November,
1901, a large popular institution was established in the city of Copen-
hagen, the Boserup Sanatorium with 126 beds. The summer of 1902
will witness the establishment of an institution for 70 scrofulous child-
ren at Jutland. Other establishments are planned by the National
League for Silkeborg (110 beds), Hasler (24 beds), and Aalborg (60
beds). Other features in the Danish warfare against tuberculosis
include the well-known Finsen light institute at Copenhagen for the

294

treatment of lupus mlgaris, and Prof eaor Bang's vigorous crusade
against tuberculosis in cattle.

There has been a great increase in the number of publications upon
tuberculosiis, whil^ interesting discussions upon the later subject have
been held in the medical societies. Circulars for popular instruction
are in press and will be distributed to householders.

ON THE WARFARE AGAINST TUBERCULOSIS IN ITALY.

Gatti (Tvbercuhsis, Vol. I, No. 1.) thinks that the results of thia
crusade while not remarkable are at least gratifying. The league orig-
inally organized for this warfare is constantly branching out with sub^
comio&ttees throughout Italy. Pc^ular publications inform the people
as to the necessary prophylactic requirements. At B<Hne an isolation-
hospital Has been planned for the reception of the consumptives who
gravitate naturally to the various city hospitals. A section for phthisi-
cal females is under consideration at Milan. The original summer
resorts for scrofulous children at the seaside are destined to form nuclei
for institutions of wider scope.

In regard to ordinary modem sanatoria for adult consumptives the
Alps are being utilized in as many as four loCialities. City institutions^
however, are not neglected. Milan is to have a sanatorium of 100 beds.
Other cities which will benefit in the same manner are, Turin, Verona,
Reggio, Novari, etc. The original Caisses d^Epargne^ when these
existed, are to be enlarged for the purpose.

Italy, however, is totally deficient in the German idea of insurance
against invalidism in combination, with tuberculosis, but this matter
is being agitated by the author and others.

PROPHYLAXIS OF PULMONARY TUBERCULOSIS*

In the great Handhueh der Prophylaxe, edited by Nobeling and
Jankau, and published at Munich in 1901, the subject of pulmonary
tuberculosis is ably considered by Eosen, of Berlin, who expresses him-
flfelf as follows: — ^He prophylaxis of tuberculosis demands an indi-
vidualized elaboration by reason of the very great prevalence of this
aifection, together with its high mortality. The origin of consumption
by contagion is not yet co];LciBded by all, for some continue to regard this
affection in the light of a dyscrasia. But not only the majority of physi-
cians, but the intuitions of the laity as well, have placed this disease

296

among. the oommunieable rofil^*^'*^- From this point of view the spu-
tum is all important for prophylaxis. No one thinks seriously of the
possibility of contamination from other excreta^ such as urine and
faeces. We must bear in mind that the expectoration of consumptives
is not necessarily virulent, and it is undoubtedly true that the greatcx
amount of this substance, can no longer contaminate. On the other
hand, it is impossible to distinguish off-hand between infectious and
non-virulent sputum, so that we are obliged in every case to disinfect
the latter. The fact that the mortality from phthisis has been reduced
in Germany by one-third since 1889 is attributed chiefly to the efforts
of the profession and public in this direction. Precautions of this sort
are carried out to best advantage in hospitals and sanatoria. In private
life patients shrink from the notoriety which is inseparable from the
parade of a Dettweiler sputum-vessel. It is much to be desired that all
individuals who must spit — ^whether bronchitics, asthmatics or other suf-
ferers from cough with expectoration — should adopt the custom of car-
ing, for the sputum in some rational manner ; for then the consumptive
would be willing to conform to the general usage. The subject of'
'^droplet infection," of the air by coughing, speaking, etc., must also be
borne in mind in this connection and proper precautions taken, although
the demonstration of contamination by this means is not yet forth-
coming.

The entire prophylaxis of the propagation of the disease — ^whether
spread by sputum or spray — could be covered by iaolating all individuals
in the later stages of phthisis. This desideratum will doubtless be
secured in the course of time.

An entirely different aspect of the subject of the prevention of
phthisis is that which relates to the acquisition of scrofula in infancy
and childhood. As this element of tuberculosis appears to be largely
a filth disease, due to infection from dirty floors, sidewalks, etc. ; and
as this inf ecton is rendered possible by abrasions of the skin and similar
lesions, much good may be accomplished by requesting parents, nurses,
etc., to cleanse the faces, hands and nails of their charges at frequent
intervals. The floors should often be mopped and even the playthings
of the children should be disinfected. The contamination in these
cases. may proceed from infected dust which reaches the room and set-
tles ; but it may come even more directly- if some member of the family
is epnsumptive, through the presence of sputum upon the floor.

Care should be taken not to alarm the laity by the exaggeration of
the possibility of infection. We diould teach that* the mere proximity

296

and the breath of a conaumptive are surely not infectious. The sub-
ject of prophylaxis should be reduced as far as possible to terms of ordi-
nary hygiene and cleanliness. One should not drinl after a tubercu-
lous subject of course, but neither should one drink from the same cup
with any individual whatever, without some attempt at self -protection
from possible disease. In apartments inhabited by consumptives, good
ventilation must prevail, and care must be taken to avoid raising a dust
while caring for the rooms, but such precautions simply belong to gen-
eral hygiene and not especially to the prophylaxis of phthisis.

So after the death of a consumptive the walls, floors and f umish*
ings should be carefully deansed, but these precautions are simply a
part of good housekeeping, and are carried out onoe at least a year with-
out special regard to past sickness. Obligatory disinfection by health-
authorities has not yet become a fact after the death or departure of a
consumptive from his abode, although these has been agitation in this
direction.

The possibility of contamination through meat and dairy products
has been fully recognized and acted upon in many countries. The
alleged presence of the tuberde bacillus in butter has recently been
explained upon the score of mistaken identity, so that at present butter
and cheese need not be feared as vehicles of infection. As for milk, it
is well to pasteurize it in all doubtful cases.

Another highly important aspect of the prophylaxis of tubercu-
losis takes cognizance of the possibility that apparently insignificant
glandular swellings which date from childhood may contain caseous
foci and virulent tubercle bacilli which are a menace to the bearer,
threatening him as they do with haematogenous infection of the lungs
in early adult life. If this point of view is correct all such glands must
be removed when accessible to the knife. Prophylaxis of this should
also be made to include strumous bone and joint disease.

Summing up the teachings of recent specialists in various branches,
it appears to be the consensus of belief that all possible "external f 0^*^
of tuberculous disease should be extirpated forthwith, whether such foci
are tonsils, adenoids, diseased petrous bone, enlarged lymph-nodes, etc

There are other cases in which the patient is not menaced by the
possibility of latent scrofulo-tuberculous lesions such as have just been
enumerated, and in which the threat of phthisis comes purely from ana-
tomo-physiological substratum. Such a disposition may be betrayed
by a history of heredity, by the presence of general debility, by the
so-called phthisical habitus (paralytic thorax, long neck, prominent

297

scapulae, etc.). With this group should be associated certain individuals
who have acquired their predisposition to tuberculosis as a sequel to
measles^ whooping cough, diabetes and possibly other affections. These
diseases often appear to render the bearer a good cultur&>medium for
the germs of tubercle, just as does the constitutional peculiarity known
as the phthisical habitus, which has just been enumerated. The dis*
position to the disease which comes from occupations, which necessitate
the inhalation of dust should be added to the preceding.

All individuals thus disposed to tuberculosis — ^whether by latent
tuberculous foci, phthisical habitus, certain diseases or certain occupa-
tions — ^should carry out the same general principles of phrophylaxis.
Exposure, accidents, overwork, painful mental emotions, overindulg-
ence in venery and stimulants should be avoided. In addition to ordi-
nary personal hy^pene, the subject should practice respiratory gymnas-
tics, and should seek to harden himself by cool baths.

When a pallid, emaciated youth or maiden with paralytic thorax,
and other stigmata of potential phthisis appears before the medical
man, nothing is so ill advised as to state, after negative physical exami-
nation, that the patient is free from disease, that the parents should not
worry, etc. All such individuals had best be regarded as acually dis-
eased, and they should be placed at once under a suitable hygienic
regimen. In no class of cases is ordinary hygiene as thoroughly indi-
cated. The public views the matter from this standpoint and is ready
to cooperate.

Naturally if these suspicious individuals present some actual evi-
dence of incipient phthisis the physician's course is a little plainer, for
probability becomes akin to proof. The medical man should therefore
familiarize himself with all the signs of beginning tuberculosis of the
lungs, some one or more of which may decide a doubtful case. The
following are suspicious symptoms : — Loss of appetite, obstinate disturb-
ances of digestion, a feeling of fullness after very limited ingestion of
food, and generally speaking, the picture of nervous dyspepsia ; disturb-
ances of the circulation, such as tachycardia, palpitation, etc., to which
may be added a general indolence and disinclination to exertion.

In all doubtful cases tuberculin should be employed — 1 mg. of the
original preparation. If no reaction appears after 16 hours or there-
abouts, the dose should be increased to 3 mg. and later, if necessary, to
6 mg. Failure of reaction under this dosage should clear the patient
of any suspicion of tuberculosis.

298

Marriage should be absolutely prohibited if one of the bethrothed
has been ill for a long time. In recent instances the question of the
advisability of marriage must be decided after weighing all the f actoia
in the case.

[While we are in sympathy with the author's views as to prophy-
laads in general, we must take exception to the statement that "the entire
prophylaxis of the propagation of the disease could be covered by isolat-
ing all individuals in the latter stages of phthisis.'' This is indeed too
broad an assertion and it must not be forgotten that tubercle bacilli may
be present in the expectoration in the very earliest stages of phthisis,
i. e. just as soon as softening and liquefaction of a caseous focus, of
however small extent, with outward discharge, occurs.

We know that destructive processes of limited extent may be pres-
ent while the patient's general condition is still such that he is quite
able to come and go and to mingle socially with others. The danger
to the community of propagation of the disease must, therefore, be far
greater from such individuals than from those in whom the disease is
so far advanced that their exhaustion and more severe illness would
naturally condition a more restricted environment. In other words,
a wandering source of infection endangers a greater number of persons
than a stationarv one.

Although the removal of scrofulous glands before they become
caseous would, in theory, appear to be an effective prophylactic meas-
ure, experience in practice has shown that it does not suffice to check
the progress of the disease. We know that in tuberculous glandular
affections the glands become involved successively and although "we
may excise those which macroscopically appear diseased, it is well-nigh
impossible to desect out every microscopic focus of infection.

Again all enlarged lymphatic nodes are not tuberculous and in this
connection we must not forget that the cervical lymphatics are liable to
become involved from various infections of the mouth, nose and throat.
To render a surgical method of prevention, thorough, all such glands
would also require removal unless we depend upon tuberculin to deter-
mine whether or not the trouble is of a tuberculous nature.

299

Further, in cervical tuberculouB adenitis at no given time, when
the glands present clinical evidence of disease, can it be known how far
the infection has already been carried along the lymphatic course from
the cervical to the mediastinal glands. Therefore, operative interfer-
ence would often prove too late to prevent secondary involvement of
the lungs even were it possible to completely eradicate every micro-
scopic tubercle from the cervical lymphatic structures. — ^Editor.]

INFANTILE MORTALITY FROM TUBERCULOUS MENINGITIS AND

TABES MESENTERICA.

Armstrong {British Medical Journal, April 26, 1902.) attempted
to verify the statement often f oimd in text-books, that tuberculous men-
ingitis is rare during the first year of life. He consulted the latest
returns of the Begistrar-General and found that in England and Wales
during 1898 and 1899, 13,180 deaths had occurred from this disease in
all periods of life, and that of this number, 3,805 were in the first year
of life. In other words, nearly 30 per ceht. of this disease appears to
occur in the nursling.

During the same two years there were 12,651 deaths in England
and Wales from tabes mesenterica, and of this number no less than
6,473 or above one-half occurred during the first year of life.

The author then investigated the post-mortem records of the liver-
pool Infirmary for children which extend over 17 years. About 1,000
children monthly is the attendance at this institution. Records were
found of autopsies upon 70 infants in the first year of life, but of this
number not a single individual had died of tuberculous ^meningitis. Of
85 cases in which the latter condition was found at death, there was not
a single case in the first year of life and but 10 in the second. In Guy's
Hospital the records of 40 years show but three cases of tuberculous
meningitis in the first year of life.

In the Liverpool Infirmary but a single case of tabes mesenterica
in the first year was found in the autopsy records.

The upshot of the author's experience is that there is some fallacy
concerning the alleged enormous death rate from these affections as
found in the Registrar-Generars Reports. This is probably as fol-
lows: — ^The meningitis from which these babies undoubtedly die in
large numbers is not tuberculous. Of the 70 autopsies on nurslings
already mentioned, a number revealed non-tuberculous meningitis which

800

may be cerebro-spinal, purulent^ syphilitic, basilar form of Barlow, etc
or some of these cases set down as examples of tuberculous meningitis*
may not have been meningitis at alL

In tabes mesenteries the conditions are still more vague. Natur-
ally many cases of death by wasting are erroneusly set down as due to
mesenteric tuberculosis.

The prime object of the author's study is probably to show that the
figures of the Kegistrar-General are not available for proving that cow's
milk causes a heavy mortality from tuberculosis among nurslings.

PULMONARY PHTHISIS IN NURSLING&

Qurin {Munch. Med. Wochenseh.j Feb. 11, 1902.) states that there
is a sort of age limit in childhood in respect to the evidences of phthisis.
After the age of 5 or 6, the latter disease begins to take on character
istics like those of adult life. Before that period, however, the symp-
tomatology is more or less equivocal. If pulmonary lesions occur
during these earlier years, they are usually secondary to tuberculosis of
the bronchial lymph-nodes. ' The resulting lung disease seldom affects
the apex, which is remote from the affected glands. Any portion of the
lung may be affected which is in relation with the latter, the hilum
being the usual locality to suffer. Implication of the lung occurs in
these cases from rupture of the suppurating nodes.

But this is not the sole method by which the lungs of the infant
may be attacked. The broncho-pneumonias which complicate measles
and whooping cough may pave the way for tuberculosis. Naturally
the apex is spared in this type of infection. A radical distinction then,
between infantile and post-infantile phthisis is the different role of the
pulmonary apex.

We know less about tubercle in yearlings than in any other age.
A study of the disease in the early months reveals some surprises. In
spite of the sweeping generalizations that the apex is not involved in the
infant, exceptions must now and then occur. The author relates the
history of a baby 5 months old which presented a great cavity in its
right apex. Such cases are excessively rare ; a parallel instance is cited
from literature, in a child only 12 days old (Demme). No other cases
are mentioned.

In regard to the diagnosis of these infantile cases, there is little
upon which to place dependence. The existence of a cachexia is evi-
dent ; cough may be absent ; rales are present, but without evidence of

301

oonsoUdation ; febrile movement may fail entirely. This is the clinical
picture than which nothing could be more vague. Personal history
can cut little figure in such young children. Unless the bacillus can be
found no diagnosis can be made, only a presumption. But these
infants cannot expectorate, hence the sputum must be obtained arti-*
Scially. Epstein aspirates- the pharynx with a catheter. The author
prefers a swab applied to the base of the tongue directly after the act
of coughing and before the sputum can be swallowed. He sometimes
uses for this purpose his foreiinger enveloped in linen.

IS THE SLIGHT RISE OF TEMPERATURE EXPERIENCED BY CONSUMP-
TIVES AFTER SLIGHT BODILY EXERTION A TRUE FEVER?

Ott (Berl Klin. Wochenschr.y Feb. 10, 1902.) refers to Penzoldt's
original announcement that the temperature of afebrile tuberculous
subjects could be seen to rise after moderate exertion, such as an hour's
walk. The rise in such cases amounted to 38° C. and upwards. This
declaration of Penzoldt was readily corroborated and Ott obtained pos-
itive results in nearly all of a series of 100 cases.

Recently Schneider, a pupil of Weicker, has called the truth of
this law into question. In patients really afebrile he found no rise of
temperature after exertion. On the contrary he sometimes found a
fall under these circumstances.

Schneider's work, however, has proven nothing. He took his tem-
peratures in the mouth instead of the rectum as was Penzoldt's method.
This, with the report of falling temperature in certain cases, (some-
thing contrary to physiological principles) would appear to invalidate
his method entirely. Besides, Bluhm has sho^vn that the mouth tem-
perature depends upon that of the surrounding media, so that it is inap-
plicable for use out of doors.

Ott has recently tested this point by taking both mouth and rectal
temperatures in the same subject both before and after a walk. Before
the exercise the two thermometers differed by but one or two-tenths of
a degree. After the exertion, Penzoldt's law was almost unanimously
confirmed by the rectal thermometer, while the other instrument
showed but a very slight rise and, as Schneider found, a fall in some
cases. Penzoldt's discovery may thus be regarded as settled beyond
doubt. Kext arises the question of its rationale.

We cannot prove that the rise of temperature is a bona fide fever.
We know that a warm bath— especially a vapor bath— will produce an
analogous result.

302

Bodily exercise produces the same kind of ''heat stagnation" as
does the direct application of heat. We know further that the heat
regulating centre acts in the tuberculous in a defective manner. Pen-
£oldt found the phenomenon also present in the corpulent and anaemic
The usual rationale of the rise in the phthisical is concerned with the
increased absorption of the toxins of the disease from infected f oci, as
a result of exercise.

We know from the researches of various observers that the injec-
tion of albumoees produces fever; and vice versa, 90 per cent, of all
febrile cases have albumose in the urine. On the other hand after sim-
ple elevation of temperature following a warm bath, albumosuria never
occurs; so that if the urine of the experiment-subject, containing no
albumose before the walk, continues free from this substance after the
physical exertion, we are justified in stating that the rise of tempera-
ture is not febrile in character.

Ott therefore tested a series of these cases for albumosuria *after
the usual walk. In about 36 per cent, he did find albumose in the
urine; and in about the same nimiber the test gave a doubtful result.
Conceding them to be positive, the conclusion is that in a considerable
majority of cases, the temperature rise was febrile in character.

We therefore learn the danger of exercise in these patients, and
the importance of the rest cure. Not that the patient must remain in
bed all day, for he must have a little exercise. He must avoid an excess
which for him means enough to produce the febrile reaction.

ON A PECULIAR ODOR OF THE EXPIRED AIR AT THE BEGINNING

.OF PHTHISIS.

Roseribach refers (Munch. Med. Wochen., 1902, No. 4.) to an
earlier paper on this subject, in which he described a peculiar odor con-
sidered by hiTn as an evidence of the disposition to consumption. Look-
ing back, he can see that this peculiar breath must have a bad prognos-
tic significance, for the possessors of it succumbed to the disease in a
strikingly unfavorable form.

It is singular that the specific odor which accompanies these cases
has no connection with the presence of pronounced destructive changes
in the lungs. It was not present in the case of cavities, or of very
extensive areas of infiltration. Even when the sputum was very abund-
ant this smell was hardly ever in evidence. All the usual causes of bad
breath were excluded in these individuals, so that the odor must have

808

originated at least as low as the bronchi. Its presence can be accounted
for only on the supposition that some decomposition takes place which
bears a relationship with the predisposition to the disease.

In a series of cases this breath first awakened in the author a sus*
picion of incipient tuberculosis and led him to investigate the lungs with
great care^ with the result that the presence of the disease was detected.

In any case of fetor ex ore in which no apparent cause is present,
such as carious teeth, the possibility of incipient tuberculosis should be
thought of. If bad teeth, ozaena, and the like are present, the author
suggests that the upper passages be treated with some deodorizer. If
after such treatment the odor persists it doubtless must come from the
lower passages. Very many of the author's cases had poor teeth. The
odor which they emitted was in any case somewhat different from the
other smell, so that during expiration the latter could always be made
out.

Poor teeth are very common in consumptives and are perhaps a
part of the condition wUch invites tiie disease.

In this connection it should be emphasized that the hygiene of the
mouth should play a great part in the prophylaxis of phthisis, for most
of the destructive changes of that disease come from the ordinary
pyogenic bacteria, which may flourish in neglected mouths.

[In regard to Rosenbach's recognition of a peculiar odor of the
breath which appeak to him not only as an evidence of a disposition to
consumption but also as of unfavorable prognostic import, it would seem
to us that the author must be endowed with an olfactory apparatus of
such a highly educated and sensitive nature as his professional contem-
poraries are so unfortunate as not to possess. — ^Editor.]

REST AND MOTION IN PHTHISIO-THERAPY.

Naegelsbach {Berl. Klin. Wochenschrifty Feb. 24, 1902.) recalls
the practice of Brehmer of ordering all patients who were not bedridden
to indulge systematically in walking. He no longer esteemed the
reclining chair, and simply strove to guard his cases from tiring them-
selves out. Dettweiler originated the rest cure in the open air, and at
first, as he admitted, may have been over-enthusiastic as to its virtues.
Others have carried the rest cure to extremes, even keeping their cases
recumbent for months. Bemheim states that it ''economizes expenses
and augments receipts ;" and that ordinary overwork is nothing but an

304

autchintoxicatio% the sjBtem being clogged with waste producta. Nau-
maniiy on the contrary, calls attention to the fact that people who aban-
don %Higorou8 life often fall a prey to the disease by reason of their
diminished activities. ^'If rest in the open air cures consiunptiony it
is the air and not the rest which is efficacious." Weber states that
patients who have considerable temperature at night may still benefit
by short walks in the morning when they are apyretic. Freudenthal
would substitute an exercise cure for a rest cure.

Much may be said about the relative indications for sleep and rest
in so mighty and proteus-likc a disease as phthisis. Three separate
elements must determine which is the more rational in a given case, viz.
the patient's temperature, his type of disease, and his constitntion.

If the temperature begins to rise, and especially if it is a high tem-
perature, rest is undoubtedly indicated. The custom of placing an
individual with very slightly elevated temperature in bed is not sanc-
tioned by the author, who would have such a patient simply lie down in
the open air. Individuals without any fever may exhibit subnormal
temperature in the morning and must not be regarded as eligible for
exercise as they undoubtedly belong in bed.

A patient who has been in bed for fever may be transferred to a
couch on a balcony, and if his temperature does not go up, he may be
allowed to remain there.

Schroder states that if a patient simply has fever and nothing else
— ^no chills, sweats, prostration, increase of cough, etc., he may remain
recumbent in the air.

Other conditions which allow him the same privilege are absence of
recent inflammatory alterations in the lungs, and maintenance of his
weight. The act of rising should not send up hJs temperature.

The author cannot follow Weber in allowing patients with fever
of intermittent type to exercise during the afebrile period.

Some transitory fever in chronic phthisis is insignificant of any
new mischief and is probably nothing more than a mild resorption fever
connected with some obsolescent lesion.

The possibility of hemoptysis necessarily comes into play in connec-
tion with the alternative of rest and exercise. For persistent bleeding,
the patient must keep strictly in bed.

Driver, hpwever, distinguishes between active and passive haem-
orrhage and claims that exercise is beneficial in the latter form, and the
author agrees that he has seen the haemorrhage cease in these erases
after the patients rose and moved about. The diagnosis between active

806

and paesive haemorrhage can be made by experts only. Hemoptysis
often follows exercise ; the possibility of the existence of a latent pleur-
isy must also be borne in mind in choosing between exercise and rest.

Aside from the conditions already enumerated certain individuals
^wiU benefit by recumbency in the open air, to-wit, all who are anaeiiuc,
-chlorotic and neurasthenia

That this mode of dealing with patients is able to slow and
strengthen the activity of the heart is a well attested fact.

In walking, the patient must always rest before he is fatigued ; and
if he perspires very readily must beware of chills. If the ground 16
uneven he must go up hill when fresh that he may return down hilL
A walk about 8 :30 a. m., after breakfast, will stimulate the circulation
-of the anaemic consumptive ; a second at 1 or 1 :80 p. m., before dinner,
will rouse the appetite. A third may be taken at about the hour when
the digestion of the dinner is finished. The length or duration of the
walks varies greatly. For a patient who has just thrown off his fever it
should not exceed 15 minutes. Those who have become strong may
walk three hours daily. We have patients who walk in the roads all dax*
taking a luncheon with them, and who return at 11 p. m. to resume
their rest cure. Individuals who are thin and unable to put on flesh
walk but little. A rule of the author^s sanatorium is that all patients
should rest at least 20 or 30 minutes before the hearty meals. Immed-
iately after the exercise the appetite does not assert itself.

Hill climbing will enable patients with bronchiectasis to expector-
ate more freely. In these cases we actually see fever disappear under
exercise, evidently because the cavities have been emptied of secretions
which had been responsible for resorption-fever. In old phthisical
teases, when contraindications are absent, exercise will improve the
weak and irregular heart action and improve the bronchitis.

FORCED FEEDING IN CONSUMPTIVES AND IN NORMAL INDIVIDUALS.

Bardswell, Ooodbody and Chapman deal with this subject in one
•of the reports of the Scientific Grants Committee of the British Medi-
•eal Association (British Medical Journal^ February 22, 1902). The
researches were made in part in the Brompton Hospital.

In case 1, which may serve as an example, the appetite and diges-
tion were good and there was only a degree or so of fever, although both
lungs were implicated and one contained a cavity. The patient weighed

306

120 ; previous maximum weight, 142. His intitial ration was milk, B
pt. ; bacon loz. ; butter 1 oz.; bread 8 oz. ; sugar 1 oz. ; vegetables 4 oz. ;
milk-pudding 5 oz. — equivilant to 120 g^ proteid, 120 g. fat and 300 g.
carbohydrate. Upon this diet there was practically nitrogenous equi-
librium, as but 0.32 g. nitrogen was retained. The absorption of nitro-
gen was 91 per cent, and of fat 94 1-2 per q^nt. The original ration
was gradually increased imtil it was about double in proteid and fat and
one-fourth more in carbohydrates. Under this increase a large amount
of nitrogen was retained, while absorption of nitrogen rose to 97 per
cent. In the last week (the experiment lasted a month) retention and
absorption fell off, and anorexia and dyspepsia appeared. The diet of
the second week gave the most satisfactory results, and the progressive
increase of the ration was followed by deranged metabolism and irrita-
tion of the alimentary canal.

The general conclusion drawn from all the experiments is that
indiscriminate stuffing of the tuberculous must give way to systematic
diet based upon activity and extent of disease, amount below normal
weight, digestive capacity and preference of patient.

The onset of dyspepsia nearly always coincides with commencing
derangement of metabolism. Despite the unfavorable symptoms pro-
duced, forced feeding certainly continues to augment the weight ; there
is no doubt that a certain amount of increase in the ordinary ration is
well tolerated.

The effects of forced feeding upon the normal individual comprise
increase in the amount of nitrogen excreted, no reduction in nitrogen
absorption, diminished absorption of fat, and a rapid and large gain in
weight, associated, however, with impairment of the general health, the
symptoms including anorexia, nausea, dyspepsia, drowiness, abdominal
discomfort and diarrhoea. These results differ from those obtained m
the earlier weeks of forced feeding in consumptives, but agree closely
with the conditions observed when the latter have regained much of
their lost weight.

TREATMENT OF HEMOPTYSIS AT BREHMER'S SANITARIUM
WITH THE SUBCUTANEOUS INJECTION OF GELATINE.

Thieme (Miinch. Med. Wochenschrifty 1902, No. 5.) having seen
the reports of other phthisiologists on this comparatively new resource,
publishes in the present paper a very brief history of twelve cases. He
made the injections exclusively in the thigh. The great pain men*
tioned in some reports was not noted, and the author thinks it due to

807

some way of preparing or using the solution. He himself used 2 per
cent, gelatine to which soda was added. The swelling beneath the skin
was strongly compressed with the thumb and the surface of injection
dressed with iodoform gauze which had been saturated with acetate of
aluminum.

In two cases in which the injection contained no soda and the man-
ipulation of the swelling was omitted extensive gangrene of the skin
developed. Tetanus^ which has followed the injection of gelatine^
caused no trouble in the author's series. Fever was present in nearly
every case, as in the experience of other reporters. Several of the
patients had very high temperatures, while the duration of the pyrexia
was one or two weeks. The amount of fluid injected was 100 c. c.

In regard to the results obtained they were decidedly good. In a
number of cases the hemoptysis appears to have been arrested promptly.
Only one absolute failure is noted. Occasionally the sputum remained
slightly bloody, or a recurrence of hemoptysis was noted after some
days.

Thieme concludes that despite the drawbacks of the remedy its use
is indicated in desperate cases where all other measures have been
exhausted. He proposes to use it in all such cases and publish his
results in due time.

ON THE GENESIS OF VAGINAL TUBERCULOSIS.

Springer (Zeitschrift f, HeiUeundej 1902, No. 1.) has investigated
this subject in the Institute of Pathological Anatomy at Prague. Dur-
ing the period 1S87-1S09 some 12 cases of this localization of tubercu-
losis had come under observation.

Theoretically vaginal infection may occur in the following ways : —
From some other portion of the genital tract (uterus, tubes) ; from the
urinary system through contamination with urine (by the urethra or
a vesico-vaginal fistula); from the intestine (through the anus or a
faecal fistula) ; from the peritoneum of Douglas' pouch in tuberculous
peritonitis; from lupus of the vulvo-vaginal region. In addition we
have infection by the blood-route and primary tuberculosis of the
vagina from direct implantation of the germs from the outer world.

These two last named varieties might well be confounded ; for in
a case of supposed primary infection of the vagina it is impossible to
prove that some small obsolescent focus in the lung may not have ante*
dated the genital lesion.

808

The only case in literature known to the author as an indubitable
example of primary tuberculosis of the vagina was reported by Fried*
lander. It occurred in a woman of 30 who had died of cerebral apo-
plexy. She presented a tuberculous ulcer about the external os and no
other ascertainable focus of the disease.

The 12 cases of the author represent very few types of infection.
'Nine of them were examples of secondary infection from the uterus or
tubes. Two others were cases of general miliary tuberculosis with
incidental deposition of a few tubercles in the vagina. The remaining
caae was simply a recto-vaginal tuberculous fistula.

TUBERCULOSIS OF THE THORAQC WALLS AND DIAPHRAGM.

In one of his Lumleian Lectures upon thoracic phthisis {Lancet^
April 5, 1902), Professor F. T. Eoberts speaks of the infrequency with
which mention is made of tuberculous lesions of the thoracic parietes.
Nevertheless, they are of great clinical importance. Beginning with the
extreme superficies, no value is to be attached to chloasma tubescentium
or myoidema as specific evidence of phthisis. The alleged hypertro-
phy of the breasts as described in some quarters has never been seen
by the author. It is said to be due to a low form of chronic mammitis.
The phenomena recogni2ed by the author are grouped as follows :

1. Wasting of the superficial tissues and muscles — ^including the
intercostals — is of course self -evidently present.

2. Abnormal rigidity of the bony and cartilaginous walls may
reach such a high degree that they become practically immovable.
When occurring in an elderly person this condition is physiological and
does not possess much significance ; but it is otherwise with the young,
and the author appears to believe in a definite relationship between this
condition and chronic phthisis.

3. The shape of the chest — soKxalled "phthinoid" or alar forma-
tion — ^with resulting change of capacity is evidence of intrathoracic
trouble, and the various lesions of the disease may produce a high degree
of outward deformity. This tj^ of change is most conmionly seen in
young and delicate subjects, but no one who contracts phthisis is exempt.

4. Phthisis sometimes develops in a chest previously deformed
and especially in connection with Pott's disease.

6. The chest walls may be actually involved in the tuberculous
process itself, which may affect the bones, cartilages, lymphnodes of the
thoracic region, etc. Finally in very florid acute phthisis the disease

300

may actually extend from the lungs through the wall of the thorax, as
has been recently seen by the author himself.

6. Subcutaneous emphysema may occur as an extension of medi-
astinal emphysema, itself due to rupture of a cavity into the cellular
tissues.

7. Finally the diaphragm may be affected as a result of intra-
thoracic phthisis.

BOOK REVIEWS.

Hbmmbtbr. Diseases of the Intestines. Their Special Pathology, Diag-
nosis, and Treatment. With Sections on Anatomy and Physiology, Microscopic
and Chemic Examination of the Intestinal Contents, Secretion, Feces, and Urine;
Intestinal Bacteria and Parasites; Surgery of the Intestines; Dietetics; Diseases of
the Rectum, etc. By John C. Hemmeter, M. D., Philos. D., Professor in the
Medical Department of the University of Maryland; Consultant to the University
Hospital and Director of the Clinical Laboratory; Author of a treatise on ** Dis-
eases of the Stomach," etc. In Two Volumes. Volume II — Appendicitis,
Tuberculosis, Syphilis, Actinomycosis of Intestine, the Occlusions, Contusions^
Rupture, Enterorrhagia, Intestinal Surgery, Atrophy, Abnormalities of Form and
Position, Thrombosis, Embolism, Amloidosis, Neuroses of the Intestines, Intesti-
nal Parasites, Diseases of Rectum. With plates and many other illustrations.
OcUvo, 675 pages. Published by P. Blakiston's Son & Co., Philadelphia, 1902.
Price, Volume II, net $5. Set complete, $10.

This, the second volume, completes the author's treatise on diseases of the
intestines. We reviewed Volume I., in the January number of the Journal and
our gratification with the manner in which Dr. Hemmeter has treated his subject
in Volume I. becomes more complete after a careful examination of Volume II.

No further comment is needed in order to interest those who have secured the
first part of this important work, but we cannot but call attention to several sec-
tions in the volume now before us which evidence the careful clinical as well as
the scientific observations and the logical conclusions of the author. One of these
is the article on appendicitis, which cannot fail to be of the greatest interest both
to the physician and to the surgeon and which may be accepted as a ^fe guide at
all times and in all questions pertaining to the treatment of this affection. This
excellent feature together with the full consideration given to the etiology,
pathology and differential diagnosis of the disease render this chapter a complete
monograph upon a subject which has attracted the best medical and surgical talent
of the world.

Chapter III on intestinal occlusion. Chapter IV on contusions, rupture and
perforation, and Chapter XII on diseases of the rectum, which deal with affections
which, like appendicitis, present both a medical and a surgical aspect, not only
S^ve evidence of the closest study, but of a comparatively large personal, practical
experience as well.

The peculiarly gratifying feature of Hemmeter's work is that he possesses the
all important faculty of presenting his subject in an exceedingly clear and compre-
hensible manner to the reader, and that in all questions, particularly in diagnosis
and treatment, he never leaves anything open to doubt, but describes methods of

810

procedure with a clearness of detail which renders the work of especial value to the
general practitioner.

In Chapter II tuberculosis of the intestine is fully considered, while naturally the
question of bovine tuberculosis in its relation to the disease in the human subject
receives adequate attention.

The author rightly offers two important objections to the conclusion that,
because primary intestinal tuberculosis is comparatively rare as exhibited post-
mortem, it follows that food products from tuberculous animals are seldom respon-
sible for infection. These objections are as follows: —

I. *' In the first place, it has been known that the bacillus of human tubercu-
losis may pass the structures of the intestinal wall (mucosa, submucosa, muscu*
laris) without leaving any trace of its existence there. After such passage without
altering the intestinal tissue, it has been known to produce tuberculosis of the
mesenteric, omental and peritoneal lymphatic structures."

II. "The positive exclusion of primary intestinal tuberculosis is a work
of enormous technical difficulty, because it necessitates not only the macro-
scopic, but even the microscopic examination of the entire digestive tract from
mouth to anus (26 to 30 feet), with its extensive mesentery, omentum, and perito-
neum, and all its Jymphatic tructures."

Hemmeter further states that the stomach and intestine give evidence of a
miraculous immunity to tuberculous infection which he ascribes to the activity of
digestive ferments, to peristalsis and also to some as yet obscure natural provisions
for their disinfection. In this connection we would remark that the nasal, oral and
bronchial mucous membranes, and in fact, all mucous membranes show this re-
sistance, and that the usual absence of ulceration in the larger bronchi of patients
who die of phthisis and who for months have discharged tuberculous sputum which
must have passed over these mucous surfaces, seems even more striking. It would
appear to us that the resistance of the mucosa of the gastro-intestinal tract to
tuberculous infiltration and ulceration, differs not materially from that of other
mucous membranes unless, perhaps, from that of certain parts of the larynx in
which the conditions are extremely favorable for lodgement and retention of
infectious matetial.

In the treatment of tuberculous conditions of the bowels, creosote has not been
found useful by the author, although one would expect that it would be in the in-
testine that large doses of creosote would produce their best effects. The writer has
also found creosote to be without influence, not only in intestinal, but in other local
tuberculous ulcerations, as well, and in several instances of cutaneous tuberculosis
where constant local applications were combined with internal administration of
the remedy, creosote was unable to hinder the disease from spreading, and pro-
duced not the slightest curative effect.

On the other hand the author, while he offers nothing with a view of cure, has
nevertheless been able to witness the cicatrization of a tuberculous ulcer of the
rectum under the use of tuberculin, and says that he has no doubt that a number
of cases have been cured by this substance, to which the writer could easily add a
score from his own records. Curiously enough, however, Hemmeter is unwilling
to recommend the systematic employment of tuberculin, because as he says, the
remedy has not yet been satisfactorily tested, and also because the intestinal lesion
is generally secondary and the localizations in other organs also demand attention.

811

We fail to appreciate the author's logic in this instance and can conceive of no
better demonstration of the value of tuberculin than the actual healing of a tuber-
culous ulcer under the observer's eye, while numerous others have reported like
results as following its use in visible tuberculous affections. As to the objection
that the disease in the intestine or rectum is, as a rule, not primary and that
concomitant tuberculous lesions also require attention, we would suggest that, in-
asmuch as we know of no other remedy which is able to cause cicatrization of
tuberculous lesions, it might not be so bad an idea to employ it for the primary
and associated tuberculous processes as well.

We know of no better guide than this work, together with the one on Diseases
of the Stomach, for the prevention and treatment of gastro-intestinal affections,
(which are of such frequent occurrence as more or less familiar complications in the
course of phthisis) . The work is replete with practical information in regard to
dietetics which cannot fail to prove of great value in phthisio-therapy in which the
issue so often largely depends upon the nutrition of the patient.

Thb Intbrnational Mbdical Annual. A Year Book of Treatment and
Practitioner's Index. Twentieth Year, 1902. New York, E. B. Treat & Co. $3.00.

In the introductory pages, Dr. William Murrell, of London, with reference to
the open air treatment of phthisis, says that there are indications that it has seen
its best days, inasmuch as it is bidding fair to come under the baneful influence
of routine. In its connection with sanitaria and the short course of treatment
usually afforded, he sees no chance for lasting results, but in proportion to the
exaggerated hope of the patient, only bitter disappointment in the end.

Dr. H. P. Loomis, who has contributed the article on phthisis, takes a hope-
ful view in regard to the advance in methods of prophylaxis and thinks that the
outlook has never been better than at the present time. In diagnosis he again
recognizes the value of the tuberculin test, reproduces the interesting table of
Anders of Philadelphia, which shows an aggregate of 1460 applications of the test
with 71.89 per cent, of positive results in cases suspected to be tuberculous, to
which in our opinion the test is to be restricted, there being nq possible advantage
in applying it when the clinical diagnosis can be made by the usual methods.

Under treatment, Harper's work in the use of urea is prominently mentioned.
The latter's experiments in the laboratory of adding urea to the culture fluid, and
which Harper reports in the same communication to the Lancet, have not received
any comment. Harper says:— " In the laboratory I have tried twice to get the
tubercle bacilli to grow in freshly prepared meat broth, adding urea from 1 to
.001 per cent., at the same time inoculating a tube without urea as a control. In
the control-tubes bacilli grew all right in the incubator; those with the urea added
failed." During the past year the writer took occasion to investigate these claims
and found that while an inhibitive influence could be obtained, it required .5 per
cent., or 1 part in 200, of urea to entirely prevent the growth of the culture. While
individual cultures of the germ may vary in virulence, our results would indicate
that there is nothing characteristic in this inhibitory action of urea upon cultures
of the tubercle bacillus ; for various other salts in smaller amount are capable of
exerting a like influence, and that these have no claim in the therapeutics of phthisis,
is acknowledged. Clinically the preparation proved entirely negative in our hands.

In regard to the open air treatment, Loomis rightly attributes the improvement
observed to its stimulating effect upon nutrition and thinks that the cases reported
by Millet of Brockton, Mass., would seem to indicate that the limit had been

312

reached in this direction. Millet reported '*that in all iiire cases resnlts appear Uy
have lieen marvelous. The temperature fell to normal, the cougfh disappeared,
respiration was improved, and at>ove all, a rapid and considerable increase of
weight ensued," and all from subjecting the patients to a fortnight's eKposare..
We also believe that the limit has been reached and that the results were marve-
lous, but that the latter were rather due to a most remarkable limit of fortunate^
coincidence than to the therapeutic effect of such exposure.

A rather favorable report on formic aldehyde in phthisis is contribnfeed by
D. T. Choury Muthu who summarizes the effects of the inhalation of the remedy
as follows: —

1. It soothes the laryngeal and bronchial mucous membranes.

2. The expectoration becomes less tenacious and in time diminishes in
quantity.

3. It lessens the fever.

4. The tubercle bacilli diminish in number, and in some cases enthrely dissp*
pear.

We have not been so fortunate in our application of the remedy; on the con-
trary we found that when inhaled in sensible quantities, even as little as yi per
cent, it caused much irritation and as a result increased the cough and fever, while
in still smaller quantities its effects appeared indifferent. Inasmuch as tubercle
bacilli which appear in the expectoration are derived from disintegrating caseous,
tissue, their increase or decrease in numbers or entire disappearance must stand
in relation to its liquefaction and outward discharge. If, therefore, from the inhal-
ation of formic aldehyde the bacilli diminished in number or disappeared, we can
at best credit it with the power only of preventing liquifaction of caseous material
in open cavities or of caseous ulcerations, and not at all on that account with any
actual influence in the way of checking the progress of the disease itself.

An interesting report of high frequency currents is from the pen of Chrisholm
Williams. Most remarkable results are claimed from their application.

Kelynack contributes a very satisfactory article on haematology. Boardman
Reed reviews the literature of dyspepsia and functional stomach disorders.

Altogether this volume gives the reader everything of importance as regards-
progress in any department of the medical sciences, and the publishers have bean
peculiarly fortunate in securing a staff of editors and collaborators, the individual
members of which are so eminently qualified, each for the discussion of his paxtic*
ular subject.

313

EDITORIAL

THE OPEN AIR TREATMENT OF CONSUMPTIVES.

Not only, as Dr. William Murrell, of London, has expressed the
<ipinion in regard to the open air treatment of consumptives, is this
method "bidding fair to come under the baneful influence of routine,"
l»ut there is a growing tendency to the adoption of measures in its appli-
cation which are so extreme that they can not be too heartily con-
demned. "There is a mean in all things," but unfortunately some of
the exponents of open air treatment seem still totally oblivious of the
truth of this maxim. Patients who have active symptoms are being
placed in open tents and especially constructed three-walled buildings
(buildings with one side left open) and exposed to all conditions of
weather in a way which is quite unnecessary and often harmful.

It is not our purpose to oppose out-of-door life in the treatment of
phthisis. Much good is to be accomplished by the intelligent applica-
tion of this method in properly selected cases, and the benefits of pure
air and sunlight are self-evident. But in order to obtain pure air and
sunlight it is not essential to resort to extreme measures. Pure air and
cold air are not necessarily synonymous and, as every one knows, an
abundant supply of pure air can be obtained in a properly ventilated,
comfortably heated sleeping room. Besides, when patients are exposed
to extremes of cold weather they must be kept warm artificially and this
amounts to the same thing as the maintainance of a comfortable tem-
peralure in the sleeping apartment, except that in the first instance
hardship and discomfort are added.

While in certain dry, salubrious climates, there is no objection to
keeping patients out of doors at night, the proposition becomes a very
different one in a rigorous winter climate. If we picture to ourselves
a patient with active symptoms, high fever, night-sweats, etc., in an
open tent, awaking in the midst of a cold winter night with, perhaps,
the snow sifting in upon and about his bed and with his nightrclothing
damp or wet with perspiration, and if we consider that this patient is
Bubjected to the choice either of lying in his damp garments or of incur-
ring the exposure attendant upon rising to change them, his escape

814

from the occurrence of complications in the way of severe colds, bron-
chitis, or pneumonic inflammation about caseous or necrotic fr«ci, would
seem to be a matter of providential dispensation, rather than an evi-
dence of good management.

It has been said that patients out of doors run a considerably lower
temperature than when in doors, but presumably these obHervatious
relate to mouth temperatures. Inasmuch as the temperature of the
mouth, or of the axilla, is influenced by that of the surrounding med-
ium, the amelioration of fever, under such circumstances, is rather
apparent than real. With even a normal or subnormal oral tempera-
ture that of the rectum will often be found three or four degrees higher
in such patients.

Those who are making a fad of open air treatment and are resort-
ing to extremes in its employment argue that exposure hardens the
patient. This is not to be denied providing that the latter does not suc-
cumb to the hardening process. Surely such methods are not suitable
in active Ftages of the disease. If they can have any value whatever,
it can only be in the nature of prophylaxis in cases in whicli thu trouble
is latent or arrested. Even then the hardening process should not con-
sist ill 1 lethods in which the patient can not or will not persist after his
discharge from treatment. People have for countless generations dwelt
in houses and the social conditions of a modern civilization indicate that
they will continue to do so. They will not live in tents in all sorts of
climates and although the individual may have successfully been hard-
ened by extreme exposures, a return to usual environments and mode of
life will prove such means to have been worse than useless and of no
avail as a protection in later years.

MISSISSIPPI VALLEY MEDICAL ASSOCIATION.

The chairman of the Committee of Arrangements for the Twenty-
Eighth Annual Meeting of the Mississippi Valley Medical Association,
Dr. A. H. Cordier, has announced the dates of the next meeting in Kan-
sas City, Mo., as October 15, 16, 17, 1902.

The president. Dr. S. P. Collings, of Hot Springs, Ark., has
announced the orators for the meeting, Dr. C. B. Parker, of Cleveland,

815

O., to deliver the address in Surgery and Dr. Hugh T. Patrick, of Chi-
cago, the address in Medicine, selections which will meet with the
approval of every physician in the Mississippi Valley.

A cordial invitation is extended every physician in the United
States but especially of the Valley to attend this meeting and take part
in its proceedings. Titles of papers should be sent the secretary, Dr.
Henry Enoe Tuley, 111 W. Kentucky St., Louisville, Ky., at as early
a date as possible to obtain a favorable place on the program.

THE ALABAMA, GEORGIA AND TENNESSEE TRI^STATE MEDICAL

SOOETY.

The fourteenth annual meeting of the Tri-State Medical Society of
Alabama, Georgia, and Tennessee will be held in Birmingham, Ala.,
Tuesday, Wednesday and Thursday, October 8, 9, and 10, 1902. The
indications point to a program of unusual interest.

316 .

SUPPtElENT TO m JOURNAL OF TUBERCULOSIS.

In this part the whole subject of Pulmonary Tuberculosis will be covered
by a continued series of articles written by Dr. Karl von Ruck to appear in the
following order :

Article I. — ^The Cause of Tuberculosis, and The Conditions Which Pre-
dispose to its Acquirement. Article II. — The Prevention of Tuberculosis.
Article III. — ^Thr Pathology and Symtomatology of Pulmonary Tuberculosis.
Article IV. — The Diagnosis of Pulmonary Tuberculosis. Article V. — The
Prognosis of Pulmonary Tuberculosis. — Article VI. — ^The Treatment of Tuber-
culosis, Dietetic, Hygienic and Symtomatic. Article VII. — The Climatic
Treatment Article VIII. — The Specific Treatment. Article IX — Laryngeal
Tuberculosis, its Diagnosis and Treatment. Article X. — Institutions for the
Treatment of Pulmonary Tuberculosis.

THE SYMTOMATIC TREATMENT OF TUBERCULOSIS.

THE MEDICINAL TREATMENT OF PULMONARY TUBERCULOSIS.

[continued FROM PAGE 3l6.]

Personally I have no experience with inunctions of iodofonn, but
made a careful trial of its internal administration, some 15 or 20 years
agO; at the time when Elsberg's claims for it popularized it in the treat-
ment of tuberculous laryngitis.

The remedy was, as a rule, pushed until it produced its known
constitutional effects and was thereafter continued in slightly dimin-
ished doses for several months. However, it did not produce sufficient
amelioration in the symptoms or course of the disease to justify its con-
tinuance then or its resumption since. In glandular cases, nevertheless,
I have seen decided influence from iodine preparations, especially from
the syrup of hydriodic acid which for internal administration seems
to me to be the most desirable form in which to exhibit iodine.

The most decided results which I have observed from the adminis-
tration of iodine or of mercury in adults were in cases which presented
either a clear history of, or w^arranted a suspicion of syphilis.

In the treatment of joint tuberculosis the value of injections of
iodoform emulsion, (5 per cent, to 10 per cent.) into the affected joint
has become a well recognized and very frequently recommended pro-
cedure. Hammerschlag* strongly endorses the application of this
method in the treatment of tuberculous lymph-glauds, particularly of
those which have undergone softening or have resisted other antiscrof-
ulous treatment. The softened gland is first punctured and the caaeous

' Bericht ueber dtn Kangress sur Bekaempfung der J^tberkuhse^ Berlin^
1899.

317

detritus evacuated. Iodoform emulaion, not exceeding 1 c. c. in
amount, is then injected and the treatment is repeated for the particu-
lar gland fortnightly. Indurated glands which have resisted other
measures are injected in the same manner and in all cases strict asepsis
is to be observed.

Arsenic in the treatment of pulmonary tuberculosis has not con*
tinned as popular as it was some years ago, although we occasionally
meet with reports of marked increase in weight having occurred )mder
its use.

Kenaut^ has given Fowler's solution per rectum in large doses
equivalent to a grain of arsemous acid in twenty-four hours and claims
that it was tolerated in these amounts for weeks and months. In three
cases treated the pulmonary symptoms disappeared. To me it is not
apparent why toxic symptoms were not produced if this amount were
absorbed. Gauthier^ uses arsenic in the form of cacadylate of soda,
an arsenical preparation, the effect of which he asserts differs mater-
ially from that of arsenious acid. By doses of from 3-4 gr. to 1 1-2 gr.
given hypodermically, the appetite and general nutrition of phthisical
patients were remarkably improved. More than this, he claims to have
obsen'^ed the occurrence of resolution in tuberculous lesions of the lung.
He states that when given by the mouth the remedy is -decomposed
into poisonous substances, and that it should be administered by the
hypodermic method only, from which in his experience of several years
no impleasant effects have occurred.

Of other general tonics I should perhaps mention strychnine,
which, however, is best reserved for cases in which it is indicated on
account of muscular weakness and insufficient force of the heart. But
Mays* sees in strychnine one of the four sovereign remedies in the
treatment of phthisis and says that its special selective influence upon
the nervous system is more particularly upon that part of the latter
which is distributed to the pulmonary organs. It raises the tone of
the respiratory nerves and aids digestion, assimilation and blood build-
ing. Mays recommends an initial dose of 1-32 gr., and gradually
pushes the remedy to its physiologic effect. According to him the
therapeutic effects are that: "Nervousness and sleeplessness are amel-
iorated, cough, expectoration and dyspnoea Avill diminish, vomiting
improves, the appetite revives, and t he patient gains in flesh ; the weak

* N. K Med, Journal^ April 9, 1898.
^ /aumel des Practiciens, March 17, 1900.
^Fennsylvama Med, Journal^ Dec. 1900, p. 357.

818

and irritable heart becomes quiet and stronger and the general strengdi
revives.'^ It is to be remembered, however, that all this improvement
is obtainable from general dietetic and hygienic management, especially
from rest, which, together with proper feeding, counter-irritation
over the pneumogastric nerves, and strychnine are the four measures
which Dr. Mays finds so valuable in phthisis. In my own experience
such improvement does not stand in relation to strychnine or to other
remedies unless the conditions are peculiarly favorable ; i. e. strychnine
will not improve a failure of appetite, nervousness, restlessness, cough
or dyspnoea when these sypmtoms are due to causes over which it can
exert no control. Strychnine can not remove the causes upon which *
these symptoms depend in the stage of softening, suppuration, etc.;
still its influence as a nerve stimulant is always desirable and often
obtainable when there is a weak heart and to the extent to which the
circulation is improved by its administration do we also secure more or
less direct benefit to nutrition, which, however, in the active period of
the disease referred to becomes but little perceptible, if at alL

Kalagua has in recent years been claimed to exert a specific cura-
tive influence upon tuberculosis, but it has not been shown to have any
other effect than to stimulate the appetite and digestion, just as do
other bitter tonics, the investigations of Bergey^ of its influence on
experimental tuberculosis having proved entirely negative.

As a general stimulant alcohol has still more or less numerous
advocates and more recently a new claim as to its value in pulmonary
tuberculosis has been advanced by Hammer* who asserts that it
induced connective tissue formation in the lungs, just as we see it in
the liver in cirrhosis of this organ due to alcohol. In regard to this
claim, even if it were proven to be true, I would suggest that the bene-
fit of increased connective tissue formation in the lung with the attend-
ing probability of acquiring at the same time alcoholic cirrhosis of the
liver is a questionable one and one whch moat physcians would prefer to
forego.

The hyi)odermic injection of camphorated oil as advocated and
practiced by Alexander is said by that author to be attended with more
than the mere stimulating effect. In his earlier communications on
this method, he recommended the camphor injections more particularly
in advanced cases, claiming a tonic action upon the muscular tissues,
especially of the heart, a nd a coinciding antipyretic effect. He also

^Univ, Med. Mag,^ Jan., 1901.
^Dtuisclu Medmnal Zeiimng^ 1901, pb 810.

819

found it to promote the jmtient's appetite in a remarkable degree.
More recently Alexander recommends camphorated oil injections in
the earlj^ stages also, and in a communication on the subject^ he
makes the remarkable statement that ^'camphor occupies the same posi-
tion in the therapeutics of phthisis, as does digitalis in the valvular dis-
eases of the heart/'

I regret that my own use of camphorated oil injections has greatly
disappointed my expectations, and beyond its known action as a stimu-
lant, I have not been able to observe the expected increase in appetite
and strength, nor any reduction in the fever, cough or expectoration,
which he so confidently asserts as following its use. The cases in which
I employed the method were by no means so seriously advanced as to
preclude probable improvement which was finally attained by other
means.

THE CLIMATIC THEATMENTi THE INFLUENCE OF CLIMATE IN THE

TREATMENT OF PULMONARY TUBERCULOSIS.

The employment of climate in the treatment of pulmonary tuber-
culosis is so ancient a procedure and benefits have been so frequently
observed therefrom in the history of the therapeutics of this disease,
that it would be superfluous to urge the proposition that it is of value.

The manner in which climate acts in bringing about amelioration
of symptoms and improvement in tuberculous patients is, however, still
an open question, and until this is fully understood, there must always
be difference of opinion in the choice of a particular resort for the indi-
vidual patient. In years past the students of this question have natur-
ally attached the greatest importance to that feature of a particular
locality which differed most strikingly from the prevailing climatic con-
ditions of the place in which the patient lived and acquired his disease ;
and they have constructed theories of therapeutic influence upon the
supposed difference of physiological effects upon the respiratory, circu-
latory or general functions of the organism. A retrospect of climatic
therapeutics shows that a great variety of climatic features were thus
studied and warmly recommended with more or less plausible theories
as to the mode of their favorable action. First the open country, then
forest-covered localities, the sea shore, piney woods, warm localities and
colder, rigorous regions, mountainous climates and sand deserts, have
all been extolled by individual observers who happened to note striking
improvement in the cases of patients who happened to resort to such
places. The benefit of a dry climate has been particularly extolled, but

^Berliner KHnische Wochenschr,^ 1898, No. 48.

820

here too, it was found that extremely dry localities, as well as those in
which the moiflture of the air was considerable, seemed to favor improve-
ment in phthisical patients.

The physiological effects observed from diminished atmospheric
pressure and the supposed discoveries of immune zones in elevated
regions, that is to say of localities where phthisis apparently did not
originate, led to the recommendation of high altitudes, the two condi-
tions being usually associated. Closer observation showed that many of
the climatic features which had previously appeared beneficial obtained
in these elevated immune regions more often to greater degree, than
at lower levels, and comparative bacteriologic examination of the air in
in large, crowded cities, and at high altitudes appeared strikingly in
favor of the latter. When to all these supposed advantages the pecul-
iar effect of altitude upon the blood count was added, the advocates of
high altitudes had made out their case sufficiently strongly as to seem-
ingly close the controversy, and the climatic treatment of phthisis at
any other than elevated regions was looked upon as a compromise that
WAS only justified by peculiar exigencies in the individual case. As
with other beliefs and theories concerning a subject that is of great
interest to its students, questions pertaining thereto are, however, never
closed until the truth has been found. This was the case in regard to
the therapeutic effects obtained at high altitudes when they failed to
prove satisfactory to such a degree as to meet theoretical expectations,
and the question, although never closed, was reopened.

More exact study showed that the effects of altitude upon the res-
piration and circulation were not uniformly beneficial ; the deeper and
more frequent breathuig, made necessary by the rarefied air, was found
to be actually an injury when the lung disease had reached a stage in
which softening and excavation were in progress, causing increased
lymphatic absorption and thereby greater degrees of fever and more
rapid decline. The effect upon the circulation proved likewise unde-
sirable in this class of cases as well as in those in which large areas were
involved, preventing even in non-febrile cases the taking of sufficient
out of door exercise, on account of local congestions and haemorrhages
which were induced. This was shown to occur through obstruction in
the pulmonary circulation by the tuberculous deposits and by the inflam-
matory, fibroid and destructive changes present, wherby the right heart
became overtaxed and failed in its power to drive the blood through the
diminished vascular channels to the left auricle.

[to bb continubd.]

THE

Journal of Tuberculosis

VOL. IV OCTOBER. 1902 No. 4

ORIGINAL CONTRIBUTIONS

ARE MEAT AND MILK A SOURCE OF SEED SUPPLY FOR HUMAN

TUBERCULOSIS?

BY LAWRENCE F. FLICK, M. D., PHILABSLPHIA.

Bovine tuberculosis can be inoculated into human beings. This
has been accidentally demonstrated in at least seven instances when
veterinarians inoculated themselves while making autopsies upon tuber-
culous carcasses.^ Of the seven cases reported, which have come to my
notice, one died of pulmonary tuberculosis two and one-half years after
the inoculation. In the other six cases recovery apparently took place
and in all but one the local sore healed upon excision of the nodule. In
this one case a joint became involved. In the case which died two and
one-half years after inoculation, there is a strong probability that the
seed supply came from the animal upon which the man made the
autopsy, but standing by itself and with the other six cases of recovery
standing against it, such a conclusion must not be accepted too readily.
There is nothing in the record of the case which would justify absolute
exclusion of a human seed supply. But even admitting that the tuber-
cle bacilli which led to a fatal termination in this case were derived
from an animal by inoculation, with the six cases of recovery before ua
we would still have to conclude that the bovine tubercle bacillus does
not find a congenial soil in human beings.

Apparently the converse of this proposition is likewise true —
namely, that human tubercle bacilli do not find a congenial soil in ani-
mals. Human tuberculosis has frequently been given to animals both
by inoculation and by feeding. It is the concensus of opinion of experi
mentors, however, that animals are more resistant to human tubercu*
losis than they are to animal tuberculosis. Koch, in his paper before the
'Repp, American Medicine ^ Z901.

322

British Congress on Tuberculosis, maintained that cattle are immune
to himian tuberculosis and fortified his position by a number of experi-
ments and by the recorded experiments of Ohauveau, Gnnther, Harms
and Bollinger.^ Koch has been severely arraigned for his position on
this subject, but many of his critics are unfair. Koch has not claimed
that all animals are immune to tuberculosis. His experiments were
made on beef cattle, goats, asses and sheep, the kind of animals from
which it is usually supposed that human beings derive a seed supply for
tuberculosis. All of these animals resisted human tuberculosis when
human tuberculous matter was fed to them and inoculated into them.
The position here taken by Eoch is really supported by the experiments
of other men, who, however, place a different interpretation upon the
facts. Bavenel,^ for example, who likewise read his paper and related
his experiments to the British Congress on Tuberculosis, found all his
animals less susceptible to human tuberculosis than to animal tubercu-
losis and found his horses, calves, sheep, and goats almost entirely
immune to human tnberculoeiB. It is true that some of his cattle did
develop tubereuloeis, but it is probable that all of them would have
recovered had he not killed them. The majority of them remained free
from all symptoms of tuberculosis, and those which he fed with tubercu-
lous matter and even some of those which he inoculated, remained free
from all evidence of tuberculosis discoverable at autopsy. Practically,
£och's facts and Haveners facts are the same so far as they apply to the
point at issue, but their interpretation of the facts are diametrically
opposite. Eoch concludes that because cattle are immime to human
tuberculosis, human beings must be immune to cattle tuberculosis ; Rav-
enel, on the other hand, concludes that because cattle are more suscepti-
ble to animal tuberculosis than to human tuberculosis, human beings
must likewise be more susceptible to animal tuberculosis than to human
tuberculosis, or in other words, because bovine tuberculosis is more path*
ogenic for animals than it is for human beings, it must likewise be more
pathogenic for htmian beings than is human tuberculosis. Of the twc
interpretations that of Eoch is undoubtedly the more rational and logi-
caL All nature is akin and the same fundamental laws govern every-
where. If human tuberculosis, by reason of continuous growth upon a
certain soil has become indigenous, it is probable that animal tubercu-
losis, for the same reason, has become indigenous in animals. More-
over, the authentic cases of transmission of animal tuberculosis to
human beings, of which we have record, show the same benignity as

Koch, /ouma/ of Tii^ercu/osis, Vol, III, No. 4, p. 334.
*Ravcncl, 7%/ University of Penn. Medical Bulletin, 1901.

328

the transmiaaion of human tuberculoBis to animals. And in the paucity
of numbers of cases of accidental inoculation of human beings with ani*
mal tuberculosis, when we consider the number of people who are using
the knife daily upon tuberculous carcasses, we have, to some extent, a
parallel illustration of the immunity of human beings to animal tubercu*
losisy to the experimental demonstration of animal immunity to human
tuberculosis by inoculation. Accidental inoculation of man with ani*
mal tuberculosis must be of frequent occurrence among butchers, meat
dressers and veterinarians, and if such inoculation were followed by
implantation and growth, it would certainly come to the attention of the
physician or surgeon. Yet the most painstaking search for recorded
oases reveals but seven.

It would appear from some experiments which have been made,
that the tubercle bacillus can be changed in its pathogenicity by graft*
ing. The law governing this variability, however, is not yet discema*
ble. What bearing it may have on the relationship between human
and animal tuberculosis cannot be determined until we know more about
It. For the present we have evidence only of the increase in virulence
of human tuberculosiB when grafted upon animals. EaveneP found
that human tuberculosis which had been inoculated into pigs and recov*
ered, had greatly increased in virulence for rabbits and guinea pigs. In
this connectioii it would be interesting to know whether animal tubercu*
losis recovered from human beings has increased in virulence. So far as
I know, the fact has not yet been determined by experiment. At any
rate the little knowledge which we have upon the subject does not tol-
erate the inference that animal tuberculosis possesses greater virulence
for man than for animals, but rather combats it. According to the law
of reversion the increase in virulence of the tubercle bacillus by passing
from man to animals would indicate that the natural habitat of the
tubercle bacillus is to be found in the lower scale of the animal kingdom
and not in the higher, and that the human tubercle bacillus is a product
of evolution from a parent stem which is common to all the varieties of
tubercle badllL

Bovine tuberculosis is probably less pathogenic for man than it is
for animals; at least it is not more so. At the Storrs Agricultural
£?qperiment Station, in Connecticutt,' feeding calves with the milk of
tuberculous cows failed, in many instances, to convey the disease. 6eb-
hard has shown by experiment that attenuation of tuberculous milk,

^Ravenel, supra cito.

Twelfth Annual Report, 1899, p. 158.

324

one to fifty, makes it sterile even for inoculation of guinea pigs. Bepp'
has collected a large number of reports of inoculation experiments
and feeding experiments with milk of tuberculous cows, for the
purpose of demonstrating the transmission of bovine tuberculosis to
human beings. He quotes twenty-three series of inoculation experi-
ments and ten series of feeding experiments, made in different parts of
the world. Some of the reports of these experiments are too indefinite
to be available in the computation of per-centages of results. In eight-
een of the twenty-three series of inoculation e^tperiments and in six of
the ten series of feeding experiments results can be computed. Six-
teen of the inoculation experiments were made with milk from cows
known to be tuberculous, and two were made with mixed milk as sup-
plied to the market. From the sixteen series of experiments with tuber-
culous milk there were obtained 23.88 per cent, successful inoculations,
and from the two series of experiments with market milk there were
obtained .43 per cent successful inoculations. In five of the series of
experiments, including the two made with market milk, the milk was
centrif ugalized and the sediment used. In six of the series of experi*
ments, milk was used from herds in which there was at least one cow
with diseased udders. In one of the series of experiments in which the
milk was taken from a cow with diseased udders there were 100 per
cent, successful inoculations, and in another in which the milk was taken
from a herd of tuberculous cows, two of which had udder involvement,
there were 66.66 per cent, successful inoculations. If we remove these
two series of experiments from the entire group we have 11.98 per cent.
successful inoculations for the other ten series. The great variation in
the results of these experiments leads one to suspect that some of them
may not have been carefully performed. Stein, for example, is reported
to have had 28.6 per cent, successful inoculations with the milk of cows
with healthy udders, whilst Schroeder, in three series of experiments
with the same kind of milk, got only .19 per cent, successful inocula-
tions. Stein, moreover, inoculated only fourteen guinea pigs whilst
Schroeder inoculated eighty-eight. The combined results of AcUuni,
Ravenel, Eussell, Delepine, Schroeder and Nocard give only 4.09 per
cent, successful inoculations in four hundred and thirty-six experiments.
In the feeding experiments reported by Repp, seven out of twelve
are definite enough to warrant computation of results. The per-centage
of implantation for these seven series of experiments is 30.4 per cent.
Here again the wide divergence of results makes one suspicious of the
methods used by some of the investigators. Law, Bang and Ernst, in

'Repp, supra cito.

325

their combined experiments had 70.9 per cent, implantations, whilst
Itusselly Pench and Adami had none.

The results of experimentation with tuberculous meat, as reported
hj Bepp, are much the same as those with milk. Arloing had 30 per
i^nt. successful inoculations with the muscle juice of tuberculous
<30wb; Nocard had 5 per cent. ; and Vejssiere and Humbert had 100 per
«ent The three combined had 46 per cent. In feeding experiments
Johne, Gerlach and Peuch combined had 46.2 per cent, implantations,
whilst ilfocard, Perroncito and Oaltier had none.

The net results of all the experiments quoted by Bepp are less than
•one implantation in four seed scatterings, and this under the most fav-
orable conditions possible. It is fair to assume that under more natural
eonditions, that is, the animals taking the milk and meat as food in the
way in which they ordinarily get them, there would have been no
implantations. If milk and meat are practically harmless to animals
which are susceptible to bovine tuberculosis, surely they cannot be a
great source of danger to human beings who are insusceptible. So
far as experimental proof goes it may therefore be assumed that milk
and meat are not a source of seed supply for human tuberculosis.

Clinically we have no evidence at all that animal tuberculosis is
transmissible to human beings through milk and meat. Many cases
have been recorded in which children who had been drinking the milk
of tuberculous cows developed tuberculosis, but there is nothing in the
records of the cases to show that the occurrence was more than a mere
eoineidence. The mere absence of a tangible history of exposure to
human tuberculosis in such cases is not sufficient. Tul>erculosis is a
very insidious slow growing disease in the beginning, hence the time of
implantation may antedate the development of the noticeable symptoms
so long as to have been forgotten. Moreover, the exposure may be of
a character to be easily overlooked. A case in point will illustrate this.
A child 9 years old was stricken down in perfect health with grippe, fol-
lowed by pneumonia. The attack ran an ordinary course and in due
time convalescence set in. The lung did not get well, however, and
after some weeks a recrudescence set in which was of a rather chronic
character. A consultation was called for and the consultant diagnosed
the case one of tuberculosis. Both the family physician and the family
insisted that there had been no exposure to tuberculosis, direct or indi-
rect. The family physician had known the child from birth, having
attended at the accouchment. Prior to the present attack the child had
been a model of health, and the tuberculosis was of the acute miliary
type. The most searching inquiry revealed no history of exposure.
After three or four weeks' reflection and self-examination the mother

S26

announced that she believed she now knew where her child had gottoii
the disease. While the child was sick with pneumonia the doctor had
ordered a feeding cup« A messenger was sent to the drug store for a
eup, but could not get one. A neighbor who happened to be present
when the messenger returned, offered a cup which was accepted. Thi^
cup had been used for many months by a consumptive child and had
not been disinfected. In concluding her story the mother said that
she had noticed that the cup was not clean and for this reason had
rinsed it carefully before using. Now had the original inquiry inta
the history of this case revealed the presence of a tuberculous cow from
"which the milk had been used it would probably have been set down aa
a case in which the seed supply had come from the cow.

Standing side by side with this negative evidence and supporting it,
we have the most convincing clinical evidence that human tuberculosis
is always derived from human sources. Prolonged intimate contact
with a consumptive in the last stages of the disease undoubtedly is the
most prolific cause of new implantation of the disease. For every case
of tuberculosis which dies at home a number of people are subjected to
prolonged intimate contact. Besides this intimate contact at home^
there is prolonged intimate contact with nearly every case during the
earlier stages of the disease, by a number of persons, in the workshop,
the store and the office. Then again we have the prolonged intimate
exposure resulting from occupation of houses and rooms which have
been occupied by consumptives and the use of implements, utensils and
clothing which have been used by consumptives. In all there are prob*
ably from five to six prolonged intimate exposures for every case of
tuberculosis in existence. The number of implantations which grow
and develop into full fledged cases of tuberculosis out of these exposures^
however, is less than one new case for every old case in existence.
Every case of tuberculosis in a human being, therefore, is accounted for
many times over by the exposure to anolJier case in a human being.
Even if we demand a wdl-defined exposure to human tuberculosis for
every new case, we can find it by carefully going into the history of the
case. But in doing this we must bear in mind that tuberculosis is an
insidious, slow growing disease and exists frequently where it is not sua*
pected. Some people are so nearly immune to tuberculosis that they
\nll carry it through a long lifetime without developing symptoms which
attract attention. Such cases can give the disease to others without it
being suspected whence the seed supply came. A case in point will
illustrate this. A semi-educational institution for boys has been under
my medical supervision for some years and I have been in the habit of
visiting it daily during that time. There had not been the slightest

827

suspicion that there ^sns a case of tuberonlosb in the honse when one
day I aocidentallj discovered the disease in one of the prefects who con-
sulted me for a cold. The man had been in the house for a year. He
had a small secreting cavity from which he was expectorating bacilli*
bearing matter, and upon inquiry I found that he had been spitting
quite promiscuously around the place during the time that he had been
tiiere. Fearing that the disease might have gotten a foothold in the
place I at once made a careful examination of every boy who showed
the sli^test symptoms and to my surprise I discovered two cases, one
of which had already advanced to the stage of softening.

For the implantation of the tubercle bacillus, a liberal scattering of
seed supply is necessary, and ordinarily this scattering must continue
for a considerable period of time, because much of the seed falls on bar-
ren soil and much is destroyed by the phagocytosis of the living body.
In every day life, whether it be in the animal kingdom or in the human
family, successful implantation takes place through prolonged intimate
contact, direct or indirect, when the seed can be gradually and continu-
ously taken up until, at an opportune moment, some finds lodgment in
the right place and in the proper condition of the system for germina-
tion, or until so much has been taken in as to overpower phagocytosis.
In the animal kingdom the introduction of a tuberculous animal into a
herd means implantation of the disease in the herd in the course of time,
or tying up of the healthy animal in a stall which has been occupied by
a tuberculous animal means implantation of the disease in a healthy
animal. In the human family prolonged, intimate, social relations
between the well and the sick, prolonged use of the things which have
been used by the sick or occupancy of houses which have been occupied
by the sick, are the ordinary modes of implantation of the disease.
These facts are well established, not by artificial methods in laboratories,
but by clinical evidence in every day life. There seems to have been
too much stress laid upon laboratory deductions. The bacteriologist
is apt to conclude that what he can accomplish in the laboratory is
accomplished outside. This does not follow, however. For the pur*
pose of applying laboratory deductions to practical life the hygienist
must make full allowance for the difference in conditions.

Meat and milk are too important a food supply to permit an
imf ounded prejudice to arise or stand against them. They are not only
an important food supply during health, but they constitute a valuable
asset in the treatment of tuberculosis. For the poor there is no more
economical food than milk. A poor consumptive can find in miik
almost a complete armamentarium for his recovery. Four to five quarts
of milk a day without other food and without medicine will sometimes

328

restore incipient cases to perfect health. With milk as the basis and
meat, vegetables and fruit for supplementary purposes an economical
diet of an ideal character can be arranged for the consumptive, such as-
no other combination of food can give. Much injury already has been
done by the creation of unwarranted fear in the public mind about these*
foods. Even consumptives are afraid to use them. Of meat there ii
less fear than of milk, because it is customary to eat meat cooked. Meat
is improved by cooking and v^hen the public is advised to eat cooked
meat no mental friction is created by such advice. But with milk it is*
different. Cooked milk is disagreeable to many and indigestible ta
some. Even heating the milk to the boiling point modifies it sufficiently
in taste to make it disagreeable to many and according to some author-
ities makes it less digestible than when raw. Advice to boil milk is>
therefore not well received and frequently leads to a disuse of milk.
It is of the greatest importance of course, that milk and meat, being-
important articles of food, should be pure and be the product of healthy
animals. The government should protect the public in this regard in
every way possible, and should use every legitimate means of stamping-
out tuberculosis among domestic animals. The work of stamping out
tuberculosis among cattle should, however, be made to stand upon its
own merits and not be predicated upon stamping out tuberculosis among^
human beings.

Probably the most pernicious effect of the spreading of false doc-
trines about the dependence of huntian tuberculosis upon animal tuber-
culosis for seed supply, is the interference with the introduction of
proper measures for the prevention of hiunan tuberculosis. So long as-
the public is permitted to remain in doubt as to the true source of socd
supply for human tuberculosis, so long will it be apathetic about the-
introduction of proper measures for its prevention. Up to the present
time very little has been done by governments for the prevention of
human tuberculosis. Considerable money has been expended for t he-
stamping out of tuberculosis among cattle and this is as it should be —
indeed too little has been appropriated for this purpose ; but unfortun-
ately the impression has gotten abroad that money devoted to this pur«
pose is at the same time accomplishing the task of stamping out human,
tuberculosis. Very few governments have as yet taken money from
the public treasury for the establishment of sanatoria for the consump-
tive poor and comparatively little is as yet done by boards of health
in the sterilization of houses which have been occupied by consump-
tives. Quite recently the mayor of one of the first cities in the land
stopped the contemplated action of the board of health to register

829

tuberculosis, ostensibly upon the score of economy. Outside of pri-
Tate effort, put forth either by individuals or by societies, very little has
heen done in the way of public education on the contagiousness of
tuberculosis and personal hygiene in regard to the disease. Why all
this apathy about a matter which is of such vast importance to every
human being? Is it not because the public does not yet imder-
^and the subject? For the misapprehensions which exists the medical
profession is primarily responsible and it has been led into a falso
position upon the subject by giving too much weight to the laborat<yry
evidence and too little weight to the clinical evidence at its command.

LIGHT-ITS THERAPEUTIC IBSPORTANCB IN TUBERCULOSIS AS
FOUNDED UPON SOENTIPIC RESEARCHES.

by j. mount bleyer, m. d., f. r. a., m. l., ll. d,. new york, vice president

american congress op tuberculosis.

[continued from page 356.]

Experiments with red flnid media have shown that plants, under
certain circumstances^ have decidedly bent from it. It is a hard prob*
lem at Ihe present state of our knowledge how to explain this as the
effect of mere heat ; it would appear that some property resides in the
red rays which acts in opposition to the general law.

A few remarkable results must yet be noticed. Under all ordi-
nary' circumstances plants bend in a very decided manner towards the
light. This is known as heliotropic phenomena. Herr Wiesner pre-
sented a monograph to the Vienna Academy in 1878, which is found in
the Anzeiger of that academy; an idea of some of the fruits of his
researches on this important subject is given in detail. In studying the
influence of light and heliotropism, Herr Wiesner's experiments were
made in the light of a gas flame which burned under a constant pressure
with a uniform intensity (luminous power, 6.5 spermaceti candles).
The unit for the measurement of the light intensity was the strength
of this flame at the distance of one metre. It was found that in helio-
tropism three cardinal points of light intensity are to be distinguished,
an upper limit, a lower limit, and between the two, an optimum of light
intensity. Thus with decreasing intensity of light, the strength of the
lieliotropic effect increases to a certain point, and beyond this point
decreases. The lower limit referred to coincides with the lower limit
-of light intensity for the stoppage of growth in length, while the upper
limit does not coincide, or only occasionally coincides with the upper

880

limit of light intensity for the growth and length ; f o» in the eaae of
plants very senaitive hcliotropicallj^ it liea higher, and in leas aenaitiTe
plants lower, than the upper linut for growth in length. The mode of
arrangement of the experiment in gaa-light did not permit of determin-
ing in all cases the limiting values of the light-intensities; thus, for
ex3imple, the upper limit for the heliotropism of etiolated shoots of
Salix alba, and of the hypocotylous portion of the stem of Viacum
alhuniy and the lower limit for the heliotropism of the growing stem of
vetch could not be ascertained. The former lies about 400, the latter
far below O.OOS. The optima were foimd to lie between 0.11 (the
growing stem of the pea) and 6.25 (etiolated shoots of i<alix alba).
Both with gas light and with natural light, it was ascertained that,
beyond a certain intensity, no growth in length occurs.

He also speaks in this treatise of the relations between the ref rang-
ibility of the light rays, and the heliotropie effects. The experiments
were made partly in the objective spectrum, partly in the varieties of
light, gotten by sending white light through colored solutions. * *
It was proved that portions of plants very sensitive heliotropically, e. g.
growing stems of Vicia 8(Uiva undergo curvatures in all kinds of light,
even in ultra-red and ultra-violet, with the exception of yellow. The
maximum of the heliotropie force of light lies at the boundary between
violet and ultra-violet ; a second (smaller) in the ultra-red. From both
maxima the power of the rays to produce heliotropism decreases grad-
ually and to the yellow. Portions of plants little sensitive heliotropie*
ally, are no longer influenced by orange, or by red and green, or even in
the case of etiolated shoots of Salix alba by ultra-red raya. The yellow
rays quite stop the heliotropism ; for example, in pure red a quicker and
stronger heliotropism oc:cur8 in a light which gives yellow besides red.
In another section of his experiments he gives us scmie important results
on the joint action of positive and negative heliotrojusm and (positive
and negative) geotropism. It is here shown inter alia that, in the caaa
of plants very sensitive heliotropically, the geotroixism is, at the opti*
mum of light intensity, apparently extinguished, even in strongly gco-
tropic organs ; further, that in many organs (growing stem of the pea)
the heliotropie and geotropic powers of curvature disappear simultane-
ously ; in others, however, (stems of cress) the younger portions of the
stem are more strongly heliotropie than the older; and the oldest after*
growing 'portions of stem no longer show bondings in the light, but,
through drawing actum on one side the heliotropie overhanging point of
the stem, show apparently heliotropie curvatures chiefly due to growth,,
which are then counteracted by negative geotropism.

331

The arguments go to prove that heliotropism is due to the phe-
nomenon of unequal growth upon unequally lighted sides of an organ,
which he forcibly sets forth in many experiments, and proof is offered
that, for heliotropism as well as for growth in length, free oxygen is
necessary.

He also furnishes proof that the conditions for heliotropism remain
constantly the same during its course and coincide with the conditions
for growth in length ; further that heliotropism (and the same holds
good for geotropism) occurs as a phenomenon of induction. It is also
shown that when light induces heliotropism in an organ, a fresh helio-
tropic or geotropic induction meets with resistances, and can only come
into action after extinction of action of the first ; and that the successive
impulses of light and gravity, of which each by itself is capable of pro*
dudng certain effects, do not have their action added together when the
effects that should be obtained separately are in the same direction,
e. g., and the same side of the organ is helped in its growth in length.

UGHT — ITS EFFECT UPON COLORED JUICES OF FLOWERS AND

OTHER PHENOMENA.

The action of light on the juices of plants has been carefully
studied by M. Chevreul ; but as his experiments were made with refer-
ence only to their permanence as dyeing materials, and with white light
as it proceeds from the sun, they afford no information as to the
influence of the separate rays, but, nevertheless, they are of vast value
from a therapeutic point This subject has alone engaged the atten-
tion of Sir John Herschel and Mrs. Somerville.

I shall mention as briefly as is consistent with a correct understand-
ing of the matter, several of the most remarkable results obtained upon
vegetable juices, referring all those who may desire more detailed
iaf ormation to his memoir itself.^

In the Philosophieal Transactions for 1844 is published an extract
of a letter from Mrs. Somerville to Sir John F. W. Herschel, dated
Borne, September 20, 1848, on the action of the rays of the spectrum
on vegetable juices. There is so much that is curious in this communi-
cation, that I have extracted a portion to show the character of the
investigations in which that lady was engaged.

'^ the following experiments the solar spectrum was condensed
by a lens of flint glass of 7 1-2 inches focus, maintained in the
same part of the screen by keeping a pinhole, or the mark of a pencil
constantly at the comer of the red rays, which were sharply defined by

^On the Action of the Rajrs of the Solar Spectrum on VegeUble Colors
etc. Philosophical Transactions y Part II, 1842.

332

using blue spectacles to protect my eyes from the glare of light, and
the apparatus was covered with black cloth in order to exclude extran-
eous light.

"Thick, white letter paper, moistened with the liquid to be exam-
ined, was exposed wet to the spectrum, as the action of the colored light
was more immediate and more intense than when the surface was dry.
As T had not access to the morning sun, the observations were made
between noon and three in the afternoon."

Mrs. Somerville approached very near to the discovery of the
extra spectral rays of Stokes, as the following paragraph shows.

"The lavender rays came vividly into view; under a condensed
spectrum, on white paper washed with a solution of sulphate of quinine
in dilute sulphuric acid, they were narrow and their length by rough
measurement was equal to the distance between the npper edge of the
violet and the lower edge of the blue. They were very brilliant on
black silk or other dark surfaces, and invariably of lavender color ; and
even on paper stained with turmuric, the pale yellow rays which yoa
had observed were tipped with lavender, on being washed with the
liquid though its duration was only momentary, as it vanished as the
surface became dry; but they were permanent in other instances.

"The lavender rays change their color with a change of the liquid ;
for instance, they are lavender color on nitrate of silver discolored by
b'ght to a very pale brown, washed with a solution of sulphate of qui-
nine in dilute sulphuric acid; whereas, on a similar surface of pale
bro>vn nitrate of silver, washed with the juice of the petals of the pale
blue Plumbago auricuUata in distilled water, to which sulphuric acid
was added, they appeared of a vivid apple green, and acquired a tip of
lavender color on the surface being washed with a solution of snlphate
of quinine in dilute sulphuric acid of considerable strength. The effect,
however, was transient. After several unsuccessful attempts to repeat
tliis experiment next day, I at length discovered that its success
depended upon the acid being strong enough to decompose the juice
and give it a redish orange hue, and even then the rays are not vivid till
the ])aj)cr has been frequently washed with the juice and become nearly
dry ; and the experiment is more successful when the liquid has been
kept a night. The action of the surface in changing the color of the
lavender rays may be illustrated by passing the spectrum over paper
coated with nitrate of silver brought to a clear yellow brown by expos-
ure to the sun, one-half washed by the liquid in question, and the other
half with a solution of sulphate of quinine in dilute sulphuric add, and
the first half of the lavender rays become vivid apple green, while on

383

passing to the other half , they instantly changed to an equally vivid lav-
ender color. These rays often darken the surface throughout their
whole length ; sometimes they acquire a powerful bleaching action, and
sometimes they have no effect^ as evidently appears from the following
experiments :

'The juice of fresh-gathered petals of double flowering pomegran-
ate in alcohol afforded an example of this. Paper washed with this
juice became rich crimson, and on being exposed wet to the condensed
spectrum, a narrow line of deep crimson was formed at the junction of
the green and yellow rays, or perhaps in the most refrangible yellow,
surrounded by a whitish lozenge shaped border (a). On agaiu washing
the juice, instead of the white border, which had vanished, there was a
crimson flame-shaped image, curved at the lower edge of the yellow
rays, and tapering upwards to the violet ; its color was darker tlum that
of the ground, though paler than the narrow line which maintained its
intensity, and although the latter increased in width, it did not become
as broad as the image in question. At the upper end of the violet
another little dark image was formed, apparently owing to the action
of the lavender rays, having exactly their form ; the orange and red
rays, especially the red, had no effect, though at the distance of about
half the length of the spectrum beyond the red, two distinct spots were
formed of deep crimson, which I believe to be the best spots which you
discovered. After some time a bleaching appearance surrounded the
whole image from the red upwards, probably owing to rapid evapora*
tion from the heat of the spectrum (b).

a 6 c

'^Exterior bleaching frequently took place in the course of the
cqperiments, permanent in some instances, while in others it vanished
5U the surface dried. When water was used with the juice instead of
alcohol, the general character of the image was similar to that

334

described^ except that the small figure beyond the violet was more dis-
tinct, and seemed to bear the same pioportion to that formed by the
rest of the spectrum -which the length of the lavender rays bears to the
length of the sum of the others ; the bleached part round the whole was
more extended and a faint crimson haze encompassed the dark spots,
which were very distinct (c).

'^The following are some of the cases in which the simnltaneoua
effect was produced. For example, V^V^^ washed with the juice of the
pet^ils of Olobe amaranthiu in distilled water, on exposure to the spec-
trum, acquired a delicate pink tint which was soon bleached to white-
ness from the upper edge of the green to the end of the lavender rays,
while at the same time a perfectly circular spot of equal whiteness was
seen under the red rays and a little way below them, which had the
appearance of being an image of the sun. After more washing with
the juice, the two bleached parts were imited by a long white neck
which speedily vanished, and was succeeded by a dark crimson image,
whose greatest intensity of color was under the yellow rays. At some
distance below the red rays two crimson spots were strongly marked,
especially the uppermost, both surrounded by a paler halo.

'^The juice of the petals of pale blue Plumbago auriculata in dis-
tilled water imparted its tint to writing paper, which after exposure to
the action of diffused light acquired a pale yellowish green hue. The
part under the lavender and violet rays of the spectrum, repeatedly
washed with the juice assumed a pale brown color. The indigo rays
seemed to have no effect, although from their lowest edge to the dis-
tance of half the length of the spectrum below the red rays, a laven-
der blue image was formed. Under the orange rays a minute indigo-
colored spot appeared, and also a larger spot of the same color under
the yellow, which were soon blended into one, f orminjg a single oblong
figure of maximum intensity, surrounded by a halo of paler indigo.
An isolated disc of the same color as the halo, with two dark spots in its
center, appeared at the same distance below the red rays.

''The juice of the beet-root in a strong solution of common salt,
imparted a pink color to the paper, and the most refrangible rays
acquired a powerful bleaching energy; the pink ground was whitened
under the lavender, indigo and blue ; a deep crimson spot was formed

335

under the yellow, with a rose-colored halo, elongated to the bleached
part on one side and to the end of the orange on the other, while a hazy
rose-colored disc was visible at a distance below the red. The crystal-
lization of the salt on this figure was, in proportion to the intensity of
color, most on the crimson spot and its halo, and on the colored disc,
but scarcely any on the bleached portion."

The great number of instances now adduced in which we have dis*
tinct evidence of chemical change under the influence of the sun's ray9
appears sufficient to support the position, that the solar and electric arc-
light rays are continually acting upon matter — ^it signifies little in what
form it may be presented to their influence. We have distinct evidence
that a sunbeam or the electric arc-light beam cannot fall upon any
«olid body without leaving permanent traces of its action. Throughout
all these cited experimental researches the observations have shown the
fact only too plainly.

The most casual observer could not fail to remark the peculiar
influences of the solar agencies at different seasons of the year. In
spring a fresh and lively green pervades the field and forest; this in
summer assumes a darker hue and in the autumn passes gradually into
a russet brown. There is no doubt that there is a marked difference
in the chemical action exerted by the solar rays an hour or two before
noon, or an hour or two after it. I was convinced at an early period of
mj experimental work of that fact, and the continued observations of
Siane years prove that similar differences are to be detected between
the solar emanations of the vernal and the autumnal periods (I have
found these facts from some phot(^aphic experiments). The changes
in the color of the leaves appear to be entirely dependent upon the
absorption of oxygen which all the green parts of plants have the
power of absorbing without intermission. This true case of chemical
affinity, it would appear, goes on equally with the spring or the summer
leaves ; but during these periods the vital force, under the stimulus of
the light, is exerted in producing the assimilation of the oxygen for the
f onnation of the volatile oils, the resins and the acids. In the autumn
this exciting power is weakened ; the summer sun has brought the plant
to a certain state, and it has no longer the vital energy necessary for
continuing these processes. Consequently^ the oxygen now acts in the
same manner on the living plant as we find in experiment it acts upon
the dried green leaves, when moistened and exposed to its action.
They abeorb gas and change color.

Sir John Herschel observes in reference to the action of light on
the juicea of plants : ^^The earlier flowers of any given species reared ia

336

the open air^ are more sensitiye tlian those produced, even from the
same plant at a later period in its flowering, and have their colors
more completely discharged by light As the end of the flowering
period comes on, not only the destruction of the color by light is slower,
but residual tints are left which resist obstinately." These residual
tints are the same which produce the brown of the autumnal leaf ; and
the same agent may be traced in the production of photographs upon
papers spread with expressed- juices and on the changing colors of
flowers and leaves.

Here we come to another most interesting physical problem which
holds our attention for a brief moment. We find that the woody
fibre of plants and all the carbon which is found as an elementary con-
stituent of the resins, gams, juices, etc, of the vegetable world, is
derived r:ic}usively from the atmosphere to which it is supplied by the
respiration of animals and all those processes of combustion which are
continually going on. By some pecidiar function these leaves of plants
during every moment of their lives are absorbing carbonic add. It has
been stated that the reverse of this takes place during the hours of
darkness, and that at night the leaves absorb oxygen, and exhale car-
bonic acid. It appears to me that this statement has been made with-
out sufficient consideration, or the requisite experimental evidence.

^^This reversal at night," says a most talented philosopher, ''of
what was done in the day, may, at first sight, appear at variance with
the unity of the plan which we should expect to find preserved in the
vegetable economy, but a more attentive examination of the prooess
wQl show that the whole is in perfect harmony, and that these con-
trary processes are both of them necessary in ord^ to produce the
result intended."

He then, evidently feeling the difficulty of the question, proceeds
to explain this harmony as follows:

''The water which is absorbed by the roots generally carriee with
it a certain amount of soluble animal and vegetable materials which
contain carbon. This carbon is transmitted to the leaves, where, dur-
ing the night, it is made to combine with the oxygen they absorb. It
is thus converted into carbonic acid, which, when daylight prevails, is
decomposed, the oxygen being dissipated, and the carbon retained. It
is evident that the object of the whole process is to obtain carbon in
that precise state of disintegration to which it ia reduced at the moment
of its separation from carbonic acid by the action of solar light on the
green substance of the leaves; for it is in this state alone that it is avail-
able in promoting the nourishment of plants, and not in the crude c<hi-
dition in which it exists, when it is pumped up from the earth along

337

vfiih the water which conveys it into the interior of the plant. Hence
the necessity of its having to undergo this double operation of first com-
bining with oxygen, and then being precipitated from its combination in
the manner above described.'' These passages are selected, not with
any view of reflecting upon their accomplished author, but because they
a£Pord the best expression of the views which have been generally enter-
tained on the strength of the experiments of Saussure and Grishchow,
which admit of another explanation.

It is the green parts of plants, principally the leaves and to a less
extent the bark, which absorb carbonic acid. Plants grow in soils com-
posed of divers materials, and they derive from these, by the soluble
power of water which is taken up by the roots and by mechanical
forces carried over every part, carbonic acid, carbonates and oi^anio
matters containing carbon.

Evaporation is continually going on, and water escapes freely from
the leaves during the night, when the functions of the vegetable, like
those of the animal world, are at rest. ^^A cotton wick," says another
experimental philosopher, '^enclosed in a lamp which contains a liquid
saturated with carbonic acid, acts exactly in the same manner as a living
plant — ^in the night. Water and carbonic acid are sucked up by capil-
lary attraction, and both evaporate from the exterior part of the wick."

A plant placed in a vessel containing water impregnated with car-
bonic add and carefully closed, so that no water could escape by evap-
oration except through the plant, was placed under the receiver of an
air pump in which was put some pure potash, and a good exhaustion
effected. The potash was found to have absorbed carbonic acid. The
same arrangement was made, only that the water now used was dii-
tilled. Under the same circumstances in every respect, a like quantity
of moisture was found to be absorbed by the caustic potash, but of
course no carbonic acid. In these experiments the carbonic acid and
water were mechanically drawn through the plant.

Precisely similar arrangements were placed under bell glasses filled
with atmospheric air which was dried and freed from carbonic acid by
exposure to potash for some time. In neither case could any diminu-
tion of the quantity of oxygen be detected, but traces of carbonic acid
were found in the air in which the plant in the carbonated water was
placed. These experiments were in the dark, and eudiometric exami-
nations of this air have convinced Mr. Hunt that some oxygen is always
given off.

There is no reversion of the processes which are necesary to sup-
port the life of a plant ; the same functions are operated in the same way
bj day and by nighty but differing greatly in degree. During the hours

388

of sunshine, the whole of the carbonic acid^ absorbed by the leaves or
taken up with water by the roots^ is decomposed, all the functions of the
plant are excited, the processes of inhalation and of exhalation are
quickened, and the plant pours out to the atmosphere streams of pure
oxygen, at the same time as it remoyes a large quantity of deleterious
carbonic acid from it In the shade, the exciting power being lessened,
these operations are slower, and in the dark they are very nearly, but
certainly not quite, suspended.

We have now certain knowledge. We know that all the carbon
which forms the masses of the magnificent trees of the forest, and of
the herbs of the fields, etc., has been supplied from the atmosphere to
which it has been given by the functions of animal life and the neces-
sities of animal existence. Man and the whole of the animal kingdom
require and take from the atmosphere, its oxygen for their support. It
is this which maintains the spark of life, and the product of this combus-
tion is carbonic acid which is thrown off as the waste material and
deteriorates the air. The vegetable kingdom, however, drinks this nox-
ious air; it appropriates one of the elements of this gas, carbon, and
the other, oxygen, is liberated again to perform its service to the ani-
mal world. It is not possible to conceive a more perfect, a more beauti-
ful system of harmonious arrangement than this, making the animal
and tihe vegetable kingdoms mutually dependent. The existence of the
one ceases when the other is destroyed. If the vegetable world was
dwept away, animal life would soon become extinct; and if all animal
existence was brought to a close, the forest would fall and the fiowers of
the field which now clothe the earth with gladness, perish in the utter-
ness of a lamentable decay. It has been supposed that the vegetable
world was called into existence long previous to the creation of animals,
and to this period is referred the formation of the coal strata. There
might have been an epoch when the disturbed condition of the earth —
its earthquake shocks, and volcanic strugglings — ^may have poured so
large a quantity of carbonic acid into the atmosphere, as to have ren-
dered this planet unfit for the habitation of animals, until a teeming
and most gigantic vegetation, by exhausting it for its own supply,
purified the air and rendered the more quiet earth a fitting abode for
creatures endowed with reason and with instinct. But the hypothesis
is unsupported by facts, and it is not within the range of probabilities
that the animal and vegetable kingdoms can ever have an independent
existence.

The animal kingdom is constantly producing carbonic add, water
in the state of vapor, nitrogen, and in combination with hydtogen^
ammonia. The vegetable Vipg^^o^Tn continually oonsumes amsipiKia^

339

nitrogen, water and carbonic acid. The one is constantly pouring into
the air what the other is as constantly drawing from it, and thns is the
eqnilibrinm of the elements maintained.

Plants may be regarded as compounds of carbon, rapor, oxygen,
hydrogen, and nitrogen gases, consolidated by the all-powerfnl, aU-per*
vading influences of the solar ray ; and all these elements are the pro*
duce of the living animals, the conditions of whose existence is also
greatly under the influence of these beams of sunlight which are poured
in unceasing flow from the center of our system.

Can anything more completely display a system of the loftiest
design and most perfect order, than these phenomena i

THB SOLAR RAYS AND THBIR IKFLUBNCB ON CHEMICAL COMBINATION.

There are many examples which show clearly the influence of the
iolar rays upon chemical combination. Here are a few remarkable
instances which are worth our notice. Vogel observes, that if chlorine
was passed into alcohol nearly saturated with that gas, and at the same
time exposed to the sunshine, each bubble of chlorine, as it entered the
spirit, e:q>loded, giving a bright purple flame and a white vapor. This
experiment I have repeated and found that the effect depends entirely
upon the agency of the chemical radiation. The interposition of an
orange glass, or a yellow fluid, is quite sufficient to stop this energetic
chemical combination.

It has long been known to chemists, that a mixture of chlorine and
hydrogen gases might be preserved in darkness,without combining for
some time, but that exposure to diflused daylight graduaUy accom-
plished their combination, whilst the direct solar rays produced the sud*
den inflammation of the mixture. This oombiBation has been investi-
gated by Qray, Lussac, and Thenard, and also by Davy. Sir Humphry
Bavy states tiiat in mixture, chlorine and hydrogen acted more rapidly
upon each other, combining without explosion, when exposed to the red
rays, than when placed in the violet rays. But he found that a solution
of chlorine in water became a solution of muriatic add most rapidly
when placed in the refrangible rays. The former statement is doubt-
ful

My own experiments appear to show that the combination of these
gases may be effected in every part of the prismatic spctrum, but that it
is entirely independent of the luminous rays. I have kept chlorine and
hydrogen without uniting, behind a yellow medium, for as long a period
as I have been able to preserve the mixture in the weakest diffused day-
light. It does not, however, appear to be quite independent of calorific

340

influence; for it is found that the combination is effected gradually
under the influence of the dark rays of heat.

We have evidence to show that the chemical agent, whatever it
may be, which accompanies light, is diffused over every part of the
prismatic spectrum, although its action is modified by the luminous and
calorific influences. Now, aa it is proved that a very small amount of
actinic power will occasion the chemical combination of these gases, we
can well understand that it is diffused over the whole of the rays,
although in different degrees.

Dr. Draper has shown that the light of a taper produces a decided
effect upon the mixed gases, chlorine and hydrogen, and also that the
light emitted during the rapid passage of the electric spark, acts power-
fully upon them. For speed of action no tithonographic^ compound can
approach it; a light which perhaps does not endure the millionth part of
a second affects it energetically. In the red the chemical influence
is pretty active, and tlus, combined with the thermic power of that ray,
accounts for the phenomenon observed by Davy. I have found, how-
ever, that the combination is effected with the greatest speed by the
extreme blue and indigo rays. Dr. Draper has fixed the maximum in
the indigo rays, and giving a numerical value to the forces exerted by
the different rays, he calls the maximum power of the

Indig:o ray 240.00

Blue ray 144 .00

Violet ray 121.00

Green ray 54.00

Extra spectral ray 12.00

Yellow ray 2.00

Orange ray 75

Red ray 50?

The red ray should have a much higher power than is here stated,
as it is found it is quite equal to the green ray, and I think superior to
it in effect, since it has been shown that if glass tubes of small bore
are used, the combination of the gases can be effected without any explo-
sion.

Taking advantage of the action of the sun's rays upon these gases,
Dr Draper devised an instrument for measuring the chemical force
exerted by light. This instrument consists essentially of a mixture of
equal volumes of chlorine and hydrogen which is evolved from and con-
fined over muriatic acid, in a graduated bent tube. The gases are lib-

^Tithonicity was a name given by Dr. Draper to the chemical rajrs, but
which is perhaps badly chosen; and certainly not at all in accordance with
the Lavoiserion principle of nomenclature.

341

erated from the liquid acid by the agency of galvanic electricity. Plat-
inum wires, which can be connected with a voltaic battery, are inserted
into the tube in such a manner that when the required quantity of the
gases is formed the decomposition ceases, owing to the fluid having
fallen below the wires. The gases combine in a longer or shorter time,
according to the amount of light, the number of degrees over which the
fluid falls in the graduated arm in a minute giving relatively the force
in action. This instrument is certainly a very ingenious application.

The formation by the sun's rays of precipitates which do not occur
in the dark, has engaged the attention of Sir John Herschel ; but fur-
ther investigations are required. Phenomena which have been observed
lead me to believe that under no circumstances, where the changes are
gradual, does precisely the same thing take place in darkness as in day*
light. As far as observations have gone, it is found that in all cases
where precipitation does not take place immediately upon mixing two
solutions, there is a very marked difference in the time required for pre-
cipitation to ensue in a fluid kept in the dark, and in one exposed even to
diffused daylight, this being, of course, more strikingly shown if one
fluid ia placed in the sunshine.

Chlorine, iodine and bromine, it is well known, act with consider-
able energy upon metallic bodies. If, however, any polished metal is
exposed to the action of them in a diluted state, the combination is at
first exceedingly weak, and the films that are formed by either of these
three elementary bodies upon any metal, undergo considerable change
under the influence of the sun. In most cases it appears that these
bodies are set free, and the metal left in a state of very fine division or
oxidization.

Oopper, tin, iron, zinc, lead, pewter, bismuth and several other
metals have offered the same results. It is still more remarkable, that
films of bromine or iodine on glass are found, under the action of the
sun's ray, to act in a similar manner; and in 1841 a scientist of note
whose name I cannot find, published in some magazine a full account of
the power of iodine in rendering wood capable of receiving photographic
images.

In connection with this section of my subject, the following obser-
vation and experiments of Dr. Franklin are most important. They are
abstracted from his ''Researches on the Organic Eadicals," published
in the Quarterly Journal of the Chemical Society,

''Scheele, Seebeck, and others found that nitric acid exposed to
sunlight is converted into nitrous acid and oxygen, whilst many metal-
lic oxides loFe the whole or part of their oxygen ; thus peroxide of lead
is resolved into metallic mercury and red oxide,, whilst red oxide of mer-

342

cury^ under water^ is decomposed into grey oxide and oxygen gaa.

^^t has been long known, that certain inorganic bodies, containing
iodine, such for instance as the iodides of silver and gold, undergo-
decomposition when exposed to light, the iodine compounds of the noble
metals appearing to be most susceptible to this change.

^Trom the close relation of hydrogen to these metals, its iodide
might be expected to possess the same susceptibility and this is, in fact,
found to be the case; for it is well known, that aqueous hydriodic acid,
even when preserved in closely stopped bottles, gradually turns brown
on exposure to light, from the separation of free iodine, but the decom-
position only becomes continuous when the iodine is removed as fast as
it is liberated; it has also been observed, that when hydriodic acid gas is
allowed to stand over mercury, its volume becomes reduced to one-half,
end the residual gas consists of pure hydrogen ; but whether this reac-
tion only occurs under the influence of light, has not been clearly estab-
lished.

^'It has been remarked by almost all chemists who have had occa-
sion to employ iodide of ethyl, that this liquid becomes brown from
the separation of iodine when exposed even to diffused daylight; this
observation, which I have myself of late also frequently had an oppor-
tunity of making, induced me to hope that a decomposition here occurs
analogous to that suffered by the iodide of hydrogen under the same
influence. I find that the ethyl c<»npound when exposed to direct solar
light, rapidly becomes of a dark brown color; but, as is the case with
hydriodic acid, this separation of iodine soon ceases, and when a certain
intensity of color has been attained no further action takes place ; if,
however, the free iodine be removed by agitating the liquid with mer-
cury, the action immediately recommences and proceeds to the same
point as before. This behavior of the iodine under light and in contact
with mercury, indicated the method by which the action could be
carried on continuously and the products collected and preserved.

'Tor this purpose several glass flasks of about 10 ounces capacity
were filled with mercury, and inverted in a vessel containing the same
metal, a few drops of iodide of ethyl being then introduced into each
by means of a pipette ; they were exposed to the direct rays of the sun.
The surface of the mercury where it was in contact with the Hquid, soon
became covered with a film of proto-iodide, which, by the further
action of the light, was converted into biniodide, whilst bubbles of gas
were continually evolved and gradually displaced the mercury from the
flask ; finally, the whole of the iodide of ethyl disappeared, the gas and
biniodide being the sole products of the decomposition. Although sim-
ple exposure to the sun's rays caused this action to take place with tol-

848

arable rapiditj, yet it was greatly accelerated by placing each flask near
the focus of an 18-inch parabolic reflector^ which was not, however, so
highly polished as to cause a very considerable elevation of temperature,
the heat never rising to the boiUng point of iodide of ethyl (71.6^ C.)-

'^As iodide of ethyl is not in the least acted upon by mercury at a
temperature of 150^ C, it could scarcely be supposed that the compara-
tively low degree of heat at which these materials were exposed in the
focus of the reflector could play any important part in the decomposi-
tion ; yet, in order to set the question entirely at rest, an inverted bell*
jar, containing iodide of ethyl, conflned over mercuiy, was surrounded
by a glass cylinder, and this latter filled, first with water, then with a
solution of chloride of copper, and lastly with a solution of bichromate
of potash. When the outer cylinder was filled with water, the decoiti-
position proceeded with as much rapidity as without the intervention of
that fluid, whilst the temperature of the water was scarcely perceptibly
raised during the operation; the same was the case when solution of
chloride of copper was employed; but on substituting the solution of
bichromate of potash scarcely the slightest action was perceptible, even
after several days exposure to bright sunshine.

'^Now, since, according to Mr. Hunt at whose suggestion I employed
these liquids, the solution of chloride of copper absorbs nearly all the
heating rays and allows about 90 per cent, of the actinic rays to pass,
whilst the solution of bichromate of potash intercepts the actinic and
gives free passage to the heating rays, it is evident that the decomposi-
tion before us is due to the chemical influence of light, and is totally
independent of the heating rays of the solar spectrum."

Based upon the above experiments and our knowledge of the action
of light on chemical combination, I undertook a series of important
experiments upon the effects of the administration of iodide of potash
and soda, and mercury, in their various forms in the treatment of
syphilis in its various forms.

Much to my astonishment, in cases where I could not get as rapid
an impression upon the disease by the administration of these remedies
in the usual way, I found that when the subject was placed under the
electric arc-light, or in the pure sunlight, in a nude state, that these
remedies acted almost magically and their impressions were noticeable
in one-half the time than by the regular method of administration at
our disposal. I had a number of mixed cases under treatment (that
is syphilis, and tuberculosis of the lungs). I could not make as rapid
a progress as I would have liked until I began the method of exposure
of the body in a nude state half an hour after the administration of
tile iodide of soda, and mercury.

344

This combination of treatment in mixed cases of tuberculosis and
syphilis will be found to give results that no other methods to date can
possibly duplicate. Further on I have something to say of iron prepar-
ations upon which light acts within the body after their administration
to which I call your attention most recommendably.

INFLUBNCB OF THB SOLAK RAYS ON PRBCIPITATION.

In 1832 Sir John Herschel commtinicat^d the remarkable fact, that
when a solution of platinum in nitro-muriatic acid which has been neu-
tralized by the addition of lime, and has been well cleared by filtration,
is mixed with lime water in the dark, no precipitation, or scarcely any,
takes place, but when (being thoroughly cleared of any sediment) this
mi^cture is exposed to sunshine it instantly becomes milky, and a white
or yellowish-white precipitate speedily falls*

By exposing this mixture behind colored media. Sir John Herschel
found that the effect was due to the influence of the most refrangible
rays. These mixtures another noted scientist placed in small glass
tubes, and so arranged them that they were individually exposed to a
separate ray of the spectrum ; after an exposure of one hour the follow-
ing results were obtained, the precipitates having been carefully washed
and dried in the tubes in which they were formed.

Host refrangible rays beyond the visible spectrum 0.07 gr.

Violet rays 1.05 gr.

Indigo rays 0.60 gr.

Blue rays 0.45 gr.

Green rays 0.10 gr.

Yellow and Orange rays

Red rays 0.05 gr.

It is a fact worthy of especial notice, that this precipitation is so
dependent upon the amount of sunshine, that precipitates obtained in
the same time, being carefully weighed off, will show the relative
amount of actinic influence to which they have been exposed.

Manganate of potash : A solution of this body, having been made
in the dark, was placed in two glass vessels and set aside. After having
been kept in darkness for two hours, the solutions remained as clear as
at first. One of the vessels with its contents was then removed into
the sunshine, when the solution immediately became cloudy and was
very speedily decomposed, the precipitate falling heavily. By experi-
ments with the spectrum I have since found that the precipitation is
due ahnost entirely to the more refrangible rays. I have not been
•enabled to decide with that degree of accuracy I could desire, in which
xay the maximum effect is produced. The precipitates formed in the

845

blne^ indigo and violet rays were nearly of the same weighty bnt it did
appear that the precipitation was most speedily produced by the mean
blue ray. After all my experimental research^ I find that the blue ray
is one of the most powerful chemical action rays in the entire spectrunu

If we dissolve the brown precipitate from the chameleon mineral
in a solution of cyanide of potassium^ we have a clear fluid. Reserve
one portion in darkness^ and expose another to direct sunlight ; the solu*
tion preserved in the dark -will remain quite clear for many days,
whereas that exposed to aclimc influence throws down a brown precipi-
tate after a few hours' exposure.

When a few grains of sulphate of the protoxide of iron are dis*
solved in rain-water and kept in perfect darkness, the solution remains
dear for a long time ; it becomes, however, eventually cloudy and col-
ored from the formation of some basic salt of iron, even in tubes hermet-
ically sealed. A few minutes' exposure to direct sunlight is sufficient
to produce this change, and tiie salt formed, instead of floating in the
fluid and, as, in, the former case, rendering it opaque, falls speedily to
the bottom.

Of course I could go into this subject deeper, taking up the ques-
tion of the solar action on various metallic compounds, non-metallic
compounds, thermography in reference to the examination of all the
phenomena connected with the supposed radiation of light in absolute
darkness, phosphorescence, the magnetizing power of light, etc., but all
this is beyond the pale of this paper.

ON THE SOLARIZATION OF THB NUDE BODY BY THE SUN OR ELECTRIC

ARC RAYS AND THB PHYSIOLOGICAL AND PHYSICAL INFLUENCE

OF THESE RAYS UPON IRON PREPARATIONS AFTER

THEIR ADMINISTRATION.

I bring before your notice here one of the physical marvels which
light is capable of producing upon the salts of iron, without and within
the human body, or upon vegetation.

This physiological discovery has been followed up closely in its
various aspects, and as a conclusion, I found that in the administra-
tion of iron-salts, in connection with the exposure thereafter of the
patient's body to sunlight or the arc-light, an immediate physical and
physiological change takes place, making it possible for metabolism to
do the rest of the work, with results that are remarkable.

It is a noted fact that photographic chemistry has taught us much
ID many respects. We are indebted for nearly all the facts connected
with the photographic properties of the salts of iron to the labors of Sir
John Herschel. In his hands these salts have become valuable photo-

846

graphic agents ; and two or three prooessea which have been deviaed are
among the most interesting within the range of the photographic art
These varions processes can be referred to in the many works on pho-
tography where the whole detail can be accurately stadied.

I have f oimd that nearly all the salts of iron, under the influence
of the sun's rays or under the electric arc-light, for a longer or shorter
period, undergo changes. Herschel found this fact : — ^Papers washed
with the f errosesquicyanuret of potassium exposed to the priamatic spe^
tram, proved that the decomposition of the salt and deposit of prossian
blue is due to the action of the blue and violet rays below the blae,
having absolutely no influence. The greatest activity appears to exist
about the region of the indigo rays. The rationale of theae different
processes in photography has been well explained by HerscheL In
nearly all cases the action of the sun's rays is a deoxididng one. In the
case of the f errosesquicyanuret-of-potassium-process, where the paper is
simply washed with the f errosesquicyanuret of potassium, it is found
highly sensitive to light. Exposed to sunlight for about an hour or leas,
with an engraving upon it, a beautiful negative photograph is the result.
Really what happens physically is that oxygen which combines with
hydrogen to form water is parted with. JPrussian blue is deposited,
the base being supplied by the destruction of one portion of the f er-
rocyanic acid, and the acid by the destruction of another. Herschel
says : '^It seems natural at first sight, to refer these curious and complei;
changes to the instability of the cyanic compounds ; and that this opinioa
is to a certain extent correct is proved by the photographic impressions
received on papers which have no iron but that which exists in the fer-
rocyanic salts themselves. Kevertheless, the following experiments
abundantly prove that in several of the changes above described, the
immediate action of the solar rays is not exerted on these salts, but on
the iron contained in the ferruginous solutions, added to them, which
it deoxidizes or otherwise alters, thereby presenting it to the f errocyanie
salts in such a form as to precipitate the acids in combination with tke
peroxide or protoxide of iron, as the case may be.

To make this evident, all that is necessary is simply to leave ovi {he
ferrocyanate in the preparation of the photographic paper which thus
becomes reduced to a simple washing over with the ammonia-citric solu-
tion. * * * If a slip of this paper be held for any four or five
seconds in the sun, or arc-light (the effect of which is quite impercepti-
ble to the eye) and when withdrawn into the shade be washed over with
the f errosesquicyanate of potash, a considerable deposit of prussian blue
is formed on the sunned part, and none whatever on the rest, so that on
washing the whole with water, a pretty strong blue impression is left.

847

tlenKmstrating the reduction of iron in that portion of the paper to the
state of protoxide. The effect in qneetion is not, it should be obserredi
peculiar to the ammonia-citrate of iron. The ammonia- and potasso-
tartrate fully possess, and the perchloride, exactly neutralized^ partakes
of the same property; but the experiment is far more neatly made and
sncceeds better with other salts.

If this salt is mixed with perchloride of iron, and washed over
paper, whilst it is e3q[K>sed to the spectrum, the action is continued down
to the Tory end of the thermic spectrum. The formation of the deposit
eolor in this region is accompanied with phenomena of a novel character,
referable to the heat developed by the thermic spectrum. Oval brown
wpotB are formed which correspond with the heat spots referred to, and
which are evidently due to calorific agency. If ammonia-citrate of iron
is used instead of the perchloride, ^^a copious and richly colored deposit
of Prussian blue is formed over the whole of the blue, violet and extra
spectral rays in that direction, extending downward (with rapid gradua-*
tion) almost to the yellow in the spectrum." If the action of light is con-
tinued, the blue and violet rays in a very strange way destroy their owi^
work. ^^A whiie oval makes its appearance in the most int^e part of
the blue, which extends rapidly upwards and downwards ; at a certain
point of the action the upper or more refrangible extremity of the white
impression exhibits a semicircular termination, beyond which is a dis-
tinct and tolerably well defined conjugate image, or insulated circular
white spot, whose center is situated far beyond the extreme visible
tiolet.'^

As far as my researches have gone, all the persalts of iron are con*
verted into proto-salts by exposure to sunlight and electric arc-light rays,
when in combination with oi^anic matter. This has beeen most fully
confirmed and even in soils all the persalts are changed to proto-salts
of iron by the action of growing v^etable and light. I have reasons
for believing that all the proto-salts undergo some change. What this
change may be it is impossible to say at the present stage of the inquiry,
but it will be seen that scarcely any of the metallic salts resist the
agency of the sun's light or arc-light rays.

It was these facts that first led me |o undertake a number of phys-
iological esqperiments to test the value of the different salts of iron in
eonjunotion with light administration. In over one hundred tubercu-
lous patients the different iron salts and organic preparations of iron
were administered and the patients placed daily in the way of the sun's
xays and electric arc-light. Much to my surprise I found that the iron
aiilts (organic iron preparations) were taken up most rapidly, showing
marvelous constitutional effects. After the first week the blood counts

• 348 ^ •

proved their richness in number to an enormous amount, as compared
^th previous counts, by the older methods of administration and with
other preparations by the old daily method. The haemoglobin increase
was very marked.

To-day for the first time since my experimental work, I bring this
new method before your notice, knowing of nothing more powerful that
will assist in supplying iron to the system more rapidly than usual, in
cases where it is indicated, than this method of administering salts of
iron in combination with light We also know that iron in various
forms is being introduced daily into the system by many articles of
food ; light aSects these forms of iron in exactly the same manner as if
it were taken in the form of the salts. It is often a good plan, where
it is feasible to allow the eating of such foods and vegetables as much as
possible. I have taken notice of this fact in a number of cases and
must say very satisfactory results have been obtained. Amongst the
different forms of iron and its compounds, that I made use of in my
investigations, were the Blaud's pill in capsule in a fresh state, the
ammonia-citrate of iron, carbonate of iron, tct. chloride of iron, and
Tropon. This organic compound with iron was selected by me upon
its merits ; I found it contained vegetable and animal materials in such
a state as light would perhaps have a rapid action upon. Much to my
own surprise I noticed that this organic food with an iron prepara-
tion showed important therapeutic results after a very short time. It
also gave the least digestive disturbances, as compared with the others.
Hard boiled eggs and iron powder gave me excellent results. All iron
preparations exhibited in connection with light rays, left beyond a doubt
their physiological workings.

HINTS IN CONNECTION WITH THE ADMINISTRATION OF LIGHT RAYS.

White or light colored clothes transmit more light to the body than
those of any other color, while black or dark colored clothes absorb the
light and degrade it into the coarser principle of ordinary heat. You
may ask me the question : Is not an object white from the fact of its
reflecting all the colors? How then can it transmit them? I answer
you as follows : The white reflects a large amount of all the rays, but
all those rays which penetrate the interstices of a white garment suffi-
ciently far, pass in as white ones beyond it from the repulsive nature of
all the threads, while a black garment from its great affinitive attraction
for all the rays greedily absorbs them and prevents their escape on the
other side. A sufficient proof of this is the fact that a black or blue
curtain will darken a room far more than a white or buff-<;olored one.
But the dark colored curtain of itself will be warmer than the white

349

one. The experiments of Dr. Franklin, in which he put various colored
cloths on the snow, are well known. The darker the color of the cloth,
the more deeply did the snow melt beneath it nnder the solar rays.
But this does not signify that the black transmitted more heat, but
absorbed it, and the garment thus warmed melted the snow because of
contact with it. If the cloths had been placed some distance above the
snow, the light colors, transmitting the heat more rapidly, would have
melted the snow more quickly/ just as we* see that yellow and orange
and red glass transmit more heat than the blue.

The rule is, that if radiant heat^^ni)e entirely transmitted, no eleva-
tion of temperature is produced in the body through which it passes,''
and the very fact that a body grows warm under the heat rays shows
that the rays are not transmitted, but absorbed.

It is for the above reasons that all clothing for general wear of
tuberculous patients should be made up from the lightest colored
materials (preferably all white garments, down to the underclothing).
This is highly commendable. The nude state of the entire chest down
to the waist exposed daily for several hours, is, of course, still better. I
have seen most wonderful results from the exposure of the entire body
in a nude state in solaria which were built for several of my patients,
and which had all the appointments suitable for the different seasons of
the year.

We read in the history of ancient Greece how the inhabitants had
axnall terraces, in the form of solaria built on the tops of their houses,
and in which they took their daily sun baths. There is nothing to pre-
i-ent the owners of general dwelUngs from providing for their tenants,
a solarium, built above the body of every house on the roofs and fum
isliing it with modem appointments, making it useful both in winter
and in summer. If provisions are made for the certain days in which
the Sim's rays are not accessible, the electric arc-lighting may be
resorted to. This takes the place of the sun's rays. In this manner a
continuous use of light rays may be had at all times.

This method should be employed in every hospital that professes lo
treat the consumptive according to modem principles.

Children who are weaklings and those who are pretuberculous
should be reared in solaria for several hours daily. The solarium
should be so constructed that it would be independent of climatic condi-
tions, from every point of view. I have had a number of practical clin-
ical experiences, within the last ten years, with solaria and I commend
their use in the highest terms.

Gymnastics must also be practiced in the nude state and hydro-
therapeutics added to the treatment in general.

360

We have thus seen that the magnetic^ electric powers of the sun's
rays reside in the violet ray, which is a compound of the blue and red
rays. These constitute what are termed the chemical powers of the
sunlight. That they are the most important powers of nature, thero
can be no doubt as without them life cannot exist on this planet With-
out these chemical powers there coidd be no vegetation or anything else,

light is inimical to, and under favorable conditions may wholly
prevent, the development of organism. The action of light entirely
destroys the bacteria, or reduces them to a condition of torpidity which
requires months of darkness in favorable surroundings for them to over-
come. In my experiments, I took small test tubes containing cultiva-
tion fluid, which were suspended in deep, narrow boxes made of gamet|
red, yellow, blue and ordinary glass, respectively. Although the blue
and yellow glasses were not monochromatic, the results showed that
the action is chiefly dependent on the blue and the violet rays.

It IB probable, therefore, that if the phenomena were represented
by a curve, the maximum elevation would be found in or near the violet.
The organisms, with which many of the experiments were carried out,
afford an example of protoplasm in a simple and uncomplicated form,
but it would be unreasonable to suppose that this protoplasm is so
essentially different in its fundamental constitution from all of the
protoplasm, that here, and here only, is this special effect of light to
be found. There are many facts which prove the contrary and indi-
cate, not with a special and fortuitous phenomenon, but with a general
law.

I have found that not all the rays of the spectrum are able to exert
an influence upon the direction of the movement of the spores, it being
only those which are strongly refracted (blue, indigo and violet) that
produce stimulation. If a vessel containing a deep-colored solution of
ammoniated copper oxide which only transmits blue or violet rays, be
placed between the source of light and the preparation, the spores are
seen to react just as if they came in contact vdth ordinary white light :
on the other hand, they do not react at all to light, which is passed
through bichromate of potassium solution, through the yellow vapor of
a sodium flame, or through ruby-red glass ; another very important and
complex manifestation of the effects due to light is seen in the move-
ments of the chlorophyll corpuscles.

light acts as a stimulus to animal and plant protoplasm. It
induces characteristic changes of form in individual cells and causes
movements in flxed directions in free-living unicellular oi^anisms.

I have discovered, by experiment and practice, the special and spe-
cific eflicacy in the use of the combination of the calorific rays of the sun,

851

and the electric arc-light in stimulatiiig the glands and cells of the body,
the nervous system generally, and the secretive oigans of man and
animals. It, therefore, becomes a most important adjuvant element in
the treatment of acute and chronic diseases, especially such as have
become chronic, or result from derangement of secretive, perspiratory
or glandular functions, as it vitalizes and gives renewed activity and
force to the vital currents that keep the health unimpaired, or restore
them when disordered or deranged.

SOMB STUDIES OP THE INPLUBNCB OP THB BLBCTRIC ARC-LIGHT UPON

GRBBNHOUSB PLANTS.

At the agricultural escperimental station of Cornell University in
the winter of 1889 and '90, some experiments on an extensive scale
were carried out to determine what influence the ordinary electric aro-
light exerts upon plants in greenhouses. Much has been said among
gardeners concerning supposed retarding or accelerating influences of
the are-light upon plants. Many have supposed that the electric li^t
can be introduced profitably into greenhouses for the purpose of hasten-
ing growth. The general opinions varied on this subject until these
experiments and those by the Horticultural Department of Washington
settled some of the most important points in connection therewith.

The first experiment to determine the influence of electric light
npon vegetation was made by Herve Mangon in 1861.^ This experiment
showed that the electric light can cause the production of chlorophyll,
or green color to plants, and also, that the light can produce heliotrope
iflm, or the phenomenon of turning or bending towards the light

In 1869, Prillieux* showed that the electric light in conmion with
other artificial lights, is capable of promoting assimilation, or the decom-
position of carbon dioxide in water. The next experiments appear to
have been those of C. W. Siemens, in England, and P. P. Deherain, in
France. These two, with those of Cornell and the Washington Horti*
cultural Department appear to be the only definite investigations of this
subject.

The English experiments, although eminently practical, were con*
ducted by an electrician, and the French were largely confined to physi-
ological problems. It seemed proper that the third «eries of experi-
ments should be approached from the particular standpoint of the gar-
dener.

Dr. Siemens' experiments may be divided into two series: In
one series the lamp was placed inside the greenhouse, and in the other

'Compt., Rend. 53, 343.
'Compt.y Rend. 69, 410.

352

snspended over it In both cases he observed marked effects upon veg-
etation in a short time.^

A great variety of plants was treated* The dynamo which Sie-
mens used in his first experiment, ^%akes 1,000 revolutions a minute;
it takes two horse-power to drive it, and develops a current of 25 to 27
meters, of an intensity of 70 volts''. The light produced is equal to
1,400 candles measured photometrically..

When the lamp was placed inside the house, plants within three
or four feet of it suffered much, the leaves of the melons and cucumbers
''which were directly opposite, the light turning at the edges and pre*
senting a scorched appearance." When these injured plants were
removed to a distance of seven or eight feet, they showed ''signs of
recovery, throwing out fresh leaves, with pearls of moisture at their
edges." In general, plants which were exposed to normal conditionB
during the day and six hours of electric light at night far surpassed the
others in darkness of green and vigorous appearance generally." The
liavor was fully as good in the electric light fruits as in the others. The
results were supplemented by larger experiment in the winter of 1880
and 1881.

In this case a lamp of 4,000 candle-power was used, and it was
placed inside a house of 2,318 cubic feet capacity. The light was run
all night, and the arc was at first not protected by a globe. The results
were anything but satisfactory, the plants soon becoming withered. At
this point a globe of clear glass was placed upon the lamp and thereafter
the most satisfactory results were obtained. Peas, raspberries, grapes,
melons and bananas fruited early and abundantly under continuous
light — solar light by day and electric by night.

The strawberries are said to have been of "excellent flavor and
color" and the grapes "of stronger flavor than usual." The bananas
were "pronounced by competent judges unsurpassed in flavor," and the
melons were "remarkable for size and aromatic flavor." Wheat, barley,
and oats grew so rapidly that they fell to the ground of their own
weight. The beneficial influence of the clear glass globe was therefore
most marked. The effect of interposing a mere sheet of thin glass
between the plants and the source of the electric light was most striking.
On placing such a sheet of clear glass so as to intercept the rays of elec-
tric light from a portion only of a plant — ^f or instance a tomato plant —
it was most distinctly shown upon the leaves. The portion of the plant
under the direct influence of the naked electric light, though a distance

^Proc. Royal Soc, XXX, tio and 293. Rep. British A, A, 5., 1881,
474* See also abstract in Nature, XXI, March, ii, 18S0, and an editorial in
the same issue.

353

from it of nine or ten f eet^ was shrivelled^ whereas that portion under
cover of the clear glass, continued to show a healthy appearance, and
this line of demarkation was distinctly visible on individual leaves ; not
only the leaves but the young stems of the plant soon showed signs of
destruction when exposed to the naked electric light, and those destruc-
tive influences were preceptible, though in a less marked degree, at a
distance of twenty feet from the source of light."

In other series of experiments Siemens placed an electric lamp of
],400 candle-power about seven feet above a sunken melon pit which
was covered with glass. The light was modified by a clear glass globe.
In the pit, seeds and plants of mustard, carrots, turnips, beans, cucum-
bers and melons were placed. The light ran six hours each night and
the plants had sunlight during the day. It all cases those plants
"exposed to both sources of light showed a decided superiority in vigor
over all others, and the green of the leaf was of a dark rich hue.'' Hel-
iotropism was observed in young mustard plants. Electric light
appeared to be about half as effective as daylight. A great difficulty
experienced in this experiment was the films of moisture which con-
denses on greenJiou&e roofs at night, and obstructs the passage of light.
The light was at one time suspended over two parallel pits nearly four
feet apart, and the effect was observed upon plants under the glass and
in the uncovered space. In all cases the growth of the plants was has^
tened. Flowering was hastened in melons and other plants under the
glass. Strawberries which were just setting f rdit, were put into one of
the pits, and part of them were kept dark at night, while the others were*
exposed to the light. After fourteen days, the light having burned
twelve nights, most of the fruits on the lighted plants "had attained
to ripeness and presented a rich coloring, while the fruit on those plants
that had been exposed to daylight only, had by this time scarcely begun
to show even a sign of redness." He concludes that a lamp of 1,400
candle-power produced a maximum beneficial result at a distance of
three meters (nearly 10 feet) above the glass but "the effect is never-
theless very marked upon plants at a greater distance."

At the close of his experiments Siemens was sanguine that the elec-
tric light can be profitably employed in horticulture, and he used the
term "electro-horticulture" to designate this new application of electric
energy. He anticipated that in the future "the horticulturist will have
the means of making himself practically independent of solar light for
producing a high quality of fruit at all seasons of the year."

Ut is to be observed that the light used by Dr. Siemens' in this case was
4,000 candle power.

354

He had shown that growth can be hastened by the addition of elec-
tric light to daylight^ that injury does not necessarily follow continuou;^
light throughout the twenty-four hours, that electric light often deepeni>
the green of leaves and the tints of flowers, and sometimes intensifies
flavors, and that it aids to produce good seeds ; and he thought that the
addition of the electric light enabled plants to bear a higher tempera-
ture in the greenhouses than they otherwise could. But whatever may
be the value of electric light to horticulture, the practical value of
Siemens' experiments is still great. They have furnished data in sev-
eral obscure relations of light to vegetation. Nature made the follow-
ing comments upon this feature of the application of the electric light
by Dr. Siemens : ^3ut the scientific interest of its present application
must rest mainly on the fact that the cycle of the transformation of
energy engaged in plant life is now complete and that we can run
through the changes from heat to electricity and thence to light, which
now we know we can store up in vegetable fuel again."

Deherain's experiments were conducted at the Exposition d'Elecr
tricite, Paris, in 1889. A small conservatory standing inside the expo-
sition building was divided into two compartments. One compartment
was darkened and the glass painted white upon the inside ; this received
the electric light and all solar light was excluded. The other compart-
ment was not changed. The amount of sunlight which the plants nor-
mally received in this conservatory within an exposition was not sufli-
cient to maintain a healthy growth. A lamp of 2,000 nominal candle-
■Jpower was used. At first the naked electric light was used and it ran
continuously. Barley in head and flax in flower were brought into the
lighted compartment ; also chrysanthemums, pelargoniums, roses and a
variety of ornamental plants. After seven days of continuous electric
lighting most of the plants were seriously injured.

All the pelargoniums lost their leaves, cannas were discolored,
four-o'clocks were tarnished and bamboos were blackened. "But the
most curious effect was produced upon the lilacs ; all the parts of the
leaves that had received the direct rays from the lamp were blackened,
while those protected by the upper leaves preserved their beautiful
green color, and the impression produced upon the epidermis by the
electric rays had the clearness of a photographic plate.'' Similar effects
were produced upon azaleas, dentzias, and chrysanthemums. It was
found that this discoloration did not extend beyond the first layer of
palisade cells. Plants which received solar light by day and electric
light at night were injured in the same manner, but only in a less degree.
The injury was most marked upon the old leaves. The pelargoniums
soon sent out new shoots and the yoimg leaves resisted the action of the

355

light much longer than did the mature ones. The flax continued to
grow and the barley ripened. It was found that plants under the elec*
trie light alone were able to assimilate, but the action was very slow.
As much asshnilation took place in an hour on a bright summer day as
in several days of electric light At the expiration of two weeks the
condition of the plants was so bad that a change was made, and there-
after a globe was used upon the lamp.

The experiment with modified light by use of a transparent glass
globe was conducted like the preceding. Sprouting seeds in electric
light alone grew for a short time, then drooped and (Ued, not being able
to make true leaves. Sprouting maize turned black, but maize in full
growth remained in apparently good condition, though not growing
even for two months. ^N'ew leaves appeared on roses and other plants,
but growth was slow or none. Elowers did not appear, and seeds did
not mature in previously formed fruits, except in the case of barley,
which made good seeds. New growths appeared at the base of some
plants, and the petioles of pelargoniums became very much elongated.
Many plants remained almost stationary throughout. Assimilation
was more feeble than under the naked light. Plants which had been
set out of doors during the day and brought into the electric light house
at night did not behave any better, if as well, than those left out of
doors continuously.

Deherain's account was replete with interesting speculations upon
the physiology of the plants under experiment. His general conclu-
sions of the influence of electric light upon plants are as follows : —

1. The electric light from lamps contains rays harmful to vege-
tation.

2. The greater part of the injurious rays is modified by a trans-
I)arent glass.

8. The electric light contains enough rays to maintain full-grown
plants two and a half months.

4. The light is too weak to enable sprouting seeds to prosper or
to bring adult plants to maturity.

I'inally, observations were made more recently upon the influence
of the electric light upon plants in the winter palace at St. Petersburg.
It was observed that in a single night ornamental plants turned yellow
and then lost their leaves. Yet it is well known that incandescent
lamps can be lodged in the corolla of a flower without injuring it

I refer vou to the literature for fuller information than it is here
my privilege to give.*

* Cornell University Afyicultural Experiment Station Bulletin^ 30, August,
1891; Electro-Horticulture Bulletin^ 42, Sept., 1892; Hatch, Experimental
Station of Massachusetts Agricultural College Bulletin^ 23, Dec, 1893.

356

I however cite a few points which are clear : — "The electric light
promotes assimilation, it often hastens growth and naturally, it is cap-
able of producing natural flowers and colors in fruits; it often intensi-
fies colors of flowers, and sometimes increases the production of flowers.
The experiments show that periods of darkness are not necessary to the
growth and development of plants. There is every reason, therefore,
to suppose that the electric light can be profitably used in growing of
plants.

The experiments suggest msjij physiological speculations upon
which it is not the province of the bulletin to enter, yet two or three of
tliem may be mentioned. It is a common notion that plants need rest
at night, but this is not true, in the sense in which animals need rest.
Plants have simply adapted themselves to the conditions of attending
daylight and darkness, and during the day they assimilate or make their
food, and during the night when, perforce, assimilation must cease,
they use the food in growth. They simply practice an individual divi-
sion of labor. There is no inherent reason why plants cannot grow in
full light, and in fact, it is well known that they do grow then, although
the greater part of growth is usually performed at night. If light ia
continuous, they simply grow more or less continuously, as conditions
require, as they do in the long days of the arctic regions, or as our plants
did under continuous light. There is no such thing as a plant becom-
ing worn out or tired out because of the stimulating influence of con-
tinuous light.

It would seem, therefore, that if the electric light enables plants
to assimilate during the night and does not interfere with growth, it
must produce plants of great size and marked precocity. But there
are other conditions, not yet understood, which must be studied."

Hundreds of these exemplary facts upon the action of light rays in
connection with chemistry, physio-chemistry, physiology and photo*
therapeutics are known to us. The facts that I have cited here and
there must suffice to give one an idea, at least, of the power that light
exerts upon matter.

BLBCTRIC ARC CROMOLUMBS FOR GBI7BRATING VIOLBT RAYS OF LIGHT
AS AN ADJUNCT TO THB TRBATMENT OF TUBBRCULOSIS.

In 1896 I published in the New York Medical Journal^ some
important remarks upon this subject, and since then have made many
important chemical and physiological tests as to the power of light in
therapeutics. Tuberculosis interested me mostly, so I dropped from

357

my list of researches many experiments which belong to other domainii
of medicine.

My specially constructed electric arc-light lamps for generating vio-
let rays of light, (color light or chemical rays) have undergone many
•changes since my early experiments. I found that concentration of
light would mean a great factor in the development of this principle
and therefore more generating power was a necessity. This gave these
parallel rays much more penetrating capacity f oj dense tissues ; I there-
fore reconstructed my older models, and now use the apparatus as illus-
trated. Next came the question of simplicity of construction and man-
agement. I have succeeded in this undertaldng after many trials.

These illustrations show several types used by me in my daily clin-
ical practice which have proved most satisfactory as to results. These
types of lamps are capable of generating rays of the highest quality,
4)e8ide8 having the power of penetration.

I showed that concentrated rays of light as produced from an elec-
tric arc lamp of high power pass through the solid tissues as well a^
through bone, by allowing these rays to fall directly upon the chest-wall
und, as a proof of this fact, printing from a negative plate or £lm upon
a sensitive plate, and subject matter thereon, in less than fifteen min-
utes. This test, as I say, has again been confirmed by Dr. J. W. Kime,
of Fort Dodge, and he difiFers in the method employed by me by using
<*oncentrated sunlight, instead of the electric arc.

As far as my clinical record goes, I can say here, that I have
<anployed these colored rays of light as an adjunct to the general treat-
ment of tuberculosis of the lungs with the most successful issue in sixty
cases. J find that electro-arc solarization can claim for itself a rank as
one of the greatest tonics and bacterial destroyers. There are many
Bcientific facts regarding the chemical and physiological action upon the
system which need study. Still, several which I have already studied
and made use of, seem to fill the long-felt want in the treatment of this
disease.

Of these sixty cases, I can report forty cured, and in twenty the
<iisease was arrested to such an extent as the pathological changes pres-
ent when they came under treatment, would admit. I now fully believe
from my experience that, as an adjunct, light rays play a leading role
in the treatment of tuberculosis. I want to stand upon these remarks
'for a future record.

The administration of these rays must be understood from the
yery first. Dosage, and how given, plays an important part, and no one
ahouid attempt to use them homeopathically. Long exposure is one of
the prime rules — nothing less than a half-hour over the nude surface of

358

the selected areas; however, a longer time is preferable for each sitting.

A simple description of these electro-arc generators of the chrom-
rayS; and the method of employing them is essential. I gave these
lamps the name of electrcHirc chramolumeSy as they are the sole
producers of these specific colored rays. Their construction is so sim-
ple that their management does not require any study. They are all
capable of giving from 2,000 to 20,000 candle-power or more. This
high candle-power or e^ciency is dependent upon the amount of cur-
rent at one's disposal. There is no difficulty in getting any amount of
electric current for their operation. All that is necessary is to have
the room wired with an exact thickness of carrying efficiency, and then
to have a transformer of exact size — ^which any company is always
ready to furnish on application.

My own plant is furnished with a 40 amperes current transformer
and the lamps are so constructed that more or less current does not
affect them. By this arrangement any one can change his installation
according to his work.

Each lamp for generating these chemical rays has fitted to it, one
rheostat, and therefore, more than one generating lamp can be set in
operation at the same time, and in the same room or elsewhere. Also
they can be installed to operate on a single rheostat in such a manner
that any special lamp may be selected where there are more than one
in use. There are several different types of my lamps now on the mar-
ket and they are made suitable to the diffemt electric currents, for the
high tension and the low tension (the alternating or the Edison direct
current), as this was a most necessary point to be considered. For the
high tension current, I constructed a lamp which operates both auto-
matically and as hand-fed. This lamp, in order to get a steady and
pure light spot, is provided with a concave mirror, and a moving gear
for adjusting the focal lines — ^a most important device, this adjustment
— as the focal parallel lines can be changed to the exact spot wanted.
The focal spot ranges from 3 1-2 inches to 17 1-4 inches of concentra-
tion. By this means any part of the pulmonary apex or other portion
of the anatomy can be treated accordingly. For the low tension, (Edi-
son direct current) the lamps are different. The focal lines are created
by a Mangin's mirror on the principle of the search-light, and have the
same advantages as the other lamps.

A screen and hood, carrying a shutter on the front of the lamp,
for cutting down the size of the light spot to be used, according to the
area to be covered with the light rays, accompanies every electro-arc
chromolume. This screen is a piece of additional apparatus and is for
the purpose of screening the heat rays emitted during the operaticm of

359

the lamp upon a selected surface with a Mgh concentration of the light-
beam, for an; length of time. It consists of blue glass, cut in strips,
Mt in a frame^vork, on a movable stand, capable of many changes of
pcwition.

All t^ese generating lamps are moimted on stands which give anv
angle of motion suitable for application. The entire lamp, screen, etc.,
can be removed over any area of the operating chamber. They have
long cables attached to the lamps, coming frcnn the electric feeder of
the installation. I have used several of these types and each one has
Hs own particular value.

Fig.20. Dfagrai;

of tbe of the Electro- Arc Chromolume tbowlng the details
of its workiDgf.

The new types which I illustrate are adaptable for all purposes ;
one can get a concentrated beam from one-half to thirty or more inchest.
These illustrations speak for tbemaelvea. I present a photo by way of
illustration, of the chromolume in full operation, taken from my earli-
est experimental work in 1S94. This gives an idea how tbe light is
applied to tuberculous patients.

GBNBRA.L INFORMATION ON THE HAN&GBMBNT OF THE BLECTRO-ARC
CHROMOLUME.

In focusing the lamps it is most important to note that the upper
carbon is positive and in connecting the lamps the positive current must

360

flow to the upper carbon. The poaitive carbon is cored 12 inches long
and negative solid 7 inches long ; in these lamps the carlxms bum In
this proportion and thus keep exact focus. When 30 to 35 amperes
is used the carbons should be of 5*8 diameter. Good carbons are nec-
essary for good light, and the lamp is often blamed when fault lies
with the carbons. These lamps have horizontal feed- carbons; the
positive is in the front holder with its point facing the mirror.

As before stated^ it is necessary to see that the positive current
flows to the positive or front carbon. Clamp in securely the long cored
positive carbon and the short solid negative, so that the meeting point
is the focus of the mirror; this varies according to the diameter of the
mirror ; the distance, approximately, is given in the following table.
See that the carbons line up straight. The lamp box is on a movable
carriage, the hand wheel at the rear of the lamp-case moves the lamp
either nearer or farther from the mirror. If the lamp is too far for-
ward the beam will have a dark center; by drawing the lamp closer
to the mirror this will disappear and the beam will be clear and round
and the rays of light entirely parallel. The mirror projectors are fitted
with attachment to feed the carbons by hand if occasion should require,
the arc-lamp bums at 45-48 volts. The lamp is perfectly steady on the
low voltage of 50 direct incandescent circuit, but the rheostat supplied
with the projector is regulated to any voltage as given.

TABLE OF THE DIFFERENT SIZES OF LAMPS AND CANDLE POWER.

Diameter of

Amperes.

Diameter Carbons.

Candle Power at

Candle Power

Focal

Mirror.

P. N.

the Arc.

Projected.

Length.

7 in.

1-2 in.

7-16 in.

2000

8000

3 1-2 in.

9 in.

9-16 in.

1-2 in.

3000

12000

4 1-2 in.

12 in.

5-8 in.

9-16 in.

5000

20000

7 in.

16 in.

11-16 in.

5-8 in.

8000

32000

9 in.

20 in.

3-4 in.

5-8 in.

12000

48000

10 in.

24 in.

7-8 in.

3-4 in.

16000

64000

12 3-4 in.

30 in.

100

11-8 in.

lin.

20000

80000

17 1-4 in.

Let me say, in concluding this short article on my chromolume, to
those who will follow up this method of photo-therapeutics as an adjunct
to the general treatment that they will be most amply paid for the trial.
With light rays, hygienic food, fresh air, exercise and such suiable
remedies as are indicated according to the case in hand, 75 per cent, of .
tuberculous patients are curable, that is curable to a certain extenti
according to the lesions or pathological changes already present at the
time the case comes under treatment.

Of course we all understand that pathological conditions which
haye in certain stages of this disease left their markings, cannot be
changed. We cannot give the patient any more breathing capacity^

361

«fter certain conditions become, so to saj, stationary. Each case, how-
ever, is taken upon its own merits and treated accordingly ; only suck
promises can be made to a patient as the existing pathological conditions
will permit. There are, however, forms of tuberculosis which can
be thoroughly cured, and a large majority, if they present themselves
at an early stage are curable by this adjunct treatment within from 2
to 8 months. One important factor must always be remembered in
this method, that much time should be alloted to each case — ^no less
than an hourly sitting daily. This phototherapy is most admirably
adaptable for sanatarium and hospital purposes. For years I have
adopted a system of generating these colored rays of light. Where
practical I have advocated the construction of solaria ; these of course
are more suitable to country than city use.; also in a climate where the
sunshine is in abundance.

The solaria must be constructed on plans which provide for all con-
tingencies and the important necessities, heating, ventUating, cooling,
glazing by colored glass intermixed with white glass, proper exposure,
etc., are some of the principles embodied in their successful employ-
ment Also proper exposure of the patient plays an important part in
the treatment. The entire body should be exposed to this light for at
least two hours or more daily.

I regret that my plan to publish in this Journal a complete treatise
in sections on light from many important sides of the question, which
it was my intention, failed. Nevertheless, I have tried in the space
alloted me to give its readers sufficient of the subject matter that I may
hope to stimulate more serious thought about light and its effects.

ICHTHYOL IN TUBERCULOSIS.

BY JOHN HEY WILLIAMS, M. D., ASHEVILLE, N. C.

In again bringing ichthyol to the notice of the profession as a rem-
edial agent in the various forms of tuberculosis, I have tried to avoid
any conclusions that were not based upon careful and exact clinical
investigation. There is of late so much strenuous advocacy of some
one particular remedy which in the hands of the exploiter has given
unmeasured success, as to produce a spirit of incredulity in the minds
of the more thoughtful. That these results cannot be obtained in the
hands of others who are possibly as well equipped in every way and are
as careful observers is certain. Extravagant and unfounded claims,
made in such a way, tend to produce a spirit of pessimism or even
nihilism in medicine. In this busy age one has little time to sit down

362

and winnow out the chaff for the few grains of wheat that may be
found. It further tends to deter honest investigators from making
public the results of painstaking and earnest endeavor to reach the
truth.

While the researches of Koch and others, resulting in the advent of
the tuberculin therapy, has given a renewed and intense interest to the
study of tuberculosis, yet its failure in the hands of so many early exper-
imenters has produced a spirit of atavism with a tendency to reversion
to the modes and methods of our forefathers.

A careful study of the lines upon which our illustrious predecea-
sors worked will serve to guide us in many ways, and we can draw
many useful deductions from centuries of observation and empirical
medication.

Our knowledge of medicine to-day is but the aggregation of the
experiments of thousands who have gone before us. The improved
instruments of precision, our improved technique in examination
and the researches of our pathologLsts are the search-lights that give
ns a broader and deeper insight into the mysteries of perverted ana-*
bolism and katabolism which, after all, is disease.

A review of the treatment of tuberculosis from its earliest history
will show that its dominant feature has been a study of the complex
features of nutrition, and those remedial agencies which find most favor
to-day are those that tend to the upbuilding of the impaired tissues of
the body and the conservation of the vital forces. The careful study
of the principles and processes of digestion, assimilation and the normal
destruction of tissue in the body has been productive of much good in
the therapy of the disease. While theories are as numerous as the
observers, yet there is a substratum of similarity through them all.
We know quite well what rest, and outdoor passive life, light and oxy-
gen or air will do for our patients. Yet we know as well that there
are remedies in our amiamentariiun that will materially aid us in the
care of those unfortunates whom some of our brothers would make ver-
itable Pariahs.

About fourteen years ago my attention was called to the thera-
pemtic ac!tion of ichthyol when exhibited internally. This drug was first
brought to our notice in 1883 by Unna of Hamburg. It was then
exploited as a remedy for external application, but study of its chemical
composition induced Professor Zueker, of the University of Berlin, to
begin a series of observations in which he was ably seconded by Dr.
Helmers. While Zuelzer noted his experiments upon others, Helmerb
experimented upon himself. Zuelzer states: — ^^It has a remarkable
power to eheds: waste; the urinary solids and the nitrogenous excteta

363

are somewhat diminished and under its administration the body weight
increases ; the income is promoted and the outgo lessened/' Helmers
found that it ^'restricted albumenoid disintegration, favored assimila*
tion and supplied fully one-third of its free sulphur to the circulation,
and was finally excreted by the urine, though slowly/'

The high character and well-known accuracy of these eminent
gentlemen induced me to give it a thorough trial in tuberculosis. Up
to the present I have had over six hundred cases treated with ichthyol
and have had most excellent results in many ways. My usage of the
remedy has been based upon the fact that grave disturbance of nutri-
tion has been one of the prime factors in all the cases that have come
under my observation, and the remedy that favorably modifies tissue
metabolism commands my attention.

I have given pretty thorough trial to creosote and while I find
that in moderate doses I get a certain amount of improvement in my
patients, yet there are certain limits to its exhibition. Gastric or d lo-
denal catarrh is an absolute bar to its use and the inordinately large
doses advocated by some conduce to this very condition.

Ichthyol is free from this objection and in even enormous doses has
never in my experience produced any distress whatsoever, but, on the
contrary, has relieved this condition, when preexisting, in a great major-
ity of cases. The scope of this paper will not admit of tabulated statis-
tics and I shall content myself with the conclusions arrived at after
careful study of the history of the cases I have charted. I have found
that the appetite and digestion have improved with corresponding
increase in weight and sense of well being. There has been a gradual
reduction of night sweats with complete disappearance in a majority of
cases.

While the bacilli gradually show degenerative changes with les-
sened number and final disappearance, I do not claim that these things
are the direct or specific result of the exhibition of the remedy. A
study of the pathological conditions incident to the caseation, softening
and eventual expulsion of the liquified tubercle would instantly neg-
ative any such claim. But I think it may be clinically shown that the
improvement in the tone and character of the cells composing the tis-
sues in immediate proximity to the infected area with resultant sterili-
sation of the soil is conducive to this end. The character of the cough
changes and becomes easier as the expectoration becomes thinner and
less tough and numular, takes on a more fiuid character, is more easily
raised and in quantity grows less. The observation of this fact lias
caused me to regard ichthyol as one of the most valuable expectorants
•at our command. Combemale confirms my views in his report of 120

364

cases treated by him in 1887. He regards it as a powerful adjuvant
to hygenic measures, and especially commends it in incipient cases, but
thinks it occasionally injurious where there is much erethism or high
temperature. He states that '4t stimulates the appetite, favors the
nutritive processes, reduces the cough and builds up the general health,
while locally it is an efficient disinfectant."

I do not wish to create the impression that I consider ichthyol a
specific in any sense of the word. I find only that it has many qualities
as an alterative and tonic with certain power to constringe engorged
tissue by its action upon the capillaries, and in my judgment, altera-
tives and tonics are excellent means with which to combat the destruc-
tive tendency of tuberculosis. By means of improved digestion and
assimilation we furnish the supplies necessary to the building up of
good healthy tissues.

I regard it as a valuable adjunct to the tuberculin treatment to
which I have given my steadfast adherence. In an article that I wrote
a year or so ago as to the relative merits of toxins and antitoxins, I stated
my belief that the toxins of the tubercle bacillus, or the watery extract
of the tubercle bacilli produce in the body of the individual that per-
sonal antitoxin which is antagonistic to the growth and development of
the tubercle bacilli, with corresponding increase in leucocytosis. It is
evident that this warfare in the tissues demands the highest grade of
nutrition. As to the physiological law of its action I am at yet in doubt.
I use it empirically as we do the most of the medicines in our daily
employ. It will have yet to undergo the crucible of the physiologist.

I have used it largely in cases of a haemorrhagic character on
account of its power to constringe the capillaries in inflamed and con-
gested tissues, as my observation is that it does not raise the blood pres-
sure. I make constant and beneficial use of it in tuberculous ulcers
of tissue and caries of bone. I have found that it is much superior to
balsam Peru or iodoform. I first curette as thoroughly as possible and
then pack the cavity with gauze saturated with the pure ichthyol. In
laryngeal tuberculosis I have found its astringent properties of service,
using it as a spray in a 10 per cent, solution. I have recently used a
suspension of ichthyol in glymol with orthoform-new and am so far
pleased with the result. The analgesic effect of the orthoform modi-
fies greatly the pain and irritation that occasionally follows the use of
the 10 per cent, watery spray. In cases of laryngeal ulceration from
the softening and breaking down of tuberculous deposits I have f oimd
it of great service and, in fact, prefer it to glacial acetic or lactic acid-
My favorite mode is to first curette and then apply with a cotton
wrapped applicator, rubbing it well into the excavations. It is, of

365

course, necessary in doing such severe work to thoroughly anaesthetize
the larynx. While I recognize fully the implacability of tuberculous
degeneration of the larynx^ yet I am glad to state that I succeeded
better with this treatment than with any other, and have some very
excellent cures or rather arrests to my credit.

I have administered it in combination with creosote plain or its
carbonate, but after a considerable experience with this mode have
reverted to the plan of giving it pure and simple. While its taste is
acrid and very disagreeable, yet I find many who can take it dissolved
in aerated water or milk. I much prefer, however, to give it in cap-
sules except to the very young. I begin with a No. 2 capsule, which
will hold about 10 minims. At the end of a week I increase to a No. 1
capsule, the third week I increase to a No. capsule, which will contain
about 20 minims. The sixth week I increase to the maximum dose of
60 to 60 minims, three times daily, given 30 to 40 minutes after taking
food. By beginning -with the smaller dose I avoid the disagreeable
eructations that sometimes follow the administration of full doses too
early. The full or maximum dose will, in a few cases, produce a slight
diarrhoea which is of a transient nature and may be readily controlled
by a few doses of dermatol. I have further noticed that in about 10
per cent, of the cases there comes on a peculiar bronzing of the skin,
sfter two or three weeks use of the full doses, giving it a uniform cop-
pery color, but this soon disappears, leaving the skin soft and clear with
a disappearance of the acne eruption, noticed in the young adult. While
I do not claim that the remedy has a specific effect upon the tuberculous
deposits, the fact remains tHat the infiltration recedes with gradual
clearing of the dull areas. The rationale of the matter, I presume,
ties in the general molecular improvement of all the tissues with absorp-
tion of the inflammatory products.

I have tried various modes and methods of administration to get
rid of the disagreeable smell and taste, but have found nothing better
than the capsule taken on a full stomach. For the past year I have
given largely the preparation known as ichthoform with most excellent
results, as the powder is comparatively tasteless and it is claimed that it
is broken up after reaching the alkaline juices of the duodenum, thus
avoiding the disagreeable eructations. The only objection that I find
to it in general practice is its excessive cost, as the dose to Ve effective,
must be not less than 20 to 30 grains.

While I have collated freely from the writings and opinions of
others my motive has been to attract attention to this most useful drug
in the treatment of a condition that is to-day absorbing the attention of
a majortiy of our profession. While I cannot, and do not, laud it as a

366

specific, yet I can conacientioufily claim for it, after twenty-two yean
of careful observation and experience in the treatment of tubercuolus
diseases, that it is, by far, the most useful drug that we have at our
command. My notes and charts of over 600 cases cover a period of
over fourteen years. I have had opportunity to follow a majority of
the cases that have been discharged from my care as Cured or improved,
and am satisfied that the results have been more satisfactory with this
L'ne of medication than with any and all others I have tried.

I should perhaps have stated earlier, that the preparation of ich-
thyol to which I constantly refer in this paper is the sulpho-ichthyolate
of ammonium, the chemical composition of which is given as O^g Hje S^
Oq (NH4)2. The chemical description of this and other forms of ich*
thyol may be readily referred to in any of Merck's recent publications.

THE DIAZO-REACnON: ITS VALUE AS A PROGNOSTIC SIGN IN

PULMONARY TUBERCULOSIS.

BY CHA8. R UPSON, M. D., WATERBURY, CONN.

Essentials for the successful management and treatment of pul-
monary tuberculosis are an early diagnosis of the disease — of which the
patient should at once be advised — and the assurance of a favorable
prognosis, even though our prognosis may in some cases present a double
face — to be viewed on the one side by the patient and on the other by
the patient's family.

Dr. Walker, writing most interestingly on the therapeutic value
of prognosis, says :* — "The relationship of the physician to a patient
and to a patient's family i3 wholly different. It is the physician's duty
to give the most favorable prognosis possible to the patient as a part, and
the initial part, of treatment. If he errs, let it always be towards the
favorable side. To the family he may disclose his fears, and dwell more
on the hazards of the illness, but to the patient it must be hope and
assurance." To this might be added the proviso that in the physician's
judgment the family is trustworthy.

The phthisio-therapeutist stands perhaps on a somewhat different
plane from the general practitioner as regards his patient, in that he
believes more firmly in the curability of the disease than do many of
the "generalists." His verdict naturally carries greater weight in the

'Prognosis: Its Therapeutic Value. Medical Record^ January i8, 190a.

367

minds of the patient and his family, hence the lung specialist must be
prepared to give a more decided prognosis when required.

The diagnosis of tuberculosis no longer necessarily means to the
intelligent physician an unfavorable prognosis. We fcaow how confi-
dently the consumptive, even in an advanced stage of the disease, views
his own condition. It would seem that the more serious the case the
more hopeful the patient. In many or most of these cases a conclusion
is easily reached, but how shall we solve the prognostic problem in those
cases less clearly marked ?

In some cases of tuberculosis, even in the early stages, certain
waste products are retained in the blood which in a healthy state are
eliminated. While the retention of these substances may cause but few
noticeable symptoms, they are productive, nevertheless, of certain
changes in the patient's urine, readily detected by mean of the diazo
reaction — discovered by Gries — ^which when found for a considerable
period is indicative of a most unfavorable condition.

This reaction is not infrequently demonstrable in afebrile periods
of tuberculosis and in cases where but few, if any, tubercle bacilli are
to be found in the sputum. While the reaction may be marked in
some cases even in the early stages of the disease, it may be altogether
absent in other and more advanced cases.

We are indebted to Michaelis for much valuable information
regarding the application of the diazo reaction to the prognosis of tuber-
culosis. In 1899 he published the results of his examinations of 106
cases. Of these, 75 presented positive, and 81 negative results. Of
the positive cases none recovered, eight were somewhat improved and
ftfty-nine died. Of the negative cases, with the exception of two deaths
and two cases in which there was no improvement, all the cases showed
improvement, with two cases cured.

While it is true in rare instances that the reactioij may under
proper management and treatment disappear from the urine and the
tuberculous patient regain his health, in the majority of cases, however,
in which a decided diazo reaction is persistently present there is but
slight hope of recovery.

Michaelis believes that patients exhibiting an intense diazo reac-
tion should be excluded from tuberculosis sanatoria, as unfavorable
cases for treatment, and Koch holds that such cases will not be benefited
by the tuberculin treatment. Dr. Karl von Kuck thinks that the diazo
reaction does not present a hopeless significance, especially in cases
wheife in its absence the clinical prognosis would be different. In quite
a number of instances in his practice where it was present and well
marked, he has seen it disappear permanently under proper treatment

868

directed to the elunination of waste products through the kidneys,
such cases having thereafter progressed as favorably as did others in
which the reaction had never been observed. He believes, however,
that a careful urine analysis should in all cases be made and when the
urine shows the reaction persistently, regardless of the plentiful drink-
ing of hot water or the use of mild diuretics, the prognosis may be con-
sidered bad.^

Dr. Wood, speaking before the New York Pathological Society on
the prognostic value of the diazo reaction, said that observations had
been made at St. Luke's Hospital with the diazo reaction in 230 cases.
Of these patients, 190 were still living and had presented no diazo reac-
tion. Ninety per c^nt. had presented absolutely no reaction at any
time, while the remaining 10 per cent, had occasionally yielded a slight
reaction. These results correspond very closely with those obtained in
certain German sanatoria. Of the 52 patients who had died in the
hospital, 75 per cent, had given a constant and strong reaction, and, if
the persons dying from nephritis or haemorrhage before the process in
the lungs had become advanced were eliminated, the percentage of fatal
cases giving the diazo reaction was 90. Of those giving, a strong reac-
tion extending over several weeks, 40 were fatal within three months.
They had no{ed some very strange fluctuations in the reaction. For
example, it had been repeatedly observed that in damp or rainy weatHer
a much larger proportion gave a diazo reaction. Any of the gallic-add
or tannic-acid preparations, as well as salol, creosote and phenol, would
inhibit the reaction. No connection had been observed between the
strength of the reaction and the elevation of the body temperature — ^in
other words, the reaction seemed to indicate the extent of the tubercu-
lous invasion of the lung rather than the amount of mixed infection.^

H. W. Syers, on the other hand, thinks the diazo reaction of but
little prognostic value in "phthisis." He says: — "My experience of
the diazo reaction in phthisis is not large, but I have had the oppor-
tunity of applying the test in very advanced cases of the disease. My
results do not in any way agree with those which would mark the diazo
reaction either as of usual occurence in the latter phases of the malady,
or, when it does occur, as of being of any special significance. In ordi-
nary cases of this description the result was negative, and when the
reaction was positive there was no reason whatever to suppose that the

^Karl von Ruck. <<The Prognosis of Pulmonaiy Tuberculosis." Journal
of TuherculosiSf October, 1900.

'F. C. Wood. ' < A Note on the Prognostic Value of the Diazo Reaction. ' '

Medical Record^ April xo, 1901.

369

case offered anj special feature of gravity bejond that which is usual
at the stage at which the afFectiou had arrived."^

The results of my own investigations with the diazo reaction in
tuberculosis have shown that it does not in every case indicate the extent
of the tuberculous invasion of the lung, but depends upon some other
condition of the system. I have in several cases in which there was
comparatively slight lung involvement, obtained a decided and persist-
ent reaction. In most of these cases the disease, in spite of energetic
eliminative treatment, steadily progressed to a fatal termination. To
my tnind the diazo reaction when persistently present in a given case
of tuberculosis is, even in the absence of other and more generally
accepted evidence, of considerable value as an unfavorable prognostic
sign.

TUBERCULIN OBTAINED FROM THE BOVINE TUBERCLE BAOLU

CONTRASTED VITH TUBERCULIN OBTAINED FROM THE

HUMAN TUBERCLE BACILLI, IN THEIR EFFECTS

ON HURIAN PATIENTS.

PRBLIMINART PAPER.
BY CLBMBNT A. PBNROSB, M. D., BALTIMORB, MD.

At the request of the Editor of the Journal of Tuberculosisy I
decided to publish the results of my investigations on the effects of
tuberculin obtained from the bovine tubercle bacilli on human subjects,
contrasted with those of tuberculin obtained from the human tubercle
bacilli, as far as these es^riments have gone.

Owing to the difficulty of obtaining suitable tuberculous cases, my
progress has necessarily been slow. I published an announcement of
this work August 24th, 1901, in the British Medical Journal, August
lOlh, 1901, in the Phiiaddphia Medical Journal^ and August 10th,
1901, in the Journal of the American Medical Associalion. Since
this announcement was made, there have been one or two vague publi-
cations on the subject of little scientific importance.

The address of Prof. Koch, July 23d, 1901, before the British Con-
gress of Tuberculosis, gave rise throughout the world to much contro-
versy concerning the identity of the tuberculosis of cattle with that of
human beings. In this paper Prof. Eoch gave no evidence of having
covered in his investigations the field any more closely than had Dr.
Tfaeobold Smith, of Boston, as far back as 1898 in the July and Septem-
ber editions of the Journal of Experimental Medicine, a fact that we

^H. W. Syers, ''The Diazo Reaction as a Method of Diagnosis in Clini-
cal Medicine/' JBnt. Med. Jour. ^ May 24, 1902.

370

should, as Americans, be very proud of. Prof. Koch's deductions, how*
ever, even if we believe them erroneous, had a wonderfully stimulating
effect on medical work in this direction, and perhaps, as has been sug-
gested, were made somewhat for this purpose. While reading this
address, the idea occurred to me that a very important experiment had
been omitted, at least, no mention was made of it, namely, to contrast
the products of the two bacilli or their tuberculins, in their effects on
the same human subjects, a harmless, and yet important method of
studying variations should they exist in the bacilli themselves. Knov/-
iiig how difficult it was to be sure a pure culture of the bovine bacilli
was obtained, I wrote directly to Dr. Theobold Smith, who most kindly
sent me cultures of the bovine as well as of the human tubercle bacilli,
from which through the courtesy of Parke, Davis & Co., two very excel-
lent tuberculins were prepared. These tuberculins were made by iden-
tically the same process as are the other tuberculins placed on the mar*
ket, and were contrasted in several instances with tuberculin obtained
from Dr. Trudeau's laboratory, which proved them to be up to the mark
in every respect. At present these tuberculins are being tested on sur-
gical cases in the wards of the Johns Hopkins Hospital through the kind*
ness of Dr. Halsted, and careful records kept of their reaction, effects,
and so forth.

As yet, only a few cases have been tested, which, however, have
given very suggestive results. In this article I exhibit the charts of
one case which was tested, first with Trudeau's tubereulin, then with my
himian tuberculin, and then with my bovine tuberculin.

The case, William B., negro, aged twenty-two, was admitted to the
hospital April 14th, 1902, with tuberculosis of the left ^vrist joint and a
tuberculous abscess over the dorsum of the left foot. Otherwise he was
fairly healthy; the chest and heart were negative. From the accom-
panying chart it will be seen that in both instances a typical tuberculous
reaction was obtained, but in the case of the bovine tuberculin the reac-
tion was more marked, the acme reached one hour sooner, and then the
temperature fell to 99 degrees, where it remained for some time. In
other words, a more decided reaction was given by the bovine tuberculin
than the human tuberculin, although used several, days later, and in a
subject who had had during this time hospital diet and treatment.

I believe from this and other cases, it will be shown that, first, the
bovine tuberculin positively gives a reaction in human tuberculoiw
patients; second, that this reaction is more active than that obtained
from the himian tuberculin, evidenced by a higher temperature and a
later return to the normal temperature.

Conclusion: The products, or tuberculins of the bovine and
human tubercle bacilli seem to be identical in their effects on human

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372

tuberculous Bubjects. The bovine tuberculin appears to be the stronger,
suggesting that the bacilli themeselves are identical, but the bovine
bacilli more virulent.

It will be interesting to test these two tuberculins on tuberculous
cattle and note their effects. It is hoped that the opportunity of mak-
ing such contrast may be afforded.

THE ETIOLOGY OF THE INDUCTIVE AND INCIPIENT STAGES OF
PULMONARY TUBERCULOSIS AND SPECmC TREATMENT

BASED THEREON.*

BY THOMAS NBIL MCLBAN, M. D., BLIZABBTH, N. J.

In the consideration of the etiology of tuberculosis it will be well
for us to bear in mind that impressive couplet of Sir John Davis, the
truth of which I think we will all admit : — ^•'Skill comes so slow, and
life so fast doth fly. We learn so little and forget so much.'^

The etiology cannot be properly considered without reverting to
some of the physiological principles and facts upon which alone a suc-
cessful treatment may be based, and thus, as Austin Flint once said,
to ^'harmonize the indications of nature and science in accordance with
the dictates of common sense."

You will bear with me then, "lest we forget," while I refer briefly
to some of the salient points. I am indebted to Simon H. Oage^ for
some of the points here mentioned.

There is no function of the human body more essentially vitaly than
that of respiration. It is a sine-qua-non of human existence, and there
is no process or fHnction of the body, the incompleteness of which,
with, or without organic change, is more prolific in the production of
disease. The process of respiration is distinctly nutrient in one of its
most important phases.

The nutrition of the body depends not only upon a proper supply
of solid and liquid pabulum through the stomach, but also upon a sufii<
cient supply of gaseous pabulum through the limgs; and the degree of
health and vigor depends upon the quality and quantity furnished to the
tissues through these two receptive organs.

Few in this land of plenty starve to death for want of food in the
stomach, but hundreds of thousands are starved to death through lack of
oxygen, the gaseous pabulum of the tissues which is introduced by way
of the limgs. Man may live for a considerable period without food by

*Read at the American Congress of Tuberculosis in New York City, June
3, 1902.

^The Reference Handbook of the Medical Sciences.

373

tJic stomachy but the demand for oxygen is constant and imperative.
The blood is the carrier of nutrition to all parts of the body, and must
be constantly renewed with those elements which support the growth^
development, and sustenance of the tissues. The entire volume of
blood must pass through the lungs once in every three to five minutes,
for its necessary supply of oxygen and elimination of carbonic dioxide.
The change from venous to arterial blood may be complete or incom-
plete. The completeness of the change is not due to differences in the
constitution of the atmosphere at different places and times, for the
variation is found to be trifling, so that the cause of incomplete arter*
iolization is to be f oimd, not in the gaseous food, but in the organs in
which it is to be digested.

W'c f.nd that the digestion of air in the lungs is accomplished by
an almost complete contact with the blood, the alveolar walls alone
intervening, through which, in accordance with the well-known law of
physics, the gaseous oxygen passes from the alveoli into the blood and,
uniting with the plasma and haemoglobin, forms oxyhaemoglobin, or
bright arterial blood, while at the same time, the carbonic oxide passes
from the blood into the alveoli. The rapidity with which the inter-
change takes place depends upon the tension of the alveoli, which is
produced by the pressure of the gases therein. If the pressure is low
the interchange will be correspondingly slow, and the nutrition of the
blood and tissues will be adequate or inadequate, corresponding to the
degree of alveolar tension. Besides the process of nutrition by oxy-
gen, the elimination of excrementitious gas or carbonic oxide is stimu-
lated by a plentiful supply of oxygen. If the elimination of the excre-
mentitious gas through the lungs is deficient, general lassitude and
impairment of gastric digestion follows, through poisoning of the ner-
vous centres, with relaxation of the capillary circulation in the skin.
The amount of interchange of the gases in the tissues remote from the
lungs, depends upon the amount of oxygen in the plasma and haemo-
globin which has been received in the act of respiration and conveyed
in the capillaries to its ultimate destination. If the supply of oxygen
is small the tissues farthest from the central organs of supply are the
first to become livid — ^a state of true asphyxiation. The healthy adult
man, according to Pettinkof er and Voit, takes up in twenty-four hours,
seven hundred and fifty grams of oxygen and excretes nine hundred
grams of carbonic oxide. The same investigators have shown that the
intcroiiange depends largely upon bodily activity. The hunger for
oxygen dres not r»ome primarily from the lungs themselves, but from
all the tissues of the body. Let an individual having a normal chest
Action breathe deeply and quickly, and he will be able to cease breath-

374

iiig for a longer period than he would otherwise be able to do. ThU
shows that the interchange of the gases has been increased by the deep
breathing, so that, for a time, the demand is less urgent, because the
haemoglobin and plasma are in a state approaching saturation with
oxygen, and as we have already seen the rapidity of interchange depends
upon the tension of the alveoli. This is our first and most important
conclusion in the operation of a natural law which we are to apply in our
iiiagnosis and treatment of the inductive stage — the so-called "suitable
soil." I consider the complete vesicular murmur to be the criterion
of perfect pulmonary function and organic health, and to be as valuable
as a diagnostic sign as all the other physical signs put together.

When from any cause whatever except emphysema, the function
of respiration is incomplete, as evidenced by the absence or muffing
of the vesicular murmur, we have the positive evidence of insufficient
alveolar tension, the prime cause of a departure from health. I
believe that the surest way to keep an organ in perfect health is to keep
it in perfect function, and that in the case of the lungs, an incomplete
function must necessarily be followed by organic disease. Robin's
recent investigations as to the increased rate of gaseous interchange in
till offspring of tuberculous parents, and in the acquired disease, have
a deep significance, entirely in harmony with the physiological pro-
cesses and practical observation. Robin has done the profession a val-
uable service in proving and announcing the fact, but, as 1 believe, he
errs in his interpretation and application of the fact.

I cannot agree with him in his conclusion that the increase of inter-
change is a positive destructive process, and one which should be
restrained by rest and medication, but I believe that it is a conservative
process of nature in its efforts to maintain the integrity of the tissues,
and should be helped rather than hindered. I agree with Robin in the
conclusion, that in the non-tuberculous "such increased gaseous inter-
change is an indication of a favorable soil" for the implantation of the
bacilhis, but I cannot accept without more reasonable proof, that the
systems of such people "receive too much oxygen and produce too much
carbonic oxide." In fact, I believe that it is by this means that nature
is able to cure, according to the statistics of Nageli of Zurich, over
90 per cent, of all the cases of pulmonary tuberculosis without the aid
of the physician. With the loss of alveolar tension, there is not only a
decrease in the gaseous interchange in that portion of the lungs so
affected, but also a retarding of the blood currents.

Any reduction of the elasticity of the lungs interferes with the cir-
culation of the blood in them, whether it be as a result of inflammation,
loss of vaso-motor control, traumatism, or of- the external interference

375

with the expansion of the chest, as by tight clothing, cicatrices from
extensive burns and scalds of the chest, occupations which compel the
muscles of respiration to weaken for want of use, thus favoring blood
stasis and consequent infiltration and proliferation of cell elements,
and serves to produce what we may properly call the inductive stage
or suitable soil in which tuberculous infection is not only possible, but
highly probable. In emphysema, alveolar tension becomes alveolar
distension without the power of contraction, and here the vesicular
mniiimr is lost.

Abrams, in his recent admirable study of pulijionary disease with
the Eoentgen rays, says : "As a rule this lung emphysema in phthisis is
limited to the lower lobes, and is dependent on the fact, that the air in
entering the pulmonary treC; travels in the direction of least resistance.'*
I believe that the emphysema in the lower lobes is the result of the
efforts of nature to compensate the deficiency in the upper lobes, and is
secondary thereto, and it is during this compensating process that we
get the increased gaseous interchange of Robin, and, going still further,
the microscope proves that in the first stages the red blood corpuscles,
leucocytes and haemoglobin are kept up to the normal percentage,
until, by the overwhelming disturbances of the later stages, a true
anaemia supervenes.

To recognize the evidences of the inductive stage of tuberculosis,
then, is of the utmost importance, because, as I believe, a case is lost or
w<.n at the beginning of treatment rather than at the end. The recog-
nition depends absolutely upon the care and assiduity which the physi-
cian brings to the examination, and he should ever be upon the alert
in his daily round of practice to discover the evidences of predisposition.
In this stage the microscope furnishes no assistance. The Roentgen
rays are as far away as the moon to thousands of physicians and in
this stage would be of little avail, but if the ear catches the sound of
the true veeicular murmur, as the endence of alveolar tension with its
consequent results in the healthy chest, he may be able to diagnose the
muffling and suppression of that murmur which is a positive proof of an
imperfect function, which, unrelieved, constitutes the inductive stage,
also called the suitable soil for the propagation of the bacillus.

Having recognized the conditions of this stage, and appreciating
their far-reaching import, it is our duty to apply ourselves at once to
the restoration of the impaired function. How can this be done ? By
the administration of drugs? Positively no! But by means which
Nature herself approves and to a limited extent supplies. Our advice
to such a patient should be just as exact and specific, and as much or
more care exercised than in the prescribing of therapeutic drugs. To

876

bay to audi a patient^ change your occupation, live out of doors, go to
the inonntains, may in many casee bring about the desired restoration.
Good as this advice may be, I consider it a shotgun prescription,
because, although it may succeed, there are many chances of failure
\vbich ghould be eliminated; first through an appreciation of the exact
conditions of imperfect functioriy and second, through the knowledge of
the* fact that the function aUhoiigh involuntary is also voluntary.
Xature has this function of respiration under the control of the will,
and thereby furnishes an exact or specific course to follow, which does
not ner^essarily require a change of occupation, methods of living, or
place of residence, although these are of very great value.

My experience of thirty years has taught me two specific exerdses
which the patient must assiduously practice in the restoration of the
normal expansion, which restores the normal alveolar tension. Theso
are as follows :

First, the exercise in imitation of the cough, which should be
performed at any time or place, except in a cold dusty wind or in a
dusty room, and in any position of the body. It consists in the inhal-
ation through a chink of the lips, about the size of a common lead pen-
cil, slowly and steadily, until the lungs are filled to their utmost capac-
ity, at which time the lips are tightly closed and the cheeks bulged
forcefully, which prevents the escape of the air by the nose. The
inspired air is then held until the excess of blood in the lungs is driven
out into the general circulation, as indicated by a sense of fullness in
the forehead. This sensation is a positive proof that the patient has
-accomplished the act successf uUv and requistely. Considering the fact
that ^he patient breathes at the rate of eighteen to twenty times per
minute, he should perform the exercise as many hundred times a day,
as it is possible to think of it, or untU the complete voluntary becomes a
complete involuntary act.

The advice often given to go out in the morning, and take long
breaths, is very inexplicit, and is followed by no definite results. This
•exact method of breathing which I have described, or any other which
can be proved to be equally as good should be taught^ and the practice
of it insisted upon, throughout all the waking hours. When the muscles
of respiration have become weakened, this method may be found insuf-
ficient to accomplish the purpose alone, and we must resort to another
method which is also indicated by nature, and often witnessed as an
involimtary act, on the part of a tired individual.

The second method, which I call the stretching or yawning exer-
cise, is performed like the first, but with the addition of elevating the
Siands and arms to a nearly perpendicular line above the head, and is

377

best performed in the standing position, or while reclining with th(f
hands clasped on the top of the head. At the commencement of the
inspiration in the standing position, the arms are thrown up quickly
above the head, one hand clasping the thumb of the other, until the
chest is fully inflated, and then quickly dropped, the arms and hands
resting their weight upon the front of the chest. A much larger
amount of air can be inspired by this method, but cannot be held as
long as by the first method, the proof of the success of the act coming
much quicker.

I have found no other voluntary methods so successful as these,
because these exercises do not quicken the heart's action, but rather
retard it during inspiration. While the breath is being held, the same
effect is produced in the alveolar tissue as that of an altitude of several
thousand feet, so that by this method we bring the mountains to the
patient instead of sending the patient to the mountains. If the case
has progressed so far, before rational treatment is begun, that these two
methods are found insufficient on account of weakness of the muscles of
respiration, then promptly resort to pneumatic differentiation by alti-
tude, or in the home treatment by the pneumatic cabinet, when it can
be obtained. The principles of pneumatic differentiation although
approved by many of the best men in the profession, have never been
put into practical service by the mass of the profession, on account of
the expense of the cabinet.

If the patient's condition has gone on to the stage of exudation,
either inter-pulmonary as in choked apices, or inter-pleural with plastic
lymph, or bronchial with cough and expectoration and hemoptysis,
all of which results from excessive blood pressure, being out of propor-
tion of the air pressure in the lungs, these methods properly carried
out, check the process of exudation, and stimulate the lymphatics to
remove the debris, and prevent agglutination of the pleural surfaces.
If hemoptysis occur, I assert positively that there is no other way
besides forced expansion by which this symptom can be permanently
prevented. Vaughn claims that in hemoptysis ninety-nine cases out of
one hundred are tuberculous. By reestablishing a permanent equilib-
rium of blood and air in the lungs, the integrity of the blood vessels and
tissues is maintained and tuberculization checked in its spread. The
first indication in hemoptysis is rest in the semirecumbent or sitting
positions; then reducton of the force of the heart's action, if turbu-
lent, with high tension of arteries, by aconite, quieting the fears and
assuring the mind of the patient ; then, when fresh blood has ceased to
be expectorated, the patient should be instructed to expand his chest
gently by the first method, gradually increasing, until be is able to per-

878

form the second method^ with sufficient force to bring about the requi-
site equilibrium. If atelectasis has occurred, there is no other sure way
of opening up the choked bronchi, and reestablishing the air and blood
currents in the collapsed lobules.

After the investigations of the respiratory system by Hutchinson
and others, which pronused great results in treatment, the whole matter
was, through a xnisconceptiony relegated to the domain of Hygeia or dan-
itary science, where the majority of the profession have allowed it to
remain until the present time, thereby failing to reap the success which
should have been theirs.

Very mu<^ Jbas been written during the past twenty years in
regard to pure air» and the ventilation of workshops, officeS; living and
sleeping rooms, so that I need to say nothing in regard to this, but to
insist that confhied air once breathed is a poisoned air. I would all the
more strenuously insist, that the perfect ventilation of the lungs is of
infinitely greater importancef than the ventilation of rooms, as a prophy-
lactic against organic disease. What does it avail, however pure the air
may be, if it is barred out of the pulmonary structure^ either in part or
whple, so that the gaseous interchange cannot take plaice in the ultimate
cells? Ts there a single capillary bronchus, or a single air cell in the
entire structure, which was not intended to receive air and assist in the
aeration of the blood ? No. These tissues are made not only to receive,
but also, by the expansion and contraction of the cell walls, to continu-
ously further the interchange of the gases, whereby the blood and tis-
sues may have their vitalizing pabulum in sufficient quantity to main-
tain the conditions of health. Stagnation in the lungs is a pathologic
condition, and means disease and death. The only physiologic rest for
the lungs, is a complete function, and any other application of the
term rest, as applied to the lungs, is a misnomer, for which the term
suspended function is more appropriate.

When in consequence of the imperfect mechanical function of the
lungs, the interchange of gases is retarded, a chain of symptoms pre-
sents itself, which we all recognize as suspicious evidence of tuber-
culous infection, either impending or already existent. These symp-
toms are a loss of weight, a throaty voice, pseudo-anaemia, tachycardia,
which is the result either of essential weakness of the heart walls them-
selves or of the necessity put upon the heart to contract either with
greater force or rapidity in order to overcome the obstructions to the
flow of blood consequent upon the loss of pulmonary elasticity Avhich
is an important aid in its propulsion. Other signs are anorexia, a
higher pitch of the percussion note, diminished expansion of the che?t
as shown by measurement with the tape line, slight afternoon rise of

379

temperature, prolonged expiration from narrowing of bronchi, tlie
"gravitation" cough upon reclining, and as the disease progresses, mniny
other symptoms which are not seen in the inductive and primary inf ec-
tive stage, and which we are not now to consider. This part of my sub-
ject comprehends that of early recognition, and widens the field of
hygiene in its most important direction.

Infection by the tubercle bacillus is only possible when the soil is
prepared for it.

The only sure pulmonary prophylaxis is by the natural method as
I have decribed, putting every cell and tube and capillary blood vessel
in perfect function, thus preventing stasis, either of blood or air, and
leaving no quiet resting place for this germ to locate and grow. The
same treatment applies when infection has taken place, for the purposo
of protecting the non-infected areas, as in the inductive stage.

The impossibility of germicides, taken by the stomach, reaching
the infected tissues in sufficient strength through the blood currents
to be of any avail, is the conclusion of the entire profession. Creosote
and its congeners, are of considerable value when associated with the
methods of expansion, in ameliorating the cough and relieving bronchial
irritation.

I cannot delay you with reiterations, however strong or important,
but my plea is that the profession, whose attention for the past ten years
has been so absorbed by the bacillus and in the search after the means
for its destruction, would turn its attention to the plain physiological
principles which I am trying to enunciate. By so doing I believe it
would turn from the prevalent method of medicating tuberculous
patients, to the method of nature, which will bring a larger meed oi
success than any other method now known — a method, which, in the
inductive stage, will absolutely prevent infection, and which in the
primary infective stage, (the limit of which is mixed infection) will
protect tissue not already infected and in a majority of cases clear up
the infected areas.

It is not to be thought for a moment, that this can be done without
regard to the nutrition of the body, by the solid and liquid foods
through the stomach, for the gist of the whole matter is foody gaseous^
solid, and liquid, received in proper quality and quantity, and thor-
oughl/y digested in the receptive organs.

In addition to the above in the treatment of either stage, cold
water bathing with friction is an important aid not only in invigorating
the muscular system, but also in stimulating the respiratory nerve
center in the medulla, and should be practiced daily.

380

/•

The therapeutic indicationfi for ichthyol, creosote, chloride of
'ammonium, strychnia, hypophosphites, etc., are not to be disregarded,
but the patient must be impressed with the idea, that these are of minor
importancey and that the taking of the drug, however faithfxdly, if
unaccompanied by expansion^ will be most likely to result in failure.

The effects of deficient pulmonary expansion are f oimd not only
in the alveoli and convective tubes, but also in the terminal ramifica-
tions of the pulmonary artery. Infarction and consequent thrombosid,
with softening and cavitation, also furnishes the suitable soil for the
bacillary infection.

A proper alveolar tension is required to maintain the integrity of
the blood vessels in the lungs, and assists in the propulsion of the blood
stream. When the residual air pressure is below normal, and the right
heart strong, we will find the first sound of the heart accentuated, indi-
cating a laboring heart, also we may have its impulse stamped upon the
inspiration, as manifested by the cogwheel rythm; this symptom is
easily removed by expansion, which explains its causation.

From this physiological standpoint, natural immunity is not an
unknown quantity. !N'atural immunity consists in the absence of those
conditions which are necessary for the existence of the bacillus — that
immunity which is found in the perfection of the pulmonary functions
— and it is by this means only that hereditary vulnerability may be
resisted, and acquired predisposition prevented. The so-called resist-
ing power is thus reduced to definite proportions and brought up to a
normal standard by exact methods.

Smothered by a chain of social conventionalism, our women, wear-
ing tight clothing about the waist, are literally "dressed to kill," and
beget a race of weak chested offspring, while the fathers by thousands,
are of necessity obliged to be shut up in offices and shops, engaged in
those sedentary pursuits which paralyze the muscles of respiration. In
the first instance large areas of lung tissue are asphyxiated by direct
pressure, and in the other smothered by apathy, a direct result of a
physically indolent life. These conditions being ever present our profes-
sion must necessarily be alive to the exigencies of the times, and, with
an acute ear and cultivated senses, be alert to discover the inductive
stage afl well as the incipient, and thus by rational treatment remove the
patient from the dangers of the later stages. I claim that the inductive
stage, or as it is called, the suitable soil for the propagation of the tuber-
cle bacillus in the lungs, consists essentially and primarily in condir
tions referable to the lungs themselves, rather than to any general deprav-
ity of the entire system, as indicated by anaemia or spanaemia, or the
antarthitic diathesis, or scrofula. Dyce Duckworth says : "Many per-

381

sons are scrofulouB all their lives and yet never become tuberculizeA"
Malnutrition has been claimed as the prime cause, but that very mal-
nutrition depends upon deficiency in that last stage of food preparation,
before it enters the arterial system, viz. : — oxygenation, and until that
function is adequately performed, we can make no permanent headway
in feeding, no matter how we may stuff.

By air, water and food the body is nourished. On this tripod the
body stands. Knock away any one of these supports, and disease and
death are sure to come.

In conclusion let me say that it is important that we baae our ther-
apeutic facts upon, physiologically exact, etiologic conceptions, rather
than upon the practice of general hygiene to the exclusion of pulmon-
ary hygiene, or any blind empiricism, no matter how classical or scholas-
tically orthodox

If our conceptions are based upon physiological truth as a starting
point, we may arrive at the truth as to specific physiological error, as
in the pathology and treatment of pulmonary tuberculosis, and in no
other way will we succeed in the treatment of this disease, but in the
way and manner which nature herself dictates.

382
ORIGINAL TRANSLATION.

ON IMMUNITY AND PREDISPOSITION WITH ESPECIAL REFERENCE

TO TUBERCULOSIS.*

BY PROF. DR. P. BAUMGARTBN, TUBBINGBN.

Gentlemen: — Ideals are unattainable, bnt as goals they give a
direction to our endeavors. We may hardly dare to hope that the art
of healing will ever become superfluous in the field of medicine, but we
may strive to reduce it to narrow boundaries through the prevention of
disease. The profession has ever had this end in view, and during the
last century its efforts have been rewarded by notable success, and by
considerable gains even in the past decade. Since we have learned to
recognize bacteria as the causes of many diseases and as exciting factors
in many others, hygiene has taught us to keep these causes far from our
persons, as for instance, plague, chol ra, etc. When the disease-produc-
ing organisms cannot be kept in abeyance, as is absolutely the case in
many diseases, then it is but rarely possible for the natural protective
agencies, such as the squamous epithelium, ciliated epithelium, reflex
actions, gastric functions, etc., to prevent invasion and development of
bacteria in the organism. But Kature herself affords a certain immun-
ity in many such diseases ; she protects the organism through the act of
immunization. Certain infectious diseases are but rarely contracted a
second time. Such i.iimunity, however, can be regarded only as a sort
of Danae gift, since it is acquired at the price of going through one
attack of the disease. Much more precious, because safe and certaiiL
alike, is that immunity which protects us from one of the most deadly
diseases by preventive inoculation with a substance closely related to
the true virus of the disease, but so modified as to cause affections of a
mild type analogous to those from which we would protect ourselves.
In recent times bacilli of weakened virulence and vaccines obtained
from organs which have been attacked by bacilli, have both been suc-
cessfully applied as protective means (anthrax). These resources were
followed by others, involving the discovery of protective substances
which could not indeed shield the individual from infection for the
whole or a greater part of his life, but which had the advantage of arrest-
ing infectious processes after they had once developed. Although no
rational explanation of this latter phenomenon is as yet possible, a the-
ory has been evolved, supported by continuous experimentation, which

* Address delivered at the 23rd Public Meeting of the Balneological
Society. Stuttgait, March, T902. Translated for The Journal of Tuberculosis
from the Deut, Medizinal Zeitung, 190*, No. 39.

388

has accomplished more by arousing the adxniration of the scientitic
world, than by exciting the gratitude of the public which has been the
gainer by this line of research. Immunities are either naturally or
artificially acquired ; immunity through inununization. In addition to
these, however, there is an inborn immunity, which, it aeems to me,
ia referable to a different principle concerning which we are also still
in the dark. It is an midisputed fact that entire natural orders^ genera
and species, yes, even mere varieties of animals possess from their birth
a certain quality by virtue of which they canaot contract either natur-
ally or by inoculation, certain diseases of bacterial origin, the latter
varying with the kind of animal Even mankind enjoys an inborn
JTmrmnity to a nmnber of diseases. This negative quality has been
explained from different sides through the supposition of a destructive
psindple. In regard to inborn toxin-immunity, which does not coincide
with inborn bacterial immunity, the view which has won credit tiius far
is as follows: — The poison is not rendered harmless because it is
destroyed or neutralized by an antitoxin, but because it cannot establish
relation, either temporarily or permanently, with the tissue cells of the
body. Against the bacteria themselves, it is supposd that the body is
protected by an inherent bactericidal substance throng the immediate
destructive effect of which upon the bacteria, the organism is protected.
In particular has the ingenious phagocyte-theory of Metschnikoff gained
wide acceptance, sustained as it is by a comprehensive observation of
nature. The white corpusles, phylogenetic relatives of the amoebae
seek out the substance of living vegetable organisms and take up and
digest it. The theory in question assumes that this power may be imi-
tated in the interior of highly developed animal organisms. If a hostile
bacterium succeeds in penetrating into the human body and in prolifer-
ating therein, the leucocytes, while powerless to heal the lesion thus pro-
duced, may nevertheless fuUfil a condition necessary to healing by
destroying the bacteria. If they are in position to destroy the latter at
the time of invasion, they add the power of cure to that of protection.
If the latter power is completely developed, the animal may be said to
be immune. Vice versa, wherever this immunity is encountered it has
licen conferred by prompt phagocytosis. Thus far, we have no satis-
factory proofs that the bacteria which are found dead within the leuco-
cytes were living when they were first incorporated, because these c.u*-
puscles may take up dead bacteria and inorganic substances. On the
other hand, it is evident that the leucocytes form a favorable culture-
medium for the propagation of bacteria. One might well believe
that if the bacteria die they are incorporated within the leucocytes,

384

but if they enter the latter alive they have a good prospect of fav-
oring general inf ection« It would be a very singular thing if immun-
ity could be ascribed to phagocytosis; for if the body were inocu
lated by bacteria in large nimibers some of the microorganisms would
certainly get past their enemies, the white corpuscles, and cause
general infection. Moreover, the fact that certain species and varieties
of animals are specifically immune to certain bacterial diseases, whereas
certain other animals which also possess like phagocytes are not pro-
tected against these diseases is a convincing contradiction to the theory
of immunity through phagocytosis. For this reason the theory that
the blood cells are bacterial destroyers has generally been given up, and
their secretions or this or that still unknown substance of the circulating
fluids were believed to possess bactericidal properties. K it could be
shown that the blood or its serum was in itself directly bactericidal,
the fact of inborn immunity would be readily explained. It appears
to be a fact that blood from the veins does actually possess this property,
because bacteria in many instances cannot survive therein. From my
own studies in this field I can only state that a momentary arrest of
development occurs under these cicumstances ; and even this was
absent when I introduced into the blood the merest quantity of true
nutrient substance, and bacteria were then even able to proliferate
abundantly in this alleged bactericidal medium. Kot only one but
many varieties of microorganisms were able to flourish in blood thus
treated. The alleged bactericidal action of rabbit serum towards the
Anthrax bacillus disappeared after addition of 1 per cent, pepton and 1
per cent, sugar ; toward the typhoid bacillus when 2 per cent, saltpetre
was added, toward the cholera bacillus when 2 per cent, soda-salt-pepton
was added ; and after such additions this serum became an excellent cul-
tur<»-medium for the germs in question. Should we assume that vene-
section-serum necessarily contains bactericidal substances, we could not
conclude forthwith that the latter are also present in circulating blood
(attempts in solving this problem must be regarded so far as failures).
In any case we need have no scruples in abandoning the view liiat
inborn immunity resides in the blood ; for even in cases where the latter
appears to be bactericidal, the particular species of animal does not nec-
essarily possess immunity to the attacks of the bacillus in question.
Thus, although the anthrax bacillus dies when introduced into rabbit
serum, the rabbit itself is highly susceptible to anthrax. On the other
hand, this bacillus flourishes excellently in the venesection-serum of the
dog, yet this animal is almost immune to anthrax. It is evident that we
must look elsewhere for an explanation of inborn inununity. That any
organism is unable to live and thrive does not necessarily imply that

885

something kills it outright^ and so for the bacteria^ it is sufficient to
cause their death spontaneously if they do not find the conditions essen-
tial for their life and development. This simple explanation — ^perhaps
too simple to receive the acceptance of some scientists who can be sat-
isfied only by complex and ingenious methods — ^has nevertheless given
definite direction to the further study of immunity, aided by the result*
which newer methods of examination have developed.

Now, gentlemen 1 Permit me to go more into detail.

The various cells of the animal and of the human body, differing
as they do in form and function, sprang from one and the same mother-
cell, and do not belie their conMnon origin ; they all remain subject to
certain common laws of cell-life. Nevertheless, in their differentiation
into organs of different function, a difference in the protoplasm which
sustains the f imction must take place, and this protoplasm must be con-
stantly renewed from the accessible circulating fluids. Whosoever
brings much, brings something to somebody ; especially that which each
cell needs and can appropriate, it does actually select, not from volun-
tary power of choice, but because of the ability of the receptor of the
lateral chain of its protoplasm to anchor a corresponding uncombined
atom in the nutrient substance from the circulating fluid, according to
the principles of chemical affinity. Every cell does not anchor every
possible form of nutrient material; the receptor of one does, that of
another does not, each according to its specific needs. Proper receptors
and receptible nutrient material are the conditions of life for every cell,
and this method of representing physiological processes of nutrition
has a firm support in recent toxicological study.

These relations obtain in the unified complexity which representa
« tissue-cell. Let us next turn to bacteria. I believe that I stand in
entire accord with the principles of the doctrine of evolution and
descent — ^which are doubtless also recognized by you — when I state that
the family of bacteria has been differentiated from a common ancestor,
just as have the numerous cells of the animal body from a single cellular
formation. While the latter has been able to build up a solid individual
by the coherence of the cells, the different bacterial cells are able to pur-
sue an existence in which they are entirely independent of one another.
Although differentiated, the bacteria will probably always require inter-
mediary receptors for their nutrition, and because they are differen-
tiated they require a nutrient material for which the individual receptor
has an affinity, and this nutrient material is not the same for all and is.
not applicable to all in the same manner or in the same degree. Whilo
in a general way it may be said that bacteria make but simple demands

886

for their nutrition, this is only true in so far as under certain circmn-
Btances a simple mixture of organic substances suffices for them. But
simplicity in demand is not indifference, because by nature they are
thoroughly selective. While some prefer simple mixtures others
choose organic combinations in the dead state, upon which alone they
can thrive in nature ; still others select matter for food which is in th»>
full activity of life (obligative parasites). Some of this latter class
thrive best upon a particular species of animal and may even depend
upon a particular quality of that species, whether resident in the blood
or in the tissues. We are not justified in denying the requirement of
specific character of nutrient material because we find no chemical dif-
ferences in the blood of different species of animals. In the chemical
laboratory like bodies are not biologically equivalent. When the blood
is removed from the living body its components undergo a secession; in
their organic combination during life the degrees of reaction differ
although they are apparently alike after death. In the degrees of reac-
tion is also expressed that which differentiates species from species,
surely to a greater extent than the simple color of the hair or the length
of the tail.

Whenever we find that certain bacteria thrive exclusively in a
single species, we are forced to say that here and not elsewhere can the
receptor, in the creature which makes possible its nourishment, find its
anchoring substance ; and vice versa when it cannot secure this anchor-
age, the bacterial cell cannot proliferate ; and when it cannot prolifer-
ate, it cannot infect. Such animals are therefore bom immune; and
for them to be bom immune it is not necessary that their tissues shall
possess bactericidal properties. Such is my understanding when I say
that the inborn immimity has its foundation therein, that in the animal
or in the man the conditions essential to the growth of the particular
bacterium are not present.

When we succeed in gradually developing a bacterium upon a
given medium into a state which does not occur in nature, or again in
an animal in which it cannot thrive spontaneously, it could not well be
assumed that its ability to thrive under new circumstances depends upon
the withdrawal of bactericidal substances from the medium. Instead,
this is due to the wide range of accommodation of bacteria, that is to say,
to an ability of the receptor of the hungering cell to accustom itself to
take up that to which, in its past life in its natural state, it had but slight
relation, and through which accommodation this slight relation has been
increased and developed by practice. The artificially developed bacter-
iolysis in which, through previous treatment of the animal, its serum
acquires bactericidal properties, would speak rather for than against the

387

proposition that the inborn immunity depends npon another basis than
does the acquired.

Here I should allude briefly to the astonishment recently excited
by observations which go to show that the bacillus of human tuberculo-
sis cannot be inoculated into cattle, and vice versa. According to this,
the cow is born immune to human tuberculosis. But according to all
our previous knowledge there is little doubt of the original identity of
the two bacilli. The same bacillus, growing upon two different nutrient
media, has developed into two species or at least into two varieties. It
is readily intelligible that since the bacillus of human tuberculosis has
been propagated upon one medium for hundreds of generations, it has
become confirmed in a particular method of nutrition* The cow is
therefore immune to its attacks, and vice versa. It is unreasonable to
hold that this sort of immunity can depend upon the presence of some
bactericidal substance which can destroy one germ without affecting the
other; nor can it be stated positively that upon a common medium,
these two varieties could not be made to return to a common type.

If now beyond the aforementioned immunity or disposition of the
species and races there exists also an individual immunity and disposi-
tion is still an open question. This question has been debated with
especial zeal in the domain of human tuberculosis, and it has been
accepted that here indeed there is an individual disposition and immun-
ity. As a proof for the acceptance of this proposition, its advocates
have supported themselves by the observation that only a certain and
comparatively small proportion of the human race acquires tuberculosis,
while by far the greater proportion remains free from the disease dur-
ing the entire period of its individual lives. Today the belief in a
"tuberculous disposition" as a factor in the contraction has taken firm
root, especially among practicing physicians. So long as the cause of
tuberculosis was unknown and one was, therefore, inclined to look upon
the disease as the expression of a constitutional anomaly or a peculiar
weakness of the tissues, the "tuberculous disposition," and the hypothet-
ical and true causes of the disease were considered as one and the same
thing. It was necessary only to add an external exciting cause in the
form of any inflammatory irritation in order to develop and bring into
existence the tuberculous process in the diseased tissues. But we know
now that the exciting cause of the latter is solely a specific endogenous
parasite, and with this discovery the old idea of a predisposition has lost
its practical bearing and must at least imdergo modification, in order that
we may profitably study the natural relations between parasite and host
Experience has taught us that Koch's bacillus is parasitic to all warni-
blooded animals, although not in th§ same degree. That the «pccws

388

homo is not only receptive in a general way, but especially so, is evident
from the fact that no other species, with perhaps the exception of the
bovine, pays so high a tribute in instances of disease and death, as does
the human race. But even with this susceptibility only one seventh of
mankind dies from the disease and not more than a fourth, or a third
at most, becomes infected. Two-thirds of mankind, therefore, remain
quite free from a trace of tuberculosis throughout their lives. Are we
then to conclude that one-third of mankind is susceptible and two-thirds
insusceptible to infection with the tubercle bacillus ? Many are inclined
to give a strictly affirmative answer to this proposition and but few
would absolutely deny it. I, for my part, am unable to see in the limita-
tion of the development of tuberculosis, as related, a proof of the exist-
ence of an individual disposition. On the contrary, I believe that all
mankind is predisposed to tuberculosis, that is to say, is receptive to the
specific tubercle bacillus. Among the reasons which confirm me in
this view and cause me to differ with the general opinion in this respect
I will mention only the one which appears to me of greatest import.
Guinea pigs, rabbits and many other animals are infected spontaneously
by tuberculosis much more infrequently than is man. I have made
autopsies on these animals by the thousand and have encountered
thereby only isolated examples of spontaneous tuberculosis. Neverthe-
less in my inoculation experiments I have found that every gidnea pig
and rabbit is absolutely susceptible to infection by the tubercle bacillus.
The size, age, state of nutrition, strength, and health of the animal have
absolutely no influence upon the result. When the bacillus was pres-
ent in the requisite number and virulence, infection was invariably cer-
tain to occur, whether the germ was introduced into the subcutaneous
tissue, serous cavities, lungs, intestine or blood-vessels. The disease
showed invariably progressive development with the eventual produc-
tion of general miliary tuberculosis leading to the death of the animal.
The fact that these animals do not develop tuberculosis under natural
conditions cannot, therefore, be ascribed to absence of predisposition,
but simply to the fact that under such circumstances the specific bacillus
does not enter the body in sufficient numbers and virulence to produce
infection. What is true of rabbits and guinea pigs might also be true
of man; at least there is no obvious reason why the disease should
behave differently in the different species. If but a definite percentage
of mankind contracts the disease and dies thereof, the reason should lie
in the fact that only a minority of human beings are so situated as to
become infected, since bacilli must enter the body in a certain number
and virulence to make infection possible. Doubts formerly in vogue
regarding this point have been allayed by the recognition of the fact

389

that the bacillus is not ubiquitous and that it occurs but sparsely outside
of animal bodies. The many attempts to demonstrate the presence of
the germ in the air of dwellings and the like have not led to positive
results. Inasmuch as now the limit of tuberculous infection of man
through food products has been drawn still closer, we might wonder
why, even with the existing general predisposition, the number of
instances of the development of tuberculosis in man and the death rate
are not much less than they really are, if congenital infection did not
also supply an active and frequent mode in addition to infection from
external sources.

The assumption of an inborn individual disposition to tuberculosis
is, therefore, not necessarily demanded by the facts in our possession
concerning the appearance and distribution of the disease in the human
race. These facts may also be explained by the circumscribed opera-
tion of a tuberculous infection. Prominent authors have recently
become inclined toward the view that the so-called individual disposition
to tuberculosis is neither more nor less than an indication of "debility^*
of cell-power. Undoubtedly there is much to sustain this assumption,
and I shall return to the subject before closing. But disposition, in a
parasitological sense, is manifestly something very different from debil-
ity, for the former may occur in the strongest individual of a predisposed
species as well as in the most decrepit. This statement is proven not
only by similar experiment, but by observation upon mankind, for tuber-
culosis not infrequently snatches away individuals of athletic power and
spares those who are quite delicate. The explanation of disposition is
to be sought in all likelihood along biochemical lines, as I have already
shown.

In addition to the congenital disposition to this disease, much sig-
nificance has also been accredited to the acquired disposition. The study
of the latter involves us in very complicated problems, because thus far
our data do not distinguish sharply enough between the essential dispo-
sition of the tissues which allows the parasite to obtain a foothold, and
the subsidiary factors by which it is enabled to invade the tissues and
diffuse itself within the body. While according to all experiments,
undertaken for this purpose, the first named factor, that is the actual
tuberculous disposition, can hardly appear to be influenced through
other diseased conditions of the body, it is nevertheless conceivable and
is supported by observation that the contributory caiLses for the act of
invasion and for the dissemination of the disease within the body may
be favored or occasioned by pathological conditions of the tissues. To
cite only a few examples from the experiences of medical practice, cer-
tain inflammatory affections of the air passages and lungs and various

390

generally weakening or consuming influences such as pregnancy, par-*
turition and diabetes all appear adapted to heighten the inclination Uy
contract consumption.

Affections of the air passages may favor the aerogenous act of
invasion through injury of the protective mechanical apparatus which
the normal respiratory tract offers against the entrance of air bacteria.
This may occur, perhaps, in that the inflammatory secretions afford a
suitable culture soil which favors the development of the inhaled bacilli,
and also in that they serve as a vehicle of transportation for the bacilli
within the bronchial passages. Influences which weaken the body can
also facilitate invasion through interference with or entire suspension
of the functions of the external protective apparatus ; in addition, such
influences may facilitate the extension of the infectious process by low-
ering the general resistance and power of reaction of the tissues. The
suspension of, or qualitative anomalies of tissue metabolism, such as we
note for instance, in diabetes, may also lead to a greater tendency to ne-
crosis of the parasitical inflanmiatory process. In diabetes such a tend*
ency is distinguished in a markedly ominous manner not only in tubercu-
lous, but in other inflammations, as, for example those which are pro-^
duced by pyogenic microorganisms. It must again be emphasized that
all conditions like the preceding which favor tuberculous infection have
nothing to do with the establishment of a particular disposition to tuber*
culosis, because the sphere of such favoring influences does not only
affect tuberculosis, but also, to a greater or less degree, all infections
and all infectious diseases. In the second place it is not on account of
these favoring influences that the specific bacillus finds in such a patient
the soil for localization and further development. " On the contrary,
this soil must be presumed to have existed before the advent of the fav-
oring causes. Otherwise, and in the light of all that I have explained
and communicated in regard to predisposition and immunity, such dia*
eased or weakened individuals could not have become tuberculous. To
the pathologist who makes post-mortem examinations is opportunity
given to collect evidence as to the correctness of this view.

Cases of fatal tuberculosis following measles are occasionally
reported. In such cases autopsy almost invariably shows the presence
of an old tuberculosis of the bronchial glands, which is doubtless of
more ancient date than the attack of measles. Closer investigation
shows that one or another of the tuberculous glands has ruptured inta
the larger blood vessels, the hilum of the lung or some portion of the
bronchial tree, which is followed either by a general miliary tuberculo-
sis or by a broncliiogenous pulmonary tuberculosis. The measles, then,
has not furnished the tuberculous disposition, because the child waa

891

already tuberculous before it contracted the measles. I^or did the
measles favor, through its accompanying bronchitis, a new invasion
of tubercle bacilli, because the first eruption did not occur through new
tubercle bacilli which have entered from without, but through tuber-
cle bacilli which were contained in an old caseous gland. Kotwith*
standing these arguments the acute disease did, in all probability,
exert a most baneful influence upon the course of the tuberculosis:
An old localized focus tending to heal or to become latent was caused,
through the measles, to ulcerate and perforate the tuberculous glands,
thereby converting the tuberculous affection into a progressing and gen-
eralizing one.

Quite similar has been my experience in regard to tuberculosis in
diabetics. According to my observations from post-mortem examina-
tions of cases of diabetes, instances in which there is no trace of tuber-
culosis are not so rare as has been commonly accepted. I have also fre-
quently examined cadavers of diabetics in whom the existing tuberculo-
sis undoubtedly antedated the tuberculous affection, and cases in which
one could with certainty prove the reversed relatiopi have not come to
my notice. I believe, therefore, that to a certain degree I am entitled to
the assumption that persons who suffer from diabetes and who develop
the clinical evidences of tuberculosis were tuberculous before the advent
of the diabetic disease. This position on my part cannot at this time
appear so strange when we know how frequently we find more or less
circumscribed tuberculous localizations, in the lungs or in other organs,
but more particularly in the lymphatic glands, which are tending to
healing or to latency, in subjects who during their life have not pre-
sented the slightest evidence of tuberculosis. Such; by me, so-called
latent tuberculous foci, the origin and benign course of which can evi-
dently be referred to infection with few or with slightly virulent tuber-
cle bacilli, may under certain conditions, which are not fully imderstood
for all cases, become the point of departure for a progressive and dele-
terious tuberculous affection. Such conditions are, among other dis-
eases, also suppplied by diabetes in which it remains to be determined
whether, on account of the abnormal composition of the circulating
fluids, the bacilli attain an increase of virulence from a chemical stand-
point, or whether under the diminished general resistance and ability
of reaction of the tissues the weakened bacilli are capable of more rapid
proliferation through which their original degree of virulency is
restored.

Thus, in the light of the results of ray animal experiments and of
my observations at the autopsy table, I arrive at the conclusion that
individual disposition is not the controlling factor which governs the

392

development of human tuberculosifl, but that it is the infection with the
specific bacillus. Indeed this bacillus attaches itself and thrives onlv
upon a soil which is favorable and chemically adapted to its needs. But
we have reason for the belief that this soil exists in all human beings
and probably in the same favorable degree. As a result of the action
of the bacillus proliferating upon tissues which are predisposed in its
f avor^ and further^ as an effect of the reaction of these tissues to the
irritating and injurious action of the parasite upon them, we have tuber-
culosis, a disease proteus-like in the varied multiformity of its lesions.
All those products and processes which were formerly held to be hetero-
geneous — ^the innocent chalazion, the scrofulous gland, white swelling,
lupus, caseous pneumonia, ulcerative phthisis, chronic and acute miliary
tuberculosis — ^have been united under the sceptre of the specific badUiuk

393
REVIEW OF CURRENT LITERATURE.

INFECTIOUSNESS OF UNCLEAN FINGER NAILS IN CHILDHOOD AS A
FACTOR IN THE SPREAD OF TUBERCULOSIS.

Two of the staff of Prof, von Bokay's Pediatric Clinic at Bndapest,
Drs. Preisich and Schiitz have recently made a report upon this sub-
ject before a local medical society (Berl. Klin. Wochenschrifty May 19,
1902). The children investigated were between six months and two
years of age. At this period of life the act of creeping brings the nails
in constant contact with the dust and dirt which accumulate upon the
floor. At this age, too, the children are addicted to sucking their fing-
ers and picking their noses. The dirt was removed from beneath the
nails with a sterile sound, and while a portion was studied microscopic-
ally the rest was used for animal inoculations. The latter proved
highly unsatisfactory, as a number of the guinea pigs perished prompt-
ly from some acute infectious disease which was not tuberculosis. Keal-
izing the impossibilty of demonstrating the existence of the latter dis-
ease in the presence of this acute infection the authors depended thence-
forth exclusively upon the microscopic test. Here, indeed, the increas-
ing difficulty of distinguishing between the true bacillus tuberculosis
and numerous similarly staining bacilli must be reckoned with, but the
authors used as control the genuine bacillus as found in tuberculous
sputum.

The general outcome of these studies appears to show that of the
36 children investigated, 14 contained the tubercle bacillus under their
nails ; but as some of the germs thus encountered did not respond to all
the identification-tests of the sputum-bacillus, the actual number of posi-
tive results is placed at five.

Assuming that in the 14 cases the examples of tubercle bacilli may
all have been genuine, a search for a possible source of the germs showed
tiiat in six or perhaps seven cases some member of the household from
which the child proceeded was tuberculous. In the 52 negative cases
there were but five examples of tuberculosis in the household. It is a
matter of great interest that bone tuberculosis predominated somewhat
over the pulmonary type in the possible sources of infection.

Hitherto too little attention has been paid to the pus of tuberculous
ulcers and sinuses as a transmitter of the disease, although the existence
of this factor has been recognized by authorities like Potain, Lancereaux
and others. The subject is entirely ignored by Heubner, Marfar and
B'Espine, and has also failed of mention in several of the Congresses
for Tuberculosis.

394

Open bone and gland tuberculoeis is of course extremely common
in childhood, and but a small portion of the cases are to be found under
hospital treatment. Cared for as they are at home, these children must
be able to contaminate their surroundings through the discarded dress-
ings, bathing-cloths, etc. The tendency of the dried pus is to find its
way to the floor.

In tne animal experiments already mentioned, those which did
not end fatally from a collateral acute infection of some sort resulted
negatively. It is probable that but few bacilli are actually present un-
der the nails.

The high mortality from tuberculosis at the period of life which
corresponds to the ages of the children investigated is in all probability
due to the infectiousness of the dirt of the floor. The exposure, trifling
in some respects is nevertheless relatively continuous and therefore
cumulative.

Sooner or later some slight defect within the nose or mouth be-
comes infected and the bacilli are transported to some of the neighbor-
ing glands.

VARIETDSS OF TUBERCULOSIS AND METHODS OF ITS DIFFUSION.

Benda (Trans. Brit. Congress of TuberctUosis, III., 523.) read
the opening paper on this subject at the London meeting of 1901. A
consideration of the diffusion of the bacillus gives us an idea of the
varieties of the lesions. The bacillus itself is immobile, grows slowly
and provokes a severe reaction whenever it takes firm hold. These
three properties enable us to understand why the organism is able to
repel the invasion of the germ under certain conditions. Whenever
tubercle can spread by continuity alone, the process is always a slow
one. *

But although passive, the bacillus may be transported in different
ways. Koch, himself, showed that the migratory cells distribute these
germs throughout the body. Generally speaking any method by which
transportation may be effected within the body may be utilized by the
bacillus.

The epithelial passages of large organs like the lungs and kidneys
may play a prominent part in the transportation of this germ. 'No mat-
ter how these orp:ans become infected, be the infection primary, second*
ary, or metastatic, the epithelial tissue always participates. Thua^
whether infection of the kidney is direct, haematogenous or metastatic
the epithelia of the urinary tubules are always involved and contain
the bacilli often in large number. When the germs reach the excretory

395

dncts of glandular organs, it is possible for them to be transported far-
ther in various ways. On the other hand in the finer terminal passages
diffusion occurs in this direction. We find therefore that the disease
becomes arrested in the cortex of the kidney, and that phthisis renum
is essentially an affection of the medullary substance.

In tuberculosis of the liver the biliary passages are first attacked
and this principle holds good for organs of the same character.

If the ducts of an organ are flooded with bacilli, the latter will
be carried both upwards and downwards. We can readily see that in
the case of the lungs^ the respiratory current tends to carry the germs
in both directions. It is difficult to imderstand why the trachea and
larynx are not more frequently attacked by the disease, and it is still
harder to comprehend why the entire limg is not infected from the
lesions in one bronchus. For when the expiratory current carries mat-
ter from the latter into the main bronchus, the inspiratory air should
transport the germs into other portions of the bronchial tree. Yet we
know that the disease may remain localized for a long period. When a
caseous bronchial gland ruptures into a main bronchus, thereby convey-
ing tuberculous virus into the bronchial tree, the only portion of the
lung infected as a rule is that which corresponds to the seat of the
rupture.

The methods of diffusion of the bacillus throughout the urinary
system have been much discussed. We know that infection may travel
from the kidney to its pelvis and thence to the ureter and bladder, and
we have taken it for granted that the process may extend from the
bladder along the opposite ureter and thus reach the other kidney.
Finally it has been assumed that the epididymis and testicle could be
infected from the bladder and prostate, that one epididymis may infect
its fellow through the vasa def erentia, and that primary disease in the
genital adnexa could extend upwards into the urinary organs. Baum-
garten has attempted to discredit some of these possibilities, claiming
that in the urinary organs there is no centripetal movement of the
secretions; but he overlooks the principle of antiperistalsis — ^a condi-
tion which while not yet noted in the vas deferens is commonly encoun-
tered in the muscular tubular structures.

The subject of epithelial metastasis could be carried still further —
as in the case of infection transported from the lungs into the intes-
tinal tract.

The importance of the role of the lymphatic system in the diffu-
sion of tuberculosis is well understood. The old theories in regard to
the manner in which lymphatic metastasis is effected have given way

396

to Koch's view that the bacilli are simply carried onward by the leu-
cocytes. Anything like an universal infection of the body throughout
the lymphatic system could only occur in case of participation of the
thoracic duct; for it is readily apparent under the microscope that
tuberculosis of the lymph vessels results in the obliteration of the lat-
ter. Infection of a lymph-node results in infection of the distal lym-
phatics with closure of the latter ; while if the lymph-node itself escapes
infection the onward march of the bacillus is likewise arrested.

The subject of transportation of the bacillus by the blood-vessels
is one of great interest. We may safely assume that the smaller ves-
sels always participate in tuberculosis of any organ. As in the case of
the lymphatics^ these structures become obliterated by the disease.

When, however, larger blood-vessels become involved the results
are different and the bacilli are then able to enter the circulation. This
form of tuberculosis has been studied in the heart, larger blood vessels
and thoracic duct. It does not follow that infection of these struct*
ures results necessarily in the entrance of a large number of bacilli
into the blood, because clots may form in situ and cover the tuberculous
lesion and through subsequent organization render it harmless. Even
in the absence of this phenomenon, the blood may escape infection,
because of the poverty of the lesion in bacilli. In the cases of tuberculo-
sis of the vessels in which not very many tubercles are present and in
which not many tubercle bacilli gain entrance into the blood, the dif-
fiiflion of toxins in the blood explains the fever which constitutes an
important part of the clinical picture of acute miliary tuberculosis. We
do not know as yet that the bacilli can multiply in the blood, although
certain clinical phenomena (progressive miliary infection) appear to
sanction this hypothesis.

ON THE RELATIONSHIP BETWEEN CERTAIN CASES OF RECOVERY
FROM PHTHISIS AND THE FORBSATION OF JOINTS IN THE

CARTILAGE OF THE FIRST^RIB,

Freund, who has advanced a theory that the disposition of the
apex of the lung to phthisis depends upon defective development of
the first costal cartilage, contributes a paper upon the same subject in
the Berl Klin. Wochenschrift, 1902, No. 33.

At a meeting of the Huf eland Society of Berlin, von Hansemann
had made a distinction in reference to recovery from phthisis. He
had spoken of "healed phthisis of non-bacillary origin,^' by which term
he distinguished cases of cicatrized bronchiectatic cavities, syphilomata,

397

Sbrinous pneumonia and actinomycosis from phthisis proper. The dif-
ferences between the two types of healing were sharply marked. The
essential distinction did not lie in the character of the tubercles, but in
the presence or absence of the bacillus. Tuberculpus phthisis origin-
ated in the mucosa of a bronchial tube or as cheesy hepatization which
could develop from a gelatinous pneumonia. Both types of the lesion
were of bacillary origin and both could undergo recovery if miliary
tuberculosis did not supervene, the latter being incurable. Tuber-
culous phthisis almost always begins at the apex. Kecovery may occur
by resolution, in which case hardly a trace of the disease would be left,
or by cicatrization. In the latter case a mere cicatrix might result, with
no inclusion of tuberculouB tissue; or the scar would possess a calcified
caseous centre within which bacilli might long survive in a virulent
state; or, finally, the cicatrix might enclose a cavity which, as a rule^
communicated with a bronchial tube. Such cavities may develop an
epithelial lining, and even tubercle bacilli may be found within, but
without causing further infection.

Freund now returns to the subject of the first costal cartilage and
recapitulates his doctrine — the result of 45 years' study — as follows:
Some individuals have the first costal cartilage in a state of arrested
development. It is unnaturally short, broad and firm, and thereby
interferes greatly with the normal twisting of the first rib during
inspiration. The inspiratory muscles undergo compensatory hyper-
trophy and their attachments to the rib and cartilage become the seat
of perichondritis and periostitis, leading to ossification; so that the
anterior surface and two borders of the cartilage become sheathed with
bone. In certain cases a fracture takes place in the ossified cartilage
with formation of a false joint.

Freund has been able to demonstrate all of these changes from
anatomical specimens which have been shown before societies and illus-
trated. These include; in addition to what has already been indicated,
preparations with free joints, the manubrium and sternum proper,
which formation may also compensate when present for immobility of
the first rib.

Freund next compares his findings with those of von Hansemann.
It is evident that the latter's "non-bacillary phthisis" can have no nec-
essary connection with the anomaly described by Freund. The latter
constitutes a predisposing cause of bacillary phthisis and cannot in any
way favor the development of the non-bacillary lesions described by
von Hansemann, which, however, do not have a seat of predilection in
the apex. The formation of false joints in the superior aperture of the

398

thorax would of course exert no favorable influence over the diseases
which have been styled non-bacillary phthisis.

On the other hand, in tuberculous or apical phthisis the formation
of joints in the first rib or between the manubrim and corpus stemi
would permit increased ventilation of the apices, improved circulation of
blood, augmented expectoration, etc., and would thereby directly favor
recovery with production of the form of healing deacribed by von
Hansemann,

In Freund's earlier papers, the coincidence of recovery from apical
tuberculosis with these compensatory changes in the muscles and bony
atructures of the upper thoracic aperture is mentioned as having leen
verified repeatedly upon autopsy. The author reiterates his suggestion
of dividing or resecting the first rib in threatened phthisis.

ON THE INTERPRETATION OF THE LESIONS CAUSED BY THE

BAQLLUS TUBERCULOSIS.

Hamilton (Trans. Brit, Congress of TvhercidosiSy HI, SSO.), states
that certain questions in the pathogeny of phthisis remain uni^nswered.
Tot example, why are certain tissues immune to the attacks of the bacil-
lus? Why do some lesions remain local while others infect? We do
not know why the bacilliiB sometimes refuses to stain.

In regard to natural inoculation the lung and ileum are the po\tals
of choice; the author has never seen but one case of primary tubercu-
losis of the stomach. The duodenum, upper two-thirds of the jejunum,
pharynx and oesophagus are very seldom attacked primarily b> the
bacillus. Why should the lower portion of the small intest'jies be so
much more vulnerable than the upper part of the alimentary canal f
We can answer ^.^ul}- by jiointing to the analogy which is apparent here
betwec^n labercnlniis on tht* one haiid^ and typhoid fever, seps^b^ etc., on
the other. When typhoid germs are ingested, when virulent pus is swal-
lowed, we see infection begin at the ileum, although the upper portion
of the gut, provided with the same absorbents and similarly exposed to
infection, enjoys some sort of immunity.

The author has seen many cases of tuberculous cervical glands in
which he could find no port of entry for the bacillus save carious teeth.
There is no evidence that the teeth, gums, or jaws are attacked by the
germ in its passage to the lymph-nodes ; and this fact furnishes an argu-
ment in support of the view that the bacillus may penetrate the sldn,
nmcosae, etc. without causing local lesions. It is impossible otherwise
to explain the appearance of isolated tubercle in the bones, joints, per-
itoneum, etc. Furthermore, we know that the germs of anthrax, the

399

plague, etc., do not cause lesions at the point of entry.

In regard to the mode of diffusion of the bacilli in the body, evi-
dence appears to show that this o^burs by the lymphatics rather than
by the blood-stream. There appears to be no definite relationship
between the number of bacilli absorbed and the character of the lesions ;
nor is there any regularity of inyolvement on the part of the tissues*
This is what one would expect of a lymphatic infection. But when the
germs really gain the blood-stream in large quantity, a more or less gen-
eralized infection necessarily results. The predominance of the lymph-
atics in diffusing the disease is very obvious. Thus from a focus of
tuberculous caseous pneumonia, nothing is more connnon than to see
the radiating lymph-vessels attacked by secondary tubercle. Recently
it has been claimed with some degree of probability that infection may
be transmitted along the lymphatics in the reverse direction, L e.^
against the natural current.

It is a singular fact that in primary tuberculosis of the intestine
and peritoneum, the lymphatics of Glissons's capsule may be studded
with tubercles, while the liver substance remains healthy. This dis*
crepancy is best explained by the supposition that the bacilli thrive in
the lymphatics but perish in the blood. We know that the hepatic
capillaries have a tendency to arrest foreign particles of all kinds, and it
appears probable that the leucocytes, having a higher phagocytic qual-
ity than the lymphocytes, dispose of the bacilli as soon as they reach
the portal blood.

In regard to giant cells, they are never encountered in primary
tuberculous pneumonia and hence are not an essential phenomenon
of tuberculosis. They may be seen in secondary lymphatic tubercles.
The giant cell is evidently derived from connective-tissue alone, being
in fact an overgrown connective-tissue cell. For this reason we do not
encounter it in tuberculous catarrh. In some of the lower animals we
find the giant cells packed with tubercle bacilli, while in other species
not a solitary bacterium is discoverable in these formations. In other
words their phagocytic properties vary with the animal. The barrier
of young living cells about chronic tubercles doubtless prevents the
diffiision of bacilli to a certain extent, but this defensive apparatus may
give way under various circumstances, especially when the bacilli thrive
to such an extent that a pure culture results with accompanying lique-
faction of the tubercle.

The outward aspect of tuberculous formations varies more than in
any other form of tumor-disease. There may be produced large masses
which resemble cancer and sarcoma. The tendency to caseation varies
greatly with the species of animal, and when it is absent or nearly so^

400

huge sarcoma-like masses are readily produced. In organs having
excretory ducts tuberculosis assumes one of two types, viz.: miliary
or catarrhal, the former being of haematogenous origin.

The nature of caseation is still a mystery. Probably a necrosis
inducing substance is formed in the bacillus after its death. A singular
unexplained peculiarity of ulcerating tuberculouB tissues is the absence
of any odor of putrefaction.

ON THE DIAGNOSIS OF THE INHERITED PREDISPOSITION

TO PHTHISIS.

Sticker, (Miinch. Med. Wochenschrifty August 19, 1902) states
that recovery occurs more frequently than death when an individual
has been attacked by tuberculosis. This fact may be explained in
three ways, viz. : —

1. The virus may be of different intensity.

2. Complicating factors may coexist.

3. There are differences in receptivity to the infection which may
include both local and general elements.

Differences in virulence are in evidence clinically, for an insidious
invasion of a community may pass by degrees into a veritable scoturge ;
while conversely, a stock of tuberculous antecedents may become
slowly immunized, the disease dying out. Such intensifying and weak-
ening of virulence may also be observed in the laboratory. There is
no doubt that our conception of the bacillus is too loose in character
and that more attention should be paid to race, species and variety.

In regard to the cooperation of extraneous factors in the production
of what is clinically tuberculosis, such conditions may of course act by
raising the virulence of the germs. Under this head belong alcoholismi
other diseases, defective nutrition, etc.

It is evident, however, that this subject of relative virulence is not
broad enough to account for the fact that individuals and families often
exhibit a special susceptibility to infection. This prediapoeition may
be a purely local affair, or may involve the entire constitution of the
individual.

The morphology of the special victim of tuberculosis has been
studied in detail and the peculiar thorax, small heart, etc., have been
carefully described. But this line of research has left us in the lurch ;
and the future should take more cognizance of the physiology of these
candidates for consumption. Functional aberrations are more readily
recognized and measured than anatomical deviations. We should
determine such points as the organic capacity of the lungs, the power of
regeneration of epithelium and connective tissue, the metabolism, leu-

401

cocytoeis, antitoxic capacity and the like.

In his investigations upon pneumatometry the author found his
path beset with difficulties. It appeared to be impossible to determine
the organic capacity of the lungs in a satisfactory manner. He suc-
ceeded to some extent, however, in measuring the force of the inspira-
tory muscles by an apparatus which he terms the thoraco-dynamometer.

He determined that the inspiratory force of healthy men from 19
to 25 years should be from 32 to 46 kilos for a single maximum effort,
and from 30 to 44 kilos for the constant exertion, kept up from 10 to
20 inspiratory efforts. His subjects were infantry soldiers, and the
power of the right hand was also taken by the dynamometer. Of two
individuals with good hand power, but strikingly small inspiratory
f orce, one exhibited commencing phthisis, while the other had enlarged
tonsils and pharyngeal and bronchial catarrh. Following up this clue
he found that the disproportion between the strength of the grip and
inspiratory power was often accompanied by such conditions as bilateral
apex-catarrh, pleuritic and bronchial affections, etc. After fever and
dyspnoea had developed, the consumptive sustained a rapid loss of
inspiratory force.

Attention was next turned to individuals who presented the tradi-
tional picture of congenital disposition to phthisis. He measured 23
young people whose ages ran from 17 to 24 years. They exhibited
such stigmata as paralytic thorax, and delicacy and slendemess of buUd,
and some of them had grown rapidly after puberty. All were appar-
ently free from tubercle and were healthy enough save for anaemia,
palpitation and lack of endurance. The dynamometer in this series
ranges from 18 to 39 kilos. While the maximum inspiratory effort
was 22 to 23 kilos and the steady effort from 18 to 26 kilos. All
these individuals showed retarded development of the heart, as indi-
cated by the anomalous site of the apex-beat.

Further investigation along this line has convinced the author that
the diminished inspiratory power of the types of individuals studied
adds another diagnostic token of incipient phthisis, the pretuberculoua
state, the candidate for tuberculosis, etc.

ON THE DIAGNOSIS OF THE PULMONARY ALTERATIONS PRODUCED

BY THE INHALATION OF DUST IN CONNECTION

VITH VARIOUS OCCUPATIONS.

Baumler (Miinch, Med. Wochenschrifty 1900, No. 16) states that
all physicians who practice much among artisans, whether in hospitals
or in the private pursuit of their callings, must be more or less familiar
with a condition which simulates chronic pulmonary phthisis mth the

402

striking exception that it pursues a favorable course. A study of the
antecedents of these patients leads to the conclusion that tuberculosis
plays little or no part in the production of these benign affections.

The individuals who are subject to these pulmonary troubles are
usually in middle life or of more advanced years. While chiefly of the
male sex, some of them are women. The initial picture is one of
coughy expectoration, consolidation in the upper portion of the lungs,
and more or less extensive bronchial catarrh. Fever is slight or
absent, at least as an initial phenomenon. The symptoms just enumer-
ated, taken in conjunction with the profuse muco-purulent expectora-
tion, the poor nutrition and defective circulation, appear to point toward
the existence of tuberculosis, although Koch's bacillus is not found in
the sputum.

If these patients are placed under favorable hygienic conditions,
they may be seen to recover with surprising rapidity; so that nothing
remains to tell of the past save certain phenomena of consolidation and
slight bronchial catarrh. These subjects are able to earn their living
and may remain well indefinitely, although sooner or later it is not
unconunon to note the supervention of emphysema or cardiac disease.
Autopsy usually shows the presence of induration at the apices, emphys-
ema, pleural adhesions, and a dilated hypertrophic heart. It will be
learned that all such patients have worked for a term of years at some
occupation which necessitates a constant inhalation of dust.

These intra-thoracic alterations which are known collectively by the
term pneumokoniosis are found in connection with a number of callings.

Before 1870 it was known that stone-cutters, millers, grinders,
bakers, miners, flax-spinners, tobacco-workers, etc., were subject to this
type of disease. Some of the original authorities on pneumokoniosis
were Virchow, Zeuber, Merkel and Arnold. The pathogeny of this
process is as follows: — ^Particles of dust enter the lymph-channels of
the bronchi and lung-tissue and are transported to the bronchial and
mediastinal lymph-nodes and also to the intra-alveolar and sub-pleural
connective tissue. Here they locate and give rise to the production
of new connective tissue with subsequent sclerotic changes. The
pleura may become studded with fibrous nodules which are surrrounded
by areas of pigment. Lymph-nodes are seen to have undergone contrac-
tion about pigmentary deposit. These fibroid changes have been known
to extend to contiguous structures like the oesophagus and recurrent
laryngeal nerve, with the production of serious structural and func-
tional changes.

The consequences which next follow dust inhalation are bronchial
catarrh — at first in serial attacks which become more and more f re-

403

quent and prolonged. Emphysema develops at the same period, and
^om time to time attacks of broncho-pneumonia supervene with marked
participation of the interstitial tissue, leading in turn to induration and
sclerotic change. Pleurisy is a natural sequence to the changes just
narrated, and may be attended with exudation, but is, as a rule, dry and
succeeded by thickening and adhesions. The changes in the lung
already narrated lead in time to formation of atelectasis and bronchi-
ectasis in the lower lobes. Tuberculosis may of course be superadded
to the preceding picture, and cause the patient to succumb rapidly ;
when bronchiectatic cavities have formed, putrid bronchitis may devel-
op, especially when the dust inhaled is of foul character, but in a cer-
tain class of cases, the coincidence of pneumokoniosis and tuberculosis,
80 far from being prejudicial to the patient, appears to result in recovery
from the latter disease. It is not improbable that cases of tuberculosis
have often been partly arrested by the hyperplastic changes which result
from the persistent inhalation of dust. We must therefore be careful
in practice to differentiate between pneumokoniosis which is not com-
plicated with tuberculosis, and the slowly advancing type of the latter
in which the constant inhalation of dust has exerted a modifying
influence by producing indurative and sclerotic changes.

The contraction undergone by the connective tissue produces a
shortening of one or both apices which may be recognized by percus-
sion. The anterior margins of the upper lobes of both lungs may be
similarly involved. Since I became aware of this fact, I have encoun-
tered these changes a number of times, either with or without the cor-
responding changes in the apices. Most of the cases were examples
of simple pneumokoniosis, having neither fever, nor bacilli in the spu-
tum. In certain instances the remainder of the lungs was emphysema-
tous. The following case will be very instructive: A man aged 69
was admitted to the clinic with a severe diffuse bronchitis. He showed
a pronounced emphysematous habit and complained of dyspnoea, chief-
ly expiratory in character. There was much cough with muco-purulent
sputum containing neither tubercle bacilli nor influenza bacilli. There
was no fever, the pulse ranged from 72 to 96 and the respiration was
rapid (48-56). Sonoious and sibilant rales were audible everywhere
over both lungs. The impulse of the apex of the heart could not be
made out. There was cardiac hypertrophy and the liver was both
enlarged and depressed. Some ascites was present and the urine con-
tained albumin. Upon percussion of the thorax the usual evidences
of emphysema were not too apparent. The percussion note at the
back of the lungs was indeed overfull, but in front, the lung tissue was
in part displaced by the enlarged heart and in part retracted as a result

404

of old inflammatory changes; so that in no place did it overlap the
anterior mediastinum. The patient was a confectioner and before giv-
in^^ up his occupation had been exposed to a very dusty atmosphere.
He had had two severe attacks of pulmonary haemorrhage^ which had
necessitated a sojourn of 10 weeks in the hospital. It is very evident
that the man originally had tuberculosis, which produced apical
changes, while at a later period he went through an experience with
pneumokoniosis which led to the alterations in the remainder of the
lung tissue. The last named affection in turn caused the changes in
the heart and vascular system.

The peculiar changes in the anterior borders of the limgs enable
us to diagnosticate the presence of pneumokoniosis by percussion and
are therefore of great practical significance, especially in respect to the
coincidence of tuberculosis. Whenever we find this retraction in a pa-
tient who has been tuberculous as well, we may infer that the progress
of the infectious disease has been arrested. If a patient with tuber-
culosis develops pneumokoniosis, the prognosis for life is improved.

ON THE PROGNOSIS OF TUBERCULOUS MENINGITIS.

Gross (Berl. Klin. Wochenschrift^ August 18, 1902) begins his
paper by an allusion to the definite relationship which may exist
between the cause of a disease and the prognosis. Hence the import-
ance of a bacillary examination whenever specimens are obtainable.
Limibar-puncture has greatly added to our prognostic resources through
enabling us to make differential diagnosis. We now know that tuber-
culous meningitis is not incurable, because of the coincidence of bacil-
lary findings with recovery. The author has an instructive case to
report in this connection.

A youth of 17 was taken suddenly ill with violent headache. He
took to his bed soon afterwards and vomited upon an empty stomach.
The bowels became obstinately constipated. Systematic examination
showed rigidity of the spine, fever (39° to 40° C), slow and dicrotic
pulse and boat-shaped, retracted abdomen. The skin showed the cus-
tomary vaso-motor irritability. Photophobia was present and the
excruciating headaches persisted. The patient was otherwise intact,
and there were no disturbances of the cranial nerves. The disease
might possibly have been of traumatic origin, for five days before its
supervention the boy had been hit over the parietal bone with a beer
glass. The skin at the site of injury had sloughed but the bone beneath
was found intact. It was difficult to understand how this lesion could
have induced intracranial infection, so that the diagnosis was thought

405

to lie between the simple serous meningitis, epidemic cerebro-spinal
meningitis, and tuberculous meningitis. The sudden onset and absence
of old tuberculous lesions spoke against the latter, but a history with
cicatrices of suppurating glands in childhood somewhat offset this point.
On the other hand the absence of herpes febrilis and the course of the
fever which had abated, spoke against the likelihood of epidemic menin-
gitis. The injury might perhaps have caused a serous effusion or even
haemorrhage, with production of simple meningitis. Owing to the
impossibility of making an exact diagnosis, lumbar puncture was per-
formed. The fluid was found to be cloudy, a coagulum separating:
after standing. The sediment consisted chiefly of polynuclear leuco-
cytes, but contained microorganisms at first sight. After repeated!
search, however, 3 acid-proof bacilli were recognized among the leuco-
cytes. Further research, attempts at cultures and animal-inoculation
ail resulted negatively. The meager find of bacilli was held to establish
the diagnosis of tuberculous meningitis, because in well marked cases
of the latter all tests of the cerebrospinal fluid have been known to
fa?l. The trauma now came into consideration as an exciting element
in the development of the disease, which often appears after some such
history.

After an illness of 16 days the boy made a complete recovery f ron»
the meningitis but a careful exploration of the lungs revealed certain
evidences of bilateral apical involvement, so that whatever doubt might
have remained as to the nature of the intracranial affection was now
removed.

TWO CASES IN VHICH THE ACTIVITY OF PHTHISIS VAS EXaTEI>
BY OPERATIONS FOR LOCAL TUBERCULOSIS.

Eodocanachi (London Lancety Jan. 18, 1902) gives a brief narra-
tion of two cases as follows :

1. Man, aged 40, with disease affecting a metatarso-phalangeal
joint. History of some strumous disease of the lower jaw which had
healed. There had been some cough before the operation, but no evi-
dence of pulmonary lesions. Before surgical intervention was practiced
the patient was put upon a roborant plan of treatment During the
month of May the diseased bone was gouged away, and during the per^
iod of healing the toe corresponding to the metatarsal bone became gan-
grenous and came away. The immediate result was excellent, but the
cough became worse and the patient was dead of rapid phthisis in less
than two months after the operation.

406

n. ]yCan, aged 22, with enlarged inguiiial glands on both sides.
This patient also had a cough, but his sputum contained no bacilli.
There were physical signs over one apex which pointed to tubercle. An
attempt was made to build up the patient's general nutrition and to
cause resolution of the glands. It became evident, however, that pus
was forming and the glands were extirpated; in the course of the opera-
tion several large veins were wounded. Three days later the tempera-
ture rose several degrees and never subsided. A diagnosis of sepsis was
followed by the exhibition of Marmorek's serum. Improvement ap-
peared to result and the wound began to granulate naturally. The
thoracic symptoms, however, became worse, bacilli appeared in the spu-
tum, vomiting set in and death occurred from exhaustion about three
weeks after the operation.

TUBERCULOSIS OF THE APPENDIX AND RIGHT UTERINE

APPENDAGES.

Kraus (Monatsschrift fiir Oeburtshulfe und Oynaekol.y February,
1902) states that there was no suspicion of tuberculosis in his case,
as the patient was strong and florid in appearance. The diagnosis was
tumor of the right uterine appendage of imknown origin. There was a
history of two attacks of peritonitis, with ten years intervaL The
tumor was extirpated and was found to consist of the right tube, a piece
of altered omentum, the appendix and a spheroidal mass which was
found to consist of tuberculous granulation-tissue. The uterine append-
age and the appendix vermif ormis were also found to be tuberculous.

The author attempts to explain the rationale of this case as fol-
lows : — The first attack of peritonitis, having been violent in character,
was in all likelihood non-tuberculous and of appendicular origin. It
may reasonably be assumed that the appendix was left in a vulnerable
condition and was eventually infected with tubercle bacilli from the
intestine. The second attack of peritonitis ten years after the first was
doubtless tuberculous. It pursued a highly chronic course, and even
the formation of an abscess (perhaps from perforation) was imaccom-
panied by any violent symptoms. The formation of pus extended
toward the ovary beneath the peritoneal investment of the latter. The
so-called appendiculo-ovarian ligament directly favors this extension of

disease. •

The ovary was completely disintegrated by the suppurative pro-
cess, but despite this fact it did not become tuberculous. The tube,
"however, was readily infected through its abdominal ostium and became
•obliterated. The author believes that this case is unique.

407
ORIGINAL ARTICLE.*

THE PRODUCTION OF IRIMUNITY AGAINST TUBERCULOSIS IN

CATTLE THROUGH ^tJENNERIZATION.^

BY GEHEIMRATH PROF. E. VON BEHRING OF MARBURG, GERMANY.

In speaking of "Jennerization," I mean thereby the protection of
an individual against infection through intentional inoculation of a mod-
ification of the same virus which produces the disease against which pro-
taction is sought — of a modification which by proper application i&
harmless to the individual whom we seek to protect.

While to the present time I have found no absolutely harmless
tuberculosis-virus for healthy young cattle, I have nevertheless demon-
strated in my institute a relatively harmless virus in the form of pure
cultures of tubercle bacilli derived from human sources, further in cul-
tures originally obtained from a tuberculous fowl, in the Arloing tub-
ercle bacilli, and finally in cultures of bovine tubercle bacilli which were
reduced in virulency by treatment with trichloride of iodine.

The virulency of human tubercle bacilli cultures obtains a greater
degree when they are first passed through goats or sheep, and are then
used for inoculation of cattle ; they are, however, reduced in virulency
after having been grown on artificial media for a long time. In, my
method of Jennerization I have preferably employed the latter kind.

In order to secure a perfectly uniform dosage for protective inocir-
lations, and especially when the material to be used is to be sent to dis-
tant points, I use the pure tubercle cultures in a dry state, and in con-
nection with an operative course which I gave last August, I formulated
the method and dosage as follows : "The protective virus for the first
inoculation consists of living human tubercle bacilli the effect of which
upon cattle has been carefully examined in the Institute for Experimen-
tal Therapy at Marburg."

For the first inoculation the tubercle bacilli are employed in
a dried state without, however, having lost their vitality. When kept
in sealed glass tubes during a period of 30 days, these dried tubercle
bacilli remain unimpaired in their action upon cattle, and can be used
for their immunization without hesitancy within that time, from the
date which appears upon the label of the vial.

*Thc printing of The Journal of Tuberculosis was too far advanced on the
arrival of this article to insert it under ' 'Original Communications."

fWritten for lite Journal of Tuberculosis, and translated from the author's
manuscript.

408

While the immunization value is not entirely lost even after this
period has elapsed, it is diminished to a degree which renders the mater-
ial useless.

Each glass tube contains an exactly weighed quantity of tubercle
bacilli and each animal receives as a first dose four milligrams. The vial
<5ontains 25 doses (100 milligrams).

For injection the tubercle bacilli are prepared by the following
method : —

First the whole contents of the tube are pulverized in a mortar in
Ihe dry state and then rubbed into a homogeneous emulsion by gradual
4iddition of two or three cubic centimeters of a boiled and subsequently
•cooled one per cent, salt solution.

This emulsion is then poured into a graduated cylinder of 50 c. c.
<;apacity, care being taken that every particle of it is washed out of the
mortar by rinsing repeatedly with the salt solution until the cylinder
«oontains exacdy 40 c. c.

The contents of the cylinder are now transferred to a sterile, wide-
anouthed flask, holding 100 c. c. and 10 more cubic centimeters of the
salt solution are used for rinsing the cylinder and are added to the 40
c. c. in the flask, which now contains 50 c. c. of the virus ready for
injection, of which 2 c. c. represent the proper dose for the first inoc-
ulation, provided that the tube contained 25 doses or 100 miligrams.
This method has been followed by those who attended my course and
no undesirable effects were observed either in my institute at Marburg,
or on a farm in the neighborhood.

That the dried tubercle bacilli so used are however not absolutely
without danger to cattle, is shown by a large number of laboratory
experiments in which under the use of larger doses of emulsions in
which the tubercle bacilli were not uniformly distributed, the animals
became ill vidth high fever and manifested clinically demonstrable local
lung changes which disappeared in the course of 8 to 14 days.

The dose of dried tubercle bacilli which I regard as an immun-
iizing unit, has for cattle "approximately the same degree of virulent
power as have 2 milligrams of a six weeks old serum culture; a conclus-
ion which I arrived at by comparative experiments. Now if one
immunization unit, that is four milligrams of dried tubercle bacilli,
is equal in virulency to 2 milligrams of serum culture, the former con-
tains 10 times as many tubercle bacilli as the latter, showing that my
dried tubercle bacilli represent a modification of reduced virulency.

The toxic value of four milligrams of dried tubercle bacilli is equal

to about 0.05 gr. of Koch's tuberculin; but it should be noted that

ithe same amount of tuberculosis-toxin is greater in its effect upon

409

tuberculous cattle when given intravenously than when applied subcu-
taneously.

Cattle which are highly sensitive to tuberculin show, after intra-^
venous injection of four milligrams of dried tubercle bacilli, a fever-
reaction which is identical with a positive tuberculin reaction; and
from the temperature curve of such cattle we can as readily determine-
the presence or absence of tuberculosis, as we can from that f ollowing^
a diagnostic injection of tuberculin.

In a large number of instances cattle, which had a short time-
before given a positive tuberculin reaction and which could therefore-
be regarded as tuberculous, were treated by inoculation of dried tuber-
cle bacUli. The fever reaction following upon the inoculation with
dried tubercle bacilli was then always more intense than it was in
cattle which had not reacted to tuberculin, and a cough lasting several
days appeared almost invariably as a consequence. Finally after an
average of 10 days the fever and cough disappeared. It is my present
belief that young cattle up to six months of age can receive a successful
protective inoculation although already tuberculous, provided they do
not show any other symptoms of tuberculosis except a high degree of
susceptibility for tuberculin. But cattle which must be considered
tuberculous from the results of external inspection and of physical
examination I exclude from protective inoculation under all circum-
stances.

In view of the fact that young cattle do not suffer any disadvan-
tage from protective inoculation, even if tuberculous to a degree that
they give a tuberculin reaction, and of the fact that the protective
inoculation with dried tubercle bacilli can itself be utilized for diag-
nosis, I believe that a preliminary tuberculin test is no longer necessary^

The protective inoculations with dry tubercle bacilli and with fresh
serum culture have at present (September, 1902) been performed in
such numbers that we need entertain no serious apprehensions of doing
harm. In more than 100 cattle from the age of three to twelve months
thus inoculated, no harmful consequences were observed. In a vil-
lage near Marburg (Wehrda), two such animals were slaughtered sev-
eral months after the protective inoculation; they were found in an
excellent condition of nutrition and without any trace of tuberculous
disease.

But while I emphasize the harmlessness of the protective inocula-
tion, as described above, I must also declare that at present I am unable
to guarantee that these protective inoculations will accomplish their
object in that the treated animals will be protected against infection
to which they are liable under natural conditions.

410

As I have already stated in my book on tuberculosis,* an observa-
tion of several years of such practice is necessary in order to arrive at
a final conclusion. In the meantime I consider these protective inoc-
ulations as a preliminary attempt to prove my laboratory experiments,
and I have therefore made this attempt at my own cost and upon my
own responsibility, so that owners of cattle, who will permit the inoc-
ulation, will be put to no expense.

My laboratory experiments prove that protective inoculations pro-
duce an increased power of resistance against subsequent intentional
inf ections,but not as yet to a degree that the usual fatal dose of the bov-
ine virus is well tolerated. While I presume that such a method of im-
munization (which would take much more time and prove more costly
than a single protective inoculation) will be found unnecessary for the
practical purpose of protecting cattle against ordinary infection, I am
not in a position to assert this positively, and to settle this question an
increased amount of experience in agricultural practice is required.

For this purpose the animals already inoculated will probaly b©
sufficient, and for my part I do not intend to further continue with addi-
tional inoculations until I actually know that those heretofore made
are not only harmless, but that they have also accomplished their object.

In the meanwhile I am considering the possibility that one single
protective inoculation may not suffice, and accordingly a second inoc-
ulation has been made in a series of animals located upon different
estates. Still other animals have been preliminarily treated with other
tubercle bacilK modifications which are but slightly virulent for cattle.
Further particulars may be fo\md in my publication heretofore cited.
My present object is to describe more fully the protective inoculation
which is made but once, and which will .probably become the foundation
for all future modes of immunization.

LABORATORY EXPERIMENTS CONCERNING THE IMMUNIZATION OF CATTLE

AGAINST TUBERCULOSIS.

Inasmuch as I am at present not able to claim entire success for my
protective inoculation, the confident manner in which I am testing the
method for the purpose of subduing bovine tuberculosis may be some-
what striking. But it will appear less so, after studying thoroughly
the contents of my book on tuberculosis which I published together
with Euppel and Romer, and if especial attention is given to the fol-
lowing facts calculated to supplement what has there been stated.

My confidence is based on the results obtained from a long series

^Heft 5 of Behring's Beitrage zur Experimentellen Therapie: Marburg,
Lahn, 1902, El vert* sche Buchhandlung.

411 ,

of laboratory experiments, which proved on the one hand the harm-
lessness of the method of inoculating with a virus of human origin^
and on the other hand the immunity of the inoculated cattle against
infection with a bovine virus that produced a fatally ending tubercu-
losis in animals used as controls.

These two assertions I wish now to prove by particular reference
to facts cited in my book.

I. THE HARMLESSNESS OF MY METHOD.

In 1895, 1896 and 1897, I infected more than 20 grown cattle
either subcutaneous, intravenous or intraperitoneal with bouillon cul-
tures of human tubercle bacilli, and in no case was such an inoculation
followed by a single symptom of general tuberculosis ; when these ani-
mals were killed at shorter or longer periods after infection, the chest
and abdominal organs proved to be entirely free from tuberculosis. In
the years following, I have also made inoculations in young cattle, for
the purpose of determining the question of dosage, and in these experi-
ments I substituted tubercle bacilli grown on solid media for bouillon
cultures. The result was that healthy, young cattle, five to 12 months
old, became ill with fever after an intravenous injection of an emulsion
containing not more than 0.02 gr. of tubercle bacilli grown on the sur-
face of obliquely stiffened serum. In some cases cough also followed,
lasting from three or four to 20 days, but without any exception recov-
ery was complete. If the intravenous injection contained more than
0.02 gr. of tubercle bacilli the young cattle became seriously ill, and
in some cases a genuine pneumonia was demonstrable upon clinical-
examination. During 1901 and 1902, I used in my Marburg institute
80 young cattle for the purpose of observing the effect of immunizing
doses on their general health, and I am able to assert that intravenous
injections of not more than five milligrams of dried tubercle bacilli in
the form of a well prepared emulsion can be given without hesitation
for a first inoculation. In many other individual cases and upon various
large estates this conclusion received further confirmation.

2. THE RESULTS OF MY METHOD.

With the determination of the fact that doses of more than 20
milligrams, if injected intravenously, produce serious effects in young
cattle, and that doses exceeding 50 milligrams may lead to a fatal
result, the question arose whether or not it was possible to secure pro-
tection in young cattle against large doses of the virus, under the now
generally known principle of isopathic immunization. That this is
the case appears from the protocols which I have published in my book
heretofore cited, to which I will add several other protocols in the next

412

number of my "Beitrage znr Experiihentellen Therapie" and which
will show, that in a relatively short period the doses can be increased
to 0.3 gr. without thereby causing injurious effects.

Now, in what manner do cattle which have been previously treated
with protective inoculations, respond when infected with a bovine virus,
which, since Koch's communication to the London Congress we know,
has also in laboratory experiments the power, to produce a fatal effect?

This practically important question can be answered by stating
that with the increased resistance against infection with dried human
tubercle bacilli (used for protective inoculation) a like increased
resistance develops against infection with bovine virus, for the proof
of which I can not only refer to my already published protocols, but
also to new experiments which I expect to make public before the close
of the present year.

The animals which have been treated by protective inoculations
have in the meantime also been exposed to the danger of natural (epi-
demiologic) tuberculosis infection, without thus far showing any signs
of having acquired the disease, which not only justified me, but also
made it appear a duty to begin the trial of immunization for the re-
striction of bovine tuberculosis for economic purposes.

In closing I will, however, not omit to point out again that primar-
ily it has been my chief purpose to settle the question's to the neces-
sary minimum dose which will protect young animals against the dan-
ger of natural (epidemiologic) infection.

Should it appear that animals which received but one protective
inoculation, are still liable to become tuberculous, then the first inoc-
ulation must be followed by a second one, and I do not positively assert
that the primary inoculation with dried human tubercle bacilli may not
need to be followed by an inoculation with modified bovine virus. All
this, however, I am unable to determine at this time, neither am I in
favor of extensive application of this method of Jennerization until it
has been definitely elaborated and confirmed. On the contrary, I shall
give my aid in such trials only to experienced veterinarians who have
made themselves familiar with the scientific basis of the procedure in
my laboratory and who will undertake to follow my methods and give
<exact reports of their results.
Marburg, Germany, Sept. 18, 1902.

413

SUPPLEMENT TO TH E JOURNAL OF TUBERCULOSIS.

In this part the whole subject of Pulmonary Tuberculosis will be covered
by a continued series of articles written by Dr. Karl von Ruck to appear in the
following order :

Article I. — The Cause of Tuberculosis, and The Conditions Which Pre-
dispose to its Acquirement. Article II. — The Prevention of Tuberculosis.
Article III. — ^The Pathology and Symptomatology of Pulmonary Tuberculosis.
Article IV. — The Diagnosis of Pulmonary Tuberculosis. Article V. — The
Prognosis of Pulmonary Tuberculosis. Article VI. — The Treatment of Tuber-
culosis, Dietetic, Hygienic and Symptomatic. Article VII. — The Climatic
Treatment. Article VIII, — The Specific Treatment. Article IX — Laryngeal
Tuberculosis, its Diagnosis and Treatment. Article X. — Institutions for the
Treatment of Pulmonary Tubercu losis.

THE CLIMATIC TREATMENT OF TUBERCULOSIS.

THE INFLUENCE OF CLIMATE IN THE TREATMENT OF PULMONARY

TUBERCULOSIS.
[continued from PAGE 32O.]

The advent of tuberculosis among the inhabitants of the altitude
resorts dispelled the idea of an immune climate ; the very dry air was
found to be a source of irritation, especially to the upper air passages,
the difference in numbers of bacteria in the air was found to be largely
due to harmless saprophytes and did not seem to protect patients against
infection of their necrotic lung lesions with the pus germs. Pneu-
monias appeared to be even more frequent than at lower levels ; in short,
only patients who had but slight or initial changes or latent lung lesions
appeared to do well. With all others the altitude, and all that per-
tained to it in the way of supposed advantages, was found powerless to
change the course of the disease to a more favorable one.

Even the peculiar phenomenon of the increase in red blood cells
has since been questioned. The investigations of Schroeder, Gottstein,
and Meissen, within the last three or four years, tend to show that it is
more apparent than real, depending on error due to diminished air pres-
sure upon the cover-glass of the blood chamber in which the count is
made.

To reconcile these apparently contradictory facfts by a satisfactory
explanation of them, it is essential that the clinical material should also
be taken into consideration and that the pathology of tuberculosis in the
individual patient should not be lost sight of. To do this we may well
remember that the pathologic changes in tuberculosis of the lung com-
prise variations from comparatively simple to the most complex altera-
tions, and that to these the entire organism shows reaction in disturbed

414

and perverted functions and in degrees that vary with existing Inng
lesions^ as well as with the individual constitution and resistance of the
patient.

As to the therapeutic influence of climate in tuberculosis, there is
no occasion to doubt the empirical observations made during centuries
that have passed, and any attempt to ignore this influence or to deny
certain benefits derived from it will only add more confusion. There
are certain elementary facts, also, of which there can be no reasonable
doubt, both as to climatic influences and as to the disease under consid-
eration, and these elementary 'facts must be applied on both sides. In
attempting this, I desire to be strictly confiervative by stating:

Mrst: Change from an accustomed climatic environment to a dif-^
ferent one, and especially from one that is damp, chilly and cloudy , to
one that is warm and sunny has the same exhilarating influence that we
observe in ourselves without change of locality, when, after a prolonged
period of had weather^ a change to pleasant weather and to sunshine
occurs.

To such a change, react those who are well and also those who
are not severely ill, but in the case of a patient who has advanced in his
disease to degrees that his suffering and exhaustion are such that he can
think only of himself, or can take no notice of, or interest in his environ-
ment, the change is non-effective, and so far as the effort in making it
calls upon his strength and endurance, it is harmful.

Let us illustrate this proposition, simple as it is, and take, on the
one hand, a patient who has an affection of one or even both upper lobes,
which is but slowly progressing or perhaps is stationary and in which
the pathologic changes have not reached the stage of softening and
excavation; such a patient is practically free from fever, as well as
from other striking symptoms ; he may be easily fatigued and may have
lost some weight, but he is physically in fair condition. To him the
change is agreeable; he is pleased with the better state of the weather;
he notes with interest things he observes, especially the things which
are different from those he was accustomed to at home ; he tells you of
it, and he evidently feela better. That the influence is largely men-
tal cannot be doubted, but the result is that under the change he reacts
to his new environment, he eats better and sleeps better, and it has
done him good.

Take another case, one that has softening in a tuberculous area,
perhaps with a pleurisy that causes pain on deep inspiration; this
patient has fever, likely to begin with a chill, he feels badly, tired and

416

wearj; coughs, lacks in appetite^ nothing satisfies him ; he fails to take
interest in his new environment. AU he wants is to be free from his
disagreeable symptoms, and these will not subside; until they do, he
cannot react to the change. The result is that the effort of travel has
fatigued him, has perhaps increased his symptoms, and his expectations
having not been realized, he suffers the depression incident to his disap*
pointment.

Second : Cooly dry air is invigorating y and hoiy moist air is enervat-
ing and exhausting.

This is also verified in the experience of those who are healthy
as of those who are ill. For the pulmonary invalid who is to gain an
advantage by a change to a cool, invigorating climate, we must, how-
ever, condition that the air be not so cold that he is restricted in his
out-of-door life, and that he must have a sufficiently active circulation
that the cool, dry air will appear grateful to his sensations.

Third : The "breathing of pure air in the sense that it is comparatively
free from organic and inorganic matter is better for healthy as well as for
sicJe peoplcj than is the breathing of foul air, or air which contains dust
and dirt in suspension.

Applying this proposition to the pulmonary invalid, I expect no
disagreement by asserting that air laden with fine sand, dust and dirt
is the more objectionable because of local irritation in the lungs which
follows, and which is likely to be more detrimental in all those who
have more or less bronchial catarrh and on that account are proportion-
ally deficient in the mechanism for prompt expulsion, the ciliated epi-
thelium being impaired or absent from affected mucous surfaces.

In considering climatic resorts in regard to their advantages in
respect to purity of the air, there can be no objection to the claim that
the air is purer in the open country than in crowded cities and that this
difference is greater in all respects in regions having forest covered
surfaces and in which human activities as to manufacturing and agri-
culture are greatly restricted or absent, than in densely populated man*
ufacturing districts and especially in large cities.

That, theref oup, the high altitude regions which are sparsely or
not at all populated have a decided advantage, goes without saying, but
that these advantages are more or less modified and are not available
to the theoretical degree becomes apparent when we remember that in
such remote localities the average pulmonary invalid will not find the
conditions highly essential to his recovery, and that, after all, he must
seek more or less populous towns in such regions in order to have the
dietetic and professional care and environment which he requires. In

416

Bome barren and arid regions which also have certain climatic advan-
tages, the continued presence of a large amount of inorganic matter
in the air in the form of dust and fine sand, is an additional disadvan*
tage, especially to those who have advanced beyond the early stage of
the disease.

Fourth : With intaci vascular channels between right and left heart
the peripheral circulation is increased in proportion as the atmospheric
pressure is diminished.

At elevations of great height, 10,000 feet and over for instance, the
congestion of surfaces exposed to the air rarification becomes so great
that anaemia of internal organs may supervene and haemorrhages may
occur from capillaries of mucous membranes. The influence of the
effect of different degrees of rarification of the air may be taken advan-
tage of in tuberculosis of internal organs as well as of the respiratory
surfaces and integument, the benefit derivable, depending upon the
action of relative degrees of internal anaemia or external congestion
upon the pathologic alterations existing in the respective parts.

In estimating this benefit in pulmonary tuberculosis, we must take
into consideration the degree of obstruction caused by the pathologic
changes in the lung. In proportion to their extent the sum total of the
vascular channels which lie between the right and left side of the heart
is diminished, and as a result, the vascular pressure in the pulmonary
artery is increased, so long as the right ventricle is competent in its
power. Under greater degrees of obstruction or greater degrees of
rarification or both, active pulmonary congestion or rupture of branches
of the pulmonary artery in the diseased lung portions is favored if the
right heart is competent to maintain the pressure ; if the latter fails, ven-
ous congestion in parts and organs back of the right ventricle must fol-
low, while at the same time heart-strain is induced. We see, there-
fore, that in employing high altitude effects in pulmonary tuberculosis,
we may obtain varying results, according to the pathologic changes that
happen to exist in the individual case, and according to the integrity
of the right ventricle and pulmonary semilunar valves. What must
be guarded against is strain of the right ventricle and congestion of
the pulmonary tissues. In this respect the effect of considerable de-
grees of altitude is therefore the same as we observe from physical exer-
cise which may induce like conditions. When altitude and exercise
are combined patients who have considerable vascular obstruction in
their lungs are limited in a greater degree as concerns the latter at ele-
vated regions, than at the sea-level.

Fifth : A relatively dry locality is better for the pulmonary invalid
than a damp or moist one.

417

This proposition will also require no defence. While I would not
seek to establish a direct influence upon the local lung disease I see
its value chiefly in the more rapid cutaneous evaporation and through
this, in a diminished liability to contract colds and catarrhal inflamma-
tion of the air passages, while at the same time the patient's comfort
is greatly enhanced, and in addition, in the fact that influenza is favored
in its occurrence by moisture. Those who understand the development
of pulmonary phthisis know very well, if we understand by it the
initiation of destructive processes in the lung, that the phthisical stage
is preceded by another, namely the tuberculization of certain portions
of the lung, and that in the vast majority of cases in which the tuber-
culous affection is limited to a lobe or portion of a lobe, the natural
course is to a period of latency of longer or shorter duration. They
also know that this latent tuberculous deposit is liable to renewed
inflammation, and that when this occurs, softening and excavation, i. e.,
the beginning of pulmonary phthisis is the usual result. If by any
manner of means we could protect those who have latent tuberculous
deposits in their lungs against renewed inflammation in that part of
the lung where such a deposit is situated, the cases of phthisis would
be comparatively few. In our efforts to do this we must seek to rec-
ognize the causes that are responsible, and which are now very well
understood. A study of the clinical history of a material wl-.ich
amounts to 3,600 cases from my own practice shows that in 75 per cent,
the first evidence of the beginning phthisis has been immediately pre-
ceded by incidental inflammation of the air passages, occurring in the
course of ordinary good health, or in connection with acute disease.
The causes of incidental inflammations were assigned to acute bron-
chitis ("taking cold") in 29 per cent. ; to influenza (grippe) in 47 per
cent.; to pneumonia in 12.5 per cent. ; to typhoid fever in 10 per cent. ;
whooping cough, diphtheria, smallpox, quinzy and scarlet fever in 2.5
per cent. These statistics agree with others that are chiefly obtained
from adults, and they show that bronchitis from ordinary colds, is
i^esponsible for the development of phthisis in tuberculous subjects in
nearly one-third of all cases; and if we include influenza these two
causes appear in three-fourths of all cases to have initiated the phthisi-
cal stage. My statistical records bear me out in the statement, further,
that in a very large proportion of cases of early phthisis the disease
does not progress continuously to a fatal issue, but on the contrary,
an arrestment or at least a marked degree of amelioration follows evac-
uation of the flrst abscess cavity, and that the causes for renewal of
disease and relapses are often the same that excite the phthisical pro-
cess in the first place.

418

If I am right in these statements, and if our views in regard to
dampness of soil and air as causative factors in the contraction of ca-
tarrhal inflammation are correct, then it follows that, other things being
equal, a relatively dry climate protects to a certain extent against the
development of phthisis in cases which have latent tuberculous deposits
in their lungs, and that in the established disease it becomes valuable
in the treatment thereof by diminishing in a like degree the occurrence
of relapses; in other words, the patient has a better chance for recovery
in a dry climate because relapses are less frequently induced.

The study of climatology having established the fact that elevated
regions have, as a rule, less relative humidity than low sea coast local-
ities, we see from clinical experience in such localities, that many cases •
in the early stages of tuberculosis — that is in the formative and latent
stages — continue in good health in high altitudes and dry localities as
long as they remain there under otherwise favorable hygienic and diet-
etic conditions, and that in the early stages of developed phthisis in
which the disease is limited to a small area, more arrestments and
recoveries obtain than in regions where dampness of soil and air are
liable, through induction of incidental inflammation, to interrupt the
favorable course of the disease.

Sixth : Sunlight is essential to health and life through its influence
upon the vegetative processes.

This observation is so common and universal that, like the preced-
ing proposition, there is no reasonable ground for its denial. The influ-
ence of out-of-door life which is universally recognized as conducive to
the best state of nutrition and physical well-being is, in my opinion, due
to a much greater degree to the simultaneous exposure to sunlight than
to a difference in quality of the air, although I would by no means
underestimate the value of purity of the latter. Total absence of light
means perversion of the nutritive functions, physical deterioration, and
ultimately premature death. Indoor life is detrimental to the degree
that the light is diminished or withheld, a fact which we have fully rec-
ognized, in considering indoor occupation, especially in dark rooms, as
an important predisposing factor to the acquirement of infection and to
an unfavorable progress of the disease.

If we again examine the climatic features of elevated localities or
of low regions which have shown satisfactory results in the treatment
of phthisis, we find them to be, in either case, particularly those where
out-of-door life is invited by a favorable state of the weather, tempera-
ture and sunshine. If we need further evidence, we have it abundantly
in the results obtained in all institutions for the treatment of pulmonary
tuberculosis, no matter where located, in which out-of-door life, that is
to say, exposure to sunlight, is a feature of the treatment.

419

In accepting these general propositions as to the treatment of tuber-
culosis^ we can readily see that even under the most favorable combina-
tion of the advantages obtainable, the effect of climate upon the course
of puhnonary tuberculosis is not exerted directly upon the disease itself,
and that there really is no immune or curative climate. At the same
time we can appreciate that in suitably selected cases these influences
can become most important aids both in prophylaxis and in treatment.

This brings us to the selection of cases for climatic treatment. In
view of what I have said, and in the light of clinical experience at hand,
we can claim : —

1st. That the removal to a climate having the advantages consid-
ered in the preceding propositions, is of benefit to all those who in
any sense are predisposed to the acquirement of infection, so long as
ihey avoid intimate contact with careless patients who promiscuously
discharge infectious secretions,

2d. That such removal is also of advantage to all those who are
already infected, but whose tuberculous affections are either very recent,
or have become latent

3rd. That in more advanced stages such a climate becomes valu-
able in limiting relapses due to catarrhal inflammations, and in favor-
ing nutrition by the out-of-door life it allows under the influence of
favorable conditions of temperature and sunlight.

In either of the first two classes the climate is employed from a
prophylactic standpoint, against infection in the first and against the
occurrence of destructive changes — that is against the development of
phthisis — in the second. A like object in the way of prevention is
sought and often accomplished in cases of the third class which have
already passed through that early stage of phthisis in which the first
destructive changes occur, but in which active symptoms have subsided.
In such cases a favorable climate affords good prospects that thd formed
cavity will cease to secrete and will heal out, and that other existing
tuberculous areas which have not as yet broken down will continue
latent, because the chances for incidental local inflammation are much
less, and the general influence upon nutrition increases the patient's
power of resistance.

In the third class of cases suitable for climatic treatment, I include
those which after reaching the open stage of phthisis, that is to say, hav-
ing established an outlet from the formed cavity into a bronchus, show
moderate temperature elevations to between 100 and 101° F.

It is quite a different proposition when we propose climatic treat-
ment for eateg with active, progressive and acute phthisical processes.

420

and to send such patients away from their homes, involves great respon-
sibiKty on account of the uncertainties as to the future course of the
disease. When this must, nevertheless be considered, the attending
physician should not lose sight of the fact that climate can in no wise
remove or even modify the existing pathological changes in the lungs or
elsewhere, excepting through the indirect influences already enumer-
ated, which render the reparative efforts of nature less liable to be inter-
rupted, on the one hand, and which aid the general metabolic processes
on the other. The latter, however, are only to be improved when the
patient can take advantage of the out of door life and sunlight which
the selected locality affords, and such improvement usually fails to man-
ifest itself appreciably until the acute symptoms due to local softening,
suppuration or inflammation have subsided.

Here may also be included a class of patients in whom phthisis is of
a pneumonic type from the start, or in whom acute pneumonic inflam-
mation has become a complication from aspiration of sputum, or in con-
nection with grippe, bronchitis, etc., and finally patients who for the
time have acute pleurisy. In all such cases I would strongly urge delay
in seeking the advantages of any climate, but more particularly would
1 caution against removal to distant localities, whereby the incidents
of the journey, through fatigue and exposure, may greatly dimin-
ish the still existing prospects. Such patients are, as a rule, confined
to bed, or ought to be so confined for their best interests, and I cannot
see any real advantage to be derived from their removal to a better
climate where the same course of management must be adopted until
the acute symptoms have subsided. Since out of door life is out of the
question in either place, and since the danger of renewed inflammation
through exposure to prevailing conditions of bad weather practically
does not exist with bed patients, it would seem the wisest plan to await
the termination of the acute symptoms, and to consider the prospects
of climatic benefit in the light of the condition of the patient as
found at that time.

Patients who at the termination of acute processes arrive at this
stage greatly emaciated and exhausted, should be tested as to their
recuperative powers at home where through proper feeding and hygienic
measures, amelioration will show itself also, if it is still to be obtained.
When this improvement has occurred to a degree that the patient can
make the journey to a climatic resort with comfort and without danger
of seriously injurious fatigue, it is time enough to send him.

In considering complications on the part of the digestive organs,
lack of appetite in the absence of actual gastro-intestinal disease is not

421

a contraindication ; on the contrary, when the anorexia is not caused by
fever, such patients, as a rule, show prompt improvement in this respect
in moderate and high altitudes.

Although otherwise eligible, patients who have had recent haem-
orrhages, should not be started on a journey to climatic resorts until
bloody expectoration has been absent for a week or ten days, and high
altitude resorts should be avoided even if there is no other contraindica-
tion.

Excluding all such cases as have been indicated, at least for the
time being, as suitable for climatic treatment, the physician should still
take into consideration the general state of nutrition and strength as
well as the extent of the local lung disease and the complications which
may be present in all those who might otherwise be classed as suitable
cases, and here he will find again quite a number in which the removal
to climatic resorts had better be delayed.

As of doubtful utility as regards probably lasting benefits, I con-
sider climatic treatment in that stage of the disease in which large sup-
purating cavities are present or destructive changes involve large areas,
especially when such advanced lesions are manifest in both lungs,
although active only in the last involved lobe or side.

Another class of patients who should not be sent away from home
is constituted by those who in spite of drinking freely of hot water or
who under the use of mild diuretics, continue to show a marked diazo
reaction in the urine; also those who suffer from persistent diarrhoea
under proper dietetic regimen, and who fail to obtain relief from suita-
ble medical treatment, even if the general condition is still fair, and
although none of the acute processes mentioned above may be in evi-
dence.

Extensive ulcerative processes or extensive infiltrations in the lar-
ynx that cause painful deglutition are so rarely recovered from or even
materially improved that climatic treatment is of doubtful advantage
beyond the possible prospect of prolonging life. Only when skilful
local treatment is not available at home, and when the lung affection
is limited and the general nutrition and strength of the patient are
still satisfacory, and when such patients may be placed under the care
of a competent laryngologist, at the selected resort is removal to a
favorable climate to be considered.

With no greater expectations than I have enumerated in the earlier
jmrt of the consideration of climatic influences, and with a selection of
cases as here indicated, T am sure, that no serious disappointments will
follow its employment, always providing that the patient is properly

422

cared for and advised at the climatic station to which he resorts^ and
that he is conscientious in following the advice he receives.

The results that may be expected are, in cases of recent and circum-
scribed tuberculous invasions of the lung, and in cases presenting latent
processes of like character, that the latent period may be continued
indefinitely until, after a considerable number of years, an actual recov-
ery will result through gradual fibroid transformation of recent tuber-
cles and encapsulation of caseous nodules and areas. During this pro-
longed period the patient may apparently enjoy good health, and may
lead a useful and comparatively active life, which, however, should be
in the open air as much as possible and guarded against all excesses,
phygical or mental, as well as against undue exposure. Relapses and
new accessions will, however, occur for the simple res son that climate,
however favorable, is not unconditionally protective against them, inas-
much as it cannot save the patient from accidental mishaps or from
results of willful disregard of the observation of conditions that are
essential, and which many patients either fail to observe at all, or are
only too ready to interrupt, in an optimistic belief, that subsidence of
symptoms is equivalent to an actual cure.*

* Henceforth the Supplement will be discontinued as a department of the
Journal and the series of articles by Dr. Karl von Ruck will be continued in
the Original columns.

Nl2> 1^1

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