HX641 33095 
 RC311 .Z65 1888 Pulmonary tuberculos 
 
 1838 
 
 RECAP 
 
 Ziemssen 
 
 •••Pulmonary tuberculosis 
 
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PEPTONISED MILK. 
 
 (FAIRCHILD PROCESS.) 
 
 The Ideal Food for the sick, the delicate, the con- 
 sumptive, the habitual dyspeptic, the diabetic. 
 
 Peptonised Milk is milk in which the 
 caseine has been wholly or partially 
 converted into peptone, the degree of 
 this conversion to be controlled at will, 
 as determined by the needs of the case. 
 AH the other elements of the milk, the 
 sugar, fat and mineral salts, are already 
 provided by nature in a condition for 
 perfect assimilation, without digestive 
 effort. 
 
 One pint of Milk, when peptonised, 
 contains two oitoces of total dry 
 SOLIDS— MrLK Peptones, Milk Suoau, 
 Fat and Ash. 
 
 Of Beef Tea, Dr. Christison says: 
 "He was able to obtain but a quarter 
 "of an ounce of solid residue in a 
 "pint.'''' 
 
 This solid residue consists of " besides 
 '* the trifling amount of proteid mater- 
 "ial and of fat (which latter, in prac- 
 " tice, is guarded against with great 
 *' care), only the salts of the muscle, the 
 "liematin, and (dlied pigments, traces 
 "of sugar, perhaps, some lactic acid, 
 " and the nitrogenous extractives crea- 
 " tin and its congeners. As the original 
 "half pound of muscle may cont^n 
 "about forty to sixty grains of the 
 
 "salts, and ten to twelve grains of the 
 " nitrogenous waste products, the beef 
 " tea (half pint) certainly contained no 
 "more."— Prof. Bauugarten. 
 
 Of Beef Extract, Dr. Pavy says: 
 "There are grounds for believing that 
 "a considerable proportion consists of 
 " products of proteid decay, materials 
 "in course of retrograde metamorpho- 
 " sis, that are of no use as nutritive 
 "agents." 
 
 The well nigh superstitious ideas en- 
 tertained by the laity of beef tea, is 
 expressed in the allusion to the 
 "strength" which is popularly sup- 
 posed to be extracted in the tea; after 
 which the beef is thrown to the dogs. 
 The working man makes soup from a 
 joint and consumes the "strength" and 
 the beef both . 
 
 The medical profession insist that 
 patients shall profit by the knowledge 
 and progress of medical science, by the 
 use of artificially digested fresh milk, 
 etc. The Nostrum advertisers usurp 
 functions of the physician by prescrib- 
 ing fictitious " foods for invalids," foods 
 which medical science has long since 
 condemned. 
 
 PEPTONISING TUBES 
 
 In boxes of 1 dozen tubes, at 50 cents retail. Each tube peptonises one pint of 
 milk. 
 
 Pamphlets and samples gratis to physicians. 
 
 F:±IRCHILD BROS. <ft FOSTER, 
 
 82 8c 84 FULTON STREET NEW YORK. 
 
i^m^mm^m^^m^^^^'^'^^^B^ 
 
 I » * NOTICE. -• « 
 
 I In pursuance of recently effected and mutually 
 
 I satisfactory arrangements, all the publications of 
 
 8 Geo. S. Davis, Medical Publisher, will hereafter be t 
 
 I issued by William M. Warren, Medical Publisher. | 
 
 jj All contracts with reference to such publications, of 
 
 I whatever nature, entered into with Geo. S. Davis, 
 
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 jj gations, amounts due, etc., are payable to, William 
 
 1 M. Warren, Medical Publisher. 
 
PULMDNARY TUBERCULDSIS. 
 
 ITS ETIOLOGY, SYMPTOMATOLOGY AND 
 THERAPEUTICS. 
 
 PROF. DR. H. VON ZIEMSSEN, 
 
 Director of the Medical Clinic at Munich. 
 
 TRANSLATED BY 
 
 DAVID J. DOHERTY, A. M., M. D. 
 
 Instructor in the Chicago Policlinic. 
 
 1888. 
 GEORGE S. DAVIS. 
 
 DETROIT. MK;U. 
 
RC3/ 1 
 
 Copyrighted by 
 
 GEORGE S. DAVIS. 
 
 1888. 
 
PREFATORY NOTE. 
 
 This little work on Tuberculosis contains the views of 
 one of the most eminent clinical teachers and practitioners 
 in Europe. It is, I think, the most recent published utter- 
 ance on the subject. The matter was delivered in the form 
 of lectures to his pupils and consequently some diffuseness 
 and repetitions occur. The translation, though not elegant, 
 is faithful. 
 
 D. J. D. 
 ToSute St., and 143 North Ave, Chicago, lU. 
 
TABLE10F CONTENTS. 
 
 PART FIRST. 
 ETIOLOGY. 
 
 PAGE. 
 CHAPTER I. The Tubercle Bacillus— Hereditary Trans- 
 mission — Direct Infection i 
 
 " II. Inherited and Acquired Predisposition — 
 
 Social Foci 9 
 
 " III. Invasion of the Bacilli — Defence of the 
 Organism — Vulnerability of the Apex 
 — Theory of Phagocytes — Invulner- 
 ability of the Larynx 19 
 
 PART SECOND. 
 
 DIAGNOSIS. 
 
 CHAPTER I. Paralytic Thorax— Apices 30 
 
 " II. Sputum — Bacilli — Elastic Fibres — Myelin 
 
 Cells — Hemoptysis 43 
 
 " III. Fever — Idiomuscular Tumors — Contrac- 
 tion Waves 52 
 
 " IV. Spirometry — Weighing 60 
 
PART THIRD. 
 
 TREATMENT. 
 
 CHAPTER I. Prophylactic— Hygiene— Choice of Em- 
 ploytnent — Precautions against Con- 
 tagion — Hydrotherapy 64 
 
 " n. Direct — Hygienic — Climatic — Dietetic — 
 
 Medicinal 94 
 
 " ni. Secondary Tuberculosis — Complications — 
 Tuberculosis of Larynx — Tubercu- 
 losis of Intestines — Anal Fistula.... 109 
 
 APPENDIX. 
 
 A. Tuberculosis in American Prisons 114 
 
 B. Method of Examining Sputum for Balilli 119 
 
PART FIRST. 
 
 THE ETIOLOGY OF TUBERCULOSIS. 
 
 CHAPTER I. 
 
 THE TUBERCLE BACILLUS— HEREDITARY 
 TRANSMISSION— DIRECT INFECTION. 
 
 The radical revolution produced in theories con- 
 cerning the nature of tuberculosis by the classical re- 
 searches of Koch has also had a reformatory influence 
 on clinical views. So long as the nature of tuber- 
 culosis was unknown, theory drifted hither and thither 
 as the prevailing current carried it. At one time 
 tabercle was held to be a neoplasm, again something 
 specific and infectious, again a product of inflamma- 
 tion. Its origin from bronchial catarrh, pulmonary 
 hemorrhage, pneumonia, inhalation of dust, etc., was 
 asserted and denied with equal vigor. Its contagious- 
 ness was at times maintained and at other times rejected. 
 Inheritance alone was always considered to be an un- 
 assailable and sure etiological factor; but lately even 
 that has not escaped question. 
 
 Through this chaos of theory and empiricism, 
 
Koch's discovery suddenly shot a piercing ray which 
 not only illuminated the very kernel of the subject, 
 but spread light and guidance in every direction. By 
 a single stroke, the old and much debated knot of the 
 nature of tuberculosis was untied, and the parasitic 
 character both of it and of scrofula in all their forms 
 and situations was established. 
 
 I remember well the profound impression pro- 
 duced upon the members of the Pharmacopoeia Com- 
 mission by the first demonstration which Koch made 
 in the laboratory of the Imperial Sanitary Bureau. He 
 had not then made public his discovery;* but he 
 graciously yielded to our desires and those of the then 
 chief of the Sanitary Bureau (Dr. Struck), and ex- 
 plained to us his preparations and the manner in 
 which he had made the discovery. In that modest 
 laboratory of the unassuming scholar, we saw one of 
 the greatest puzzles of pathology, the nature of the 
 worst scourge of humanity, unravelled. And how 
 complete, rounded and positive his solution of the 
 problem was became evident when criticism and sub- 
 sequent investigation found not only nothing import- 
 ant to change, but even scarcely anything of value to 
 add. There was not a weak link in the entire chain 
 of demonstration. 
 
 Clinical medicine at once accepted the new doc- 
 trine and frankly interested itself in the reconstruction 
 
 *He announced it in the Berliner Kliti. JVochenschtift, 
 1882, No. 15.— Tr. 
 
of views which it imposed. Every intelHgent person, 
 however, saw clearly that there would be many diffi- 
 culties in the beginning. Various points in the sub- 
 ject of tuberculosis seemed, from the standpoint of 
 the bacillus theory, to be beset by almost insuperable 
 difficulties. Among them stood at the very threshold 
 the question of Inheritability. 
 
 In truth, no fact of experience seems so firmly 
 established as the inheritability of tuberculosis. Day 
 after day the physician sees this disease reap its harvest 
 among the offspring of tuberculous parents. In infancy 
 scrofulous, in youth tuberculous — that is the history 
 of such children as they grow up and wither away. 
 How can this axiom of experience be made to har- 
 monize with the bacillus doctrine of Koch ? Various 
 solutions have been attempted. Thus far, however, 
 most of the attempts involve hypotheses which, though 
 supported by some scattered facts, on the whole lack 
 demonstration. 
 
 The transmission of tuberculosis on the side of 
 father is supposed to take place at the moment of 
 conception, by means of spermatozoa which contain 
 bacilli. In behalf of this explanation, nothing more 
 is presented than the fact that bacilli have been found 
 in the testicles of tuberculous men. Transmission 
 from the mother at the time of conception must pre- 
 suppose an ovum either originally infected with bacilli 
 or become infected during its passage. Furthermore, 
 there is the possibility of a later intra-uterine infection 
 
— 4 — 
 
 of the child by the paternal seed or the maternal 
 blood. These hypotheses, however, are only desper- 
 ate resources. The lack of direct proof of hereditary 
 transmission has stimulated the search for other meth- 
 ods of accounting for family tuberculosis. S^e, in his 
 work on Bacillary Tuberculosis, and Riihle, in his 
 paper read before the Sixth Congress of Clinical 
 Medicine and in his Treatise on Tuberculosis (in my 
 Hand-book of Special Pathology and Therapeutics), 
 have made a notable effort in that direction, namely ,^ 
 to substitute post-foetal infection for intra-uterine. 
 Such an effort deserves the greatest attention, because 
 much more can be done to liberate mankind from 
 tuberculosis if, instead of heredity which is difficult to 
 influence, we should have to deal with extra-uterine 
 infection, the sources of which seem more easy of 
 recognition and control. 
 
 Certainly there are many and obvious ways in 
 which a child may be infected. Close contact with a 
 diseased mother or nurse, the kiss of a tuberculous 
 father, contamination of food with tubercle bacilli, 
 bacillary infection of wounds — all these are sources of 
 infection, and their power is proportioned to the 
 weakness of the infantile organism. Next to direct 
 contagion from the sick, milk containing bacilli or 
 spores is the most likely source of infection. When 
 we consider the frequency of bovine tuberculosis, we 
 must see how great the danger from this source is, 
 especially if the milk be unmixed and exclusively from 
 
a sick cow, or if the udder of the animal should be 
 tuberculous. Food experiments lately made by Bol- 
 linger and his pupils have established the noteworthy 
 fact that the milk of tuberculous cows is infectious for 
 Guinea-pigs, even when the udders are entirely 
 healthy and the cows, though afflicted with local pul- 
 monary or pleuritic tuberculosis, are in the best condi- 
 tion of nourishment. Of course, the infectiousness is 
 much diminished by the customary admixture of the 
 milk of infected cattle with that of healthy ones; and 
 it is completely destroyed by boiling for five minutes. 
 People, however, are usually negligent concerning a 
 danger which they do not see. Even in intelligent 
 families too little attention is paid to the source of 
 milk supplied to nurslings, and the regular boiling is 
 often done without due care. A mother who relegates 
 to the cook the task of preparing the baby's milk may 
 be pretty sure that it will not be properly done. Phy- 
 sicians should impress upon mothers the duty of 
 themselves attending to it. Soxhlet's bottles, which 
 prevent any injury to the babe from parasites or 
 chemical action, are the best for the purpose, provided 
 the mother herself attends to the due cleansing of the 
 bottle. Considering everything, as the matter now 
 stands, the exact degree of danger from food cannot 
 yet be determined. Perhaps, indeed, the fear of 
 bacilli and spores in the milk is excessive; but the 
 frequency of tuberculosis of the mesenteric glands in 
 children compels us ever to recur to the thought of 
 
_ 6 — 
 
 infection from that source. Since, therefore, the in- 
 fectiousness of milk from tuberculous cows has been 
 demonstrated on suitable animals, and since there is 
 no evidence against the application of that result to 
 the human race, it is the duty of the physician to in- 
 struct his patients as to this grave danger. 
 
 Many other modes of infection exist in close 
 family life which may simulate hereditary transmission 
 and by which a tuberculous father or mother may 
 exercise an unhealthy influence on the children. Con- 
 tamination of the dwelling, furniture, utensils or food 
 with sputum is the more likely to cause infection in 
 susceptible children, the smaller the dwellings, the 
 larger the family and the less the well-being and 
 cleanliness are. 
 
 However, plausible as these modes of infection 
 seem from a theoretical standpoint, viewed practically 
 they are not of great importance. That is evidenced 
 by statistics and by the daily experience of physicians. 
 Cases of transmission of tuberculosis from the sick to 
 others who come into contact with them, as husband 
 and wife, nurses, attendants, etc., are so extraordin- 
 arily rare, that its infectiousness cannot be as serious 
 as has been occasionally asserted on theoretical 
 grounds. In order, therefore, to explain the fre- 
 quency of the disease in persons descended from 
 tuberculous parents, we must still cling to the idea of 
 heredity, and await a further development of knowl- 
 edge to clear up the darkness which surrounds it. 
 
— 7 — 
 
 A special difficulty connected with the question 
 of heredity lies in the long latency of tuberculosis in 
 childhood. If congenital tuberculosis were like syphilis 
 or small-pox, where the babe brings with it into the 
 world the symptoms of the disease, the matter would 
 be easy of solution. But it is not manifest in the 
 newly-born. It is like those rare cases of syphilis con- 
 genita tarda, the symptoms of which often appear first 
 in the 'teens and the nature of which, whether con- 
 genital or post-foetal, is still a matter of controversy. 
 That tuberculosis may exist and perhaps has existed 
 for years in a child apparently in full health is often 
 learned accidentally. A single swollen gland, carefully 
 extirpated from an otherwise blooming and healthy 
 child, has been found to contain giant cells with 
 bacilli. How long were these in the body ? Are 
 there other foci of infection in the glands? Who can 
 answer ? 
 
 Another fact deserves to be mentioned in this 
 connection. During the last great epidemic of measles 
 in Munich, Bollinger had repeated opportunity, as he 
 told me, to demonstrate on the bodies of children who 
 died of that disease the presence of tubercle bacilli in 
 the lymphatic glands, especially of the root of the lung 
 and the media.stinum, although previous to the sick- 
 ness the children had been apparently healthy and 
 not at all scrofulous. 
 
 This important discovery places in a new light the 
 experience that children often develop tuberculosis 
 
— 8 — 
 
 after measles. I'he infection of measles does not in- 
 duce the tuberculosis, but it makes manifest the latent 
 disease. Probably, as has been frequently verified ia 
 the scrofula of childhood, most cases of tuberculosis 
 are preceded by a latent glandular tuberculosis of 
 years' duration. At any rate, it has not yet been 
 proven that tuberculous infection occurs in concep- 
 tion or in foetal life. More probably it may occur ia 
 in the first or second year of infancy through some 
 slight wound (as many observations would indicate) 
 or through milk containing bacilli or spores, etc. 
 Still, the difficulty always returns, namely, that all 
 these possibilities of infection are realized almost ex- 
 clusively in the children of parents who are either 
 manifestly or latently tuberculous. 
 
 Finally, as proof that tuberculosis is directly con- 
 tagious for healthy persons, cases of unintentional 
 " tubercular inoculation " have occurred, where a 
 slight injury (such as drawing a tooth, a small cut, 
 etc.) has led to secondary swelling of the neighboring- 
 lymphatic glands, and in these glands, after extirpa^ 
 tion, giant cells with tubercle bacilli have been found. 
 Such cases, however, are of doubtful value, for the 
 bacilli may have dated from some earlier period and 
 may have merely become manifest by reason of the 
 traumatic lymphadenitis. The value of experimental 
 inoculation must remain doubtful so long as we have 
 no guarantee that the lymphatic system was previously- 
 free from bacilli, and for such a guarantee we can 
 scarcely hope. 
 
CHAPTER II. 
 
 INHERITED AND ACQUIRED PREDISPOSITION- 
 SOCIAL FOCI OF TUBERCULOSIS. 
 
 Experience compels us to acknowledge that the 
 healthy organism has great power of resistance to the 
 bacillus which can make an effective and permanent 
 settlement in the lungs, intestines, etc., onlj'- when cer- 
 tain favorable conditions are present. These condi- 
 tions, this as yet unknown pathological something we 
 ■call a predisJ>ositw/i and mean thereby a certain con- 
 stitution of the tissues which furnish a suitable soil 
 for the settlement of the bacilli. We cannot at pres- 
 ent get along without the supposition of such a pre- 
 disposition which may be either inherited or acquired. 
 A disposition exists, in fact, for other infectious dis- 
 eases, iis typhus, cholera, dysentery, etc., and why 
 should not one be supposed for the settlement of the 
 tubercle bacilli ? 
 
 In what consists this predisposition which, next to 
 heredity, plays the greatest role in the etiology of 
 tuberculosis ? We do no know. We know, indeed, in 
 a general way, how a man looks who has such an in- 
 herited disposition; we know what causes may engender 
 the disposition; but we do not as yet know its nature 
 or the morphological, chemical or physiological 
 changes to which it owes its origin. Even with its 
 
external appearance, the so-called phthisical habitus ^ 
 there is often but little to be made. The slender 
 body, the flat chest, the thin limbs, the delicate tinge, 
 the vulnerability of the vessels of the mucous mem- 
 brane, the tendency to epistaxis and to catarrhal in- 
 flammations of the larynx, the frequency of cardiac 
 palpitation and of congestions, the circumscribed red- 
 ness of the cheeks, etc., all that is in many cases 
 scarcely or not at all noticeable. How many robust 
 young people are tuberculous in spite of their com- 
 pact bodies, stout muscles and natural color I Pleie 
 there is still much to be investigated ! 
 
 As to the acquired disposition, all those weakening 
 influences which so plentifully beset human life tend 
 to its acquisition, such as insufficient nourishment, un- 
 healthy dwellings and ways of life, insufficient sleep, 
 lack of fresh air, worry and trouble, care of the sick,, 
 night vigils, bodily and mental over-exertion, previous 
 sickness, childbed, etc. Of all these, none are so 
 powerful to weaken the resistance of tissues and cells, 
 as the lack of fresh air and the ins2tfficiency of ont-door 
 muscular exercise. 
 
 The effect of these last-named baneful causes can 
 be best studied in the inmates of prisons, asylums, con- 
 vents and similar institutions. The curtailment of 
 freedom and the privation of open air entail a row of 
 factors, the potency of which in individuals is not 
 easy to estimate. Among these the following are 
 chiefly to be noted: The air in the closed rooms, and 
 
especially in the dormitories, is not pure; it contains 
 dust and fungi, is poor in oxygen but rich in carbon 
 dioxide and bad odors. On account of the sedentary 
 life, respiration is not deep enough and the lungs are 
 not well expanded. The absence of out-door move- 
 ment and of vigorous muscular work diminishes as- 
 similation, and reduces the need of nutriment; whilst 
 the monotonous diet impairs the appetite. Often also 
 the quantity and mode of preparation of food are not 
 what they should be. In addition, psychical influences 
 are at work, as: in jails, repentance, longing after 
 freedom and family, etc.; in penitentiaries, the enforced 
 contact with the dregs of mankind; in the cellular 
 prisons, the solitariness of confinement and the 
 absence of all incitement. Here then we have a 
 series of weakening factors, under the influence of 
 which the organism sinks into a depraved condition, 
 and a wide door is opened for the settlement of tuber- 
 cle bacilli which certainly are ubiquitous in prisons. 
 
 That consumption is at home in prisons is gener- 
 ally recognized, but the huge proportions in which the 
 inmates succumb to that disease are not sufficiently 
 known. Figures furnished by Baer in the Zeitschrift 
 fur Klinische Medicin show a mortality from consump- 
 tion in prisons three or four times greater than out- 
 side. The mortality from it in the race is generally 
 reckoned at one-seventh, that is, about 14 or 15 per 
 cent., but in prisons from 40 to 50 per cent, of the 
 deaths is due to consumption; so that about half die 
 
from tuberculosis. The ratio, however, varies con- 
 siderably. Thus, the total mortality from consump- 
 tion in the Austrian prisons during four years amount- 
 ed to 6 1 per cent, whilst on the contrary in the pris- 
 ons of Bavaria, during eight years, it was only 38.2 
 percent. The death rate seems to vary in different 
 institutions with the conditions of the building and of 
 discipline; at any rate it is said that in the cellular sys- 
 tem tuberculosis claims fully 60 per cent, of the total 
 mortality.* 
 
 It is very noteworthy that the mortality from con- 
 sumption reaches its maximum only in the later years 
 of confinement. This shows that it is not a matter of 
 simple infection, but that in the majority of cases a 
 long-continued deterioration of the system is necessary 
 for the settlement of the bacilli. Many constitutions, 
 however, having less powers of resistance fall sick 
 much sooner, especially if the change from fresh coun- 
 try air to the prison atmosphere has been very abrupt. 
 That has been frequently observed amongst peasants 
 confined in prison. This observation is confirmed by 
 the statistical reports of French and English military 
 surgeons who have found that the frequency of tuber- 
 culous disease and death rapidly diminishes during 
 war with its drills and forced marches, and again 
 largely increases during peace, and especially during 
 winter life in the barracks. A similar danger exists 
 
 *See appendix for figures relating to American prisons. — 
 Tr. 
 
— 13 — 
 
 for the crowded population of great cities, spending, 
 as they do, their days in dusty and over-crowded work- 
 shops and their nights in close and unclean sleeping 
 rooms. 
 
 The ratio of tubercular disease among the factory 
 population to that among the rural classes is also very 
 much in favor of the view that the quantity and 
 quality of the inspired air is a decisive factor. In 
 Switzerland, for example, the mortality from consump- 
 tion in industrial districts exceeds that in rural dis- 
 tricts by more than double; in the former it averages 
 2.5 per thousand, and in mixed populations 1.7, whilst 
 in the purely rural population it is only i.i per thou- 
 sand. 
 
 Finally, mortality statistics of elevated localities 
 show definitely that the frequency of consumption is 
 in inverse ratio to the elevation, and that in very high 
 districts (as in the Mexican cities of Mexico, Puebla, 
 Quito, San Luis Potosi and Bogota, with an elevation 
 ranging from 2,500 to 4,000 meters, or about 8,000 to 
 13,000 feet) tuberculosis is very rare, and in spite of 
 the hurtfulness of industrial labor and mining is not 
 prevalent among the laboring classes. The rarity of 
 the atmosphere is not to be included among the quali- 
 ties of an elevated climate which at a height of 500 
 meters (1640 feet), and still more certainly at 
 1,000 meters, diminish consumption, for we find 
 the same farorable conditions on the ocean and the 
 steppes. Stress is to be laid rather on the rapid move- 
 
— 14 — 
 
 meiit of the air and on its freedom from microbes 
 capable of germmating. The examination of the 
 atmosphere for microbes made by Miquel and Freu- 
 denreich showed that they were entirely absent at an 
 elevation of 2,000 meters, whilst at 560 meters, or 1827 
 feet (namely, at Thun*) scarcely any were found. 
 Mareau and Miquel likewise found the atmosphere 
 on the high seas and at certain places on the sea coast 
 almost free from them. Thus the results of bacterio- 
 logical investigation are in entire accord with medical 
 experience. Other factors may also contribute to the 
 relative immunity of elevated and ocean atmospheres, 
 as atmospheric pressure, velocity of the wind, hygro- 
 metric condition, and to a certain extent also the ener- 
 getic pulmonary gymnastics required by these various 
 telluric and atmospheric conditions. 
 
 I shall again speak of this point when discussing 
 the therapeutics of tuberculosis, and I now revert to 
 the social fountains or sources of the disease. 
 Amongst these have already been mentioned prisons 
 and badly arranged barracks. Convents, largely at- 
 tended educational establishments, seminaries, orphan- 
 ages, and to a certain extent crowded schools also, be- 
 come influential starting places of tuberculosis if suit- 
 able provision is not made by sanitary regulations 
 (both as to the material edifice and the discipline) to 
 counteract the confinement by plentiful fresh air and 
 
 *A town of about 5,000 inhabitants, in the canton. of 
 Bern, Switzerland. — Tr. 
 
— '5 — 
 active out-door exercise. Convents seem to me to be 
 the most unfavorable in this regard and to rank next 
 after prisons, because most of their inmates fall victims 
 to tuberculosis. The life in narrow, ill-ventilated 
 cells, the privation of fresh air, and the complete lack 
 of bodily exercises and other movements which com- 
 pel deep inspiration, are the chief causes of the dis- 
 ease. The same applies to orphanages, educational 
 institutions and seminaries where the pupils are kept 
 in conventual seclusion and are indulged only to a 
 very limited extent in out-door exercise and play. 
 The reason that the statistics of disease are not higher 
 in such institutions is because the confinement is not 
 too strict and especially because young people do not 
 remain many years in them. 
 
 Most constitutions withstand the ill-effects of im- 
 prisonment for months and years, and not until a 
 certain degree of deterioration has been reached, do 
 the tubercle bacilli begin their destructive activity. 
 Furthermore, statistics of prison sanitation show that 
 the entrance of tuberculosis is frequently facilitated 
 by inflammatory affections of the respiratory organs, 
 especially by pneumonias which have not undergone 
 complete resolution. Certainly, many of these inflam- 
 matory troubles are the consequence of the bacillary 
 invasion, rather than favoring causes of it. But we 
 have frequent opportunity in our hospitals to see cases 
 of pneumonia which in the beginning resemble in all 
 their symptoms genuine croupous pneumonia, and yet 
 
— i6 — 
 
 the presence of bacilli in the expectoration shows- 
 them to be tuberculous. 
 
 The experiment made in hospitals of putting 
 many consumptives partly among the other patients- 
 and partly in special wards, is of special value for the 
 question of direct contagiousness. Tuberculous dis- 
 ease either among the other patients or the attendants 
 was not found in any greater proportion than outside. 
 According to Williams' report, the physicians, nurses- 
 and employes of the Brompton Hospital for Consump- 
 tives (the largest of its kind in the world) do not fait 
 sick of tuberculosis more frequently than the inhabi- 
 tants of populous cities, and that too in spite of poor 
 ventilation, insufficient cleansing of cuspedores, etc. 
 As a matter of fact, only three or four cases could be 
 attributed to contagion in the hospital. However, we 
 must not attach too much value to these statements,, 
 for it is well known that the employes of great hospi- 
 tals are subject to much changing about, and do not 
 hold their places steadily for years. 
 
 The religious orders devoted to the care of the 
 sick manifest a very great tendency to the disease.. 
 Except those who nurse patients at home, the mem- 
 bers of these orders are allowed by their strict rules- 
 but little outdoor exercise; and besides they are sub- 
 jected to all the other injurious influences which I 
 have described as disposing to tuberculosis, such as 
 exhausting work from early morn till late evening^ 
 frequent night watches, limited food, and many re- 
 
— 17 — 
 
 ligious exercises; and they enjoy but rare and too 
 brief excursions out of doors and into the country. 
 It is, indeed, not to be wondered that the organism 
 should deteriorate under such a strain and should 
 consequently furnish a suitable soil to the tubercle 
 bacilli. Right here among the Sisters of Charity in 
 our large Munich Hospital (whom we see die young, 
 one after another, of tuberculosis, so that it may be 
 said without hesitation that this disease kills 50 per 
 cent, of them), we observe the onset of the infection 
 without there being any hereditary disposition and 
 simply as a consequence of their hospital labors and 
 of their strict observance of their religious rules. The 
 young girls who enter as novices are almost without 
 exception from the country, hardy, fresh and rosy 
 cheeked. After a few months, or in few cases after a 
 few years, that ominous anaemia, which is the usual 
 forerunner of hemoptysis, sets in. It would be absurd 
 to imagine that all these healthy and fresh country 
 girls are hereditarily disposed to tuberculosis; yet in 
 spite of their healthful constitutions, with frightful 
 regularity one after another falls a victim to consump- 
 tion. Can any further argument be needed for the 
 diiect infectiousness of the disease, for the dangers 
 involved in seclusion from fresh air and outdoor ex- 
 ercise, in the curtailment of sleep, in the lack of rest 
 and recreation — all of which are necessitated by the 
 straining vocation of nursing the sick? 
 
 3 BE 
 
I will return to this subject when speaking of 
 prophylactic treatment. It is so serious that all who 
 are in a position to co-operate in improving these con- 
 ditions should lay it closely to heart. 
 
 [The author's remarks on convents, etc., are of 
 course uttered in a scientific, but friendly, spirit. 
 They do not, however, apply so strictly to similar in- 
 stitutions in this country, which, being of recent origin, 
 are built in accordance with the principles of modern 
 scientific construction. — Tr.] 
 
CHAPTER III. 
 
 INVASION OF THE ORGANISM BY BACILLI— ITS 
 DEFENCE-VULNERABILITY OF THE APEX- 
 THEORY OF PHAGOCYTES— THE 
 LARYNX. 
 
 I have now described all the conditions which 
 favor the settlement of the tubercle bacillus in the 
 human organism. It remains to briefly state what is 
 known concerning the manner of its settlement, prop- 
 agation and diffusion, and concerning the resources 
 which the organism possesses for self-protection. 
 
 The usual ways by which the bacillus gains ad- 
 mission to the body seem to be through the digestive 
 tract in children and through the respiratory apparatus 
 in adults. But there are probably exceptions. The 
 primary cause of tuberculosis of the intestines and of 
 the mesenteric glands in children would seem to be 
 food containing bacilli ; and of pulmonary and bronchial 
 tuberculosis, the direct inspiration of bacilli. To ex- 
 plain why the bacilli fix themselves and develop in 
 those places, we must necessarily postulate a pathologi- 
 cal condition of the tissues which furnishes a suitable 
 soil for them. The healthy organism is probably able 
 to free itself easily from pathogenous micro-organisms 
 by the action of its secretory and excretory appar- 
 atuses, and by encapsulating them m cells, which very 
 
20 
 
 likely destroys or, at least, curtails their activity. If 
 the body did not possess such means of protection^ 
 the maintenance of its integrity in the presence of 
 ubiquitous pathogenic micro-organisms would be im- 
 possible. The microbes of tuberculosis especially 
 would be noxious to all men on account of their per- 
 sistence for longer or shorter periods in their habitats, 
 for example, in the consumptive wards of hospitals. 
 Yet, as I have already mentioned, Dr. Williams has 
 shown that tuberculosis among the physicians, nurses 
 and employes of Brompton Hospital is not more fre- 
 quent than among city people generally. But where 
 the exposure to infection is attended by a fatal dis- 
 position to consumption and there is, as we must sup- 
 pose, less resistance of the cells to the invasion, there 
 the seeds will be planted and will find the requisite 
 conditions for increase and propagation. 
 
 I have said that, as far as is yet known, the pro- 
 tective power of the body lies in the normal function 
 of digestion, in the secretion of the bronchial mucous 
 membrane, and in the energetic activity of its amoeboid 
 cells. We may consider it established that normal 
 gastric juice digests or" at least sterilizes bacilli intro- 
 duced with food. On the other hand, disturbances of 
 digestion, neutral or alkaline reaction of the gastric 
 juice, and fermentative or putrefactive changes in the 
 contents of the stomach must open a wide door to 
 their progress. 
 
 The invasion of bacteria through the respiratory 
 
— 21 
 
 tract presents the greatest danger on account of their 
 ubiquity. That the organism does resist the admis- 
 sion of foreign bodies with the inspired air is known 
 from the study of sputum during life and of the lungs 
 post mortem. We find particles of dust and other 
 minute foreign bodies taken up by large cells, whose 
 source is not yet ascertained. In my opinion, these 
 cells do not originate in the alveolar epithelium, but 
 they are furnished, as I shall hereafter show, by the 
 bronchial mucous membrane (by its beaker-cells) and 
 perhaps also by the sub-epithelial layer. Where dust 
 is only moderately inspired, as among bakers and 
 smiths, or by staying in rooms filled with tobacco, 
 wood or coal smoke, the expectoration will show an 
 abundance of large round cells containing particles of 
 coal. But where the inhalation of dust is continuous 
 as among miners, mirror-polishers, etc., this cell 
 activity is not adequate to the task of its removal, and 
 the dust is rather taken into the alveolar epithelium 
 and lymph stomata and partly stored up in the inter- 
 stitial tissues and partly carried through the lymphatics 
 to the bronchial glands. The fine observations of 
 Zenker and Merkel on the pulmonary tissue of mirror- 
 polishers impregnated with the dust of " English- 
 red " * furnish the most convincing illustrations of this 
 
 *" English-red " is a powdery deposit in the distillatioa 
 of sulphuric acid from sub-sulphate of iron (green vitriol). It 
 consists of iron oxide and a little sub-sulphate of iron. It is 
 much used in polishing. — Tr. 
 
condition. The power of resistance of the lungs, the 
 ability to eliminate foreign bodies, is therefore limited, 
 but still very considerable. It is very probable that 
 the number of dust-eating cells and their energy in 
 swallowing foreign particles depend on a certain de- 
 gree of reactive power in the bronchial mucous mem- 
 brane and the walls of the alveoli, and that the extru- 
 sion of the cells depends on the energy of the move- 
 ment of the cilia and on the efforts at expectoration. 
 Any diminution in the energy and reaction of the 
 epithelial cells of the respiratory tract is an important 
 factor for the domiciliation of the bacilli. This is 
 shown by, among other things, the lack of reaction 
 observable in the beginning of tuberculous infection, 
 as Baer noticed in prisoners and as we ourselves see 
 in our Sisters of Charity. The patients become thin, 
 anaemic, without appetite or strength. Neither cough, 
 dyspnoea, nor other respiratory trouble is present, yet 
 the physical examination will disclose an infiltration 
 in one or both apices of the lungs. Only the higher 
 grades of cell debilitation (as found in prisons and 
 convents) are characterized by such a deficiency of 
 reactive power, but they entitle us to draw inferences 
 as to the lesser grades. 
 
 I will here consider a question which is very im- 
 portant from a practical point of view, namely why 
 the apices of the lungs arc the favorite site of tuberculosis. 
 That they are is a matter of daily observation among- 
 medical men. Hitherto it was generally supposed 
 
— 23 — . 
 
 that the settlement of the tubercle bacilli by prefer- 
 ence there was due to a deficient inspiratory expansion 
 of the parts, producing an insufficient ventilation of 
 the local bronchioles and alveoli and this in turn lead- 
 ing to stagnation of the secretions and inflammatory 
 products. Thus the frequency of apical tuberculosis 
 in persons addicted to a sedentary mode of life, and 
 especially to a stooping posture (as tailors and others) 
 was accounted for. 
 
 Hanau has lately promulgated the view, and I 
 think on good grounds, that this local disposition of 
 the apices is due not to deficient inspiration but to 
 more difficult expiration. That the apices possess a 
 good power of inspiration is well shown by their con- 
 dition in cases of anthracosis (miner's lung, grinders' 
 phthisis), occurring in industrial work and produced 
 in Arnold's experiments on animals. In such cases, 
 the apices are the parts soonest and most affected. 
 And as to the effects of a stooping posture, it changes, 
 in men, the physiological costo-abdominal inspiration 
 almost to the costal form, because the downward 
 movement of the diaphragm is impeded by the narrow- 
 ing of the abdominal cavity; but in women, costal 
 respiration is physiological, so that in their case it is of 
 no avail to suppose an insufficient expansion of the 
 lungs. The weakness of the theory of inspiration 
 lends more probability to the expiratory theory. 
 Mendelssohn first deduced theoretically, and I have 
 shown by observations made on individuals with weak 
 
— 24 — 
 
 thoracic muscles, that a backward rush of air occurs 
 in the upper lobes during forced expiration, because 
 the superior part of the thorax is deficient in contrac- 
 tile muscles. Consequently, in coughing, the air not 
 only stagnates and momentarily stands still under 
 the strong pressure, but (what is very important for 
 the subject under consideration) the expectoration of 
 foreign particles and bacteria out of the apices is 
 hindered and the contents of the bronchi are even 
 carried inwards to the alveoli by the reverse current 
 of air. The spiral course of the smallest bronchioles 
 may be in the apices an impediment as much to the 
 aspiration of dust and bacilli as to their expiratory- 
 expulsion. At all events, this anatomical condition is 
 not at all favorable but rather is very unfavorable to 
 the movement of inspired particles. I can con- 
 sequently agree with Hanau that the apices which 
 are relatively most favorable for the inspiration of 
 dust and micro-organisms are also most unfavorable 
 for their expulsion. If once the tubercle bacilli reach 
 them, they find a sort of resting place whence they 
 can press into the lymphatics between the epithelial 
 cells and establish themselves in the sub-epithelial 
 layer. 
 
 That bacilli may enter through the lymph and 
 blood routes as well as with the inspired air is beyond 
 question. But in the lungs, such a manner of en- 
 trance could be inferred only from a primary in- 
 fection of the walls^of the lymphatics and vessels. 
 
— 25 — 
 
 When the bacillus has crowded into the tissues it 
 starts up by virtue of its biological qualities (which we 
 do not yet intimately know) an irritation, and following 
 that an inflammatory reaction. Here, then, begins that 
 struggle between the living cells and the parasites, which 
 has been so much spoken about of late. Naegeli has al- 
 ready characterized the struggle between the bacillus 
 and the organic cells as the process in the infectious 
 diseases, on the issue of which the life, disease or 
 death of the individual depends. The result is de- 
 termined on one side by the vital energy of the cells 
 and on the other by the infectiousness of the bacillus. 
 If the cells conquer, the bacillus is destroyed before it 
 has time to injure the organism; if, on the contrary, 
 they should be conquered, there is no hinderance to 
 the settlement, growth and diffusion of the bacilli. 
 
 Thfs generally accepted view of the nature of in- 
 fection and the part taken by the living cells in ward- 
 ing it off has undergone a still further development in 
 Metschnikoff's doctrine of phagocytes,* which has 
 much of interest in spite of the ambiguity of the pheno- 
 mena observed by him. 
 
 According to Metschnikoff, the oflSce of defence 
 belongs to the so-called phagocytes which are recruited 
 from the leucocytes and fixed connective tissue cells. 
 The irritation set up by the invasion of the bacilli calls 
 them forth to the battle field and they at once set 
 
 * Glutton-cells, from cpdyo^, glutton, and kvroi, cell. The 
 German is Fresszellen, — Tr. 
 
— 26 — 
 
 about devouring the intruder^, that is, they take them 
 into their bodies and digest them, thereby rendering 
 them sterile. There are two classes of phagocytes, 
 the large and the small ones [makrophage?i, mikrophagen). 
 Among the former, Metschnikoff places the epitheloid 
 cells of the connective tissue, and among the latter 
 the leucocytes with lobed nuclei {gelappt kernigen). 
 In his latest publication (Virchow's Archiv., vol. 107, 
 No. 2) he states that the streptococcus of erysipelas is 
 taken up only by the small phagocytes, and that these 
 latter are then taken into the cell-bodies of the larger 
 ones and there digested. Likewise the gonococcus is 
 devoured only by the small phagocytes, whilst in 
 anthrax in rabbits and Guinea-pigs the bacilli are 
 taken up Only by the larger ones. In tuberculosis, 
 both kinds of phagocytes are active in resisting the in- 
 vasion. The larger ones take as epitheloid and giant 
 cells a prominent part in the contest, but the smaller 
 ones first begin it and also overpower a larger number 
 of invaders. Even in twenty hours after inoculating 
 the subcutaneous tissues of a rabbit or the anterior 
 chamber of its eye with a pure culture of tubercle 
 bacilli, Metschnikoff found many of the small phago- 
 cytes entirely gorged with bacilli, that is, at a time 
 when there could not be any reaction on the part of 
 the fixed cells. The larger phagocytes do not take 
 part in the contest until later, inasmuch as they swallow 
 up both single bacilli and dead small phagocytes. In 
 this way characteristic conglomerates are formed, in 
 
— 27 — 
 
 which masses of devoured substances are found, so 
 that the nuclei of the large phagocytes are covered up, 
 but still demonstrable. 
 
 The theory of phagocytes has, however, met with 
 vigorous opposition in various quarters. Its opponents 
 admit that bacilli are taken up into the bodies of large 
 and small cells; but they see in that no tendency to a 
 cure but only a mechanical intussusception of the 
 bacilli by which these gradually undergo certain 
 changes of form. Metschnikoff holds that the pro- 
 toplasm of the cells kills the bacilli, which gradually 
 break up, or at least lose their virulence and become 
 incapable of infection. 
 
 These observations on the relations of the phago- 
 cytes to the invading tubercle bacilli are of special 
 interest for our subject, and we await with great ex- 
 pectation the further contributions which Metschnikoff 
 promises on the subject of tuberculosis, and the dis- 
 cussion which will spring from them. 
 
 From a clinical standpoint, it would aid the com- 
 prehension of the stages of tubercular infection to 
 suppose that in a healthy organism an invasion of 
 bacilli should be at once overcome and made power- 
 less; that in a predisposed, organism with weakened 
 vital energy of the cells, the virulence of the invasion 
 should not be wholly destroyed, but should be tem- 
 porarily made ineffective by encapsulation in the fixed 
 connective tissue cells; and that in weak organs, their 
 storming in should bear down all opposition and rap- 
 idly destroy the individual. 
 
— 28 — 
 
 I should call attention also to the possibility of 
 the respiratory tract being flooded by putrefactive 
 products containing bacilli, which being inspired lead 
 to rapid softening of the lungs and sweep the patient 
 away. Such an auto-infection of the previously 
 healthy parts of the lungs furnishes a satisfactory ex- 
 planation of the widespread tuberculous pneumonias 
 which so frequently develop in the later stages of 
 chronic tuberculosis. 
 
 Finally, a word about laryngeal tuberculosis. It 
 is almost without exception a secondary affection, that 
 is, an accompaniment of a primary pulmonary tuber- 
 culosis. Considering that tuberculosis may be ac- 
 quired by inhalation, primary laryngeal tuberculosis 
 cannot be set down as impossible. The epithelium, 
 however, seems to furnish a very strong protection 
 against enemies from without. Dr. Kukoff made an 
 anatomical investigation of this point in our patholog- 
 ical institute. He used a freezing- microtome and 
 examined fresh larynxes from consumptives. In no 
 case was he able to detect a crowding in of the bacilli 
 from without, as, for example, from sputum hanging 
 in the larynx; but, on the contrary, he found the epi- 
 thelium well preserved, and saw the bacilli pushing 
 from the sub-epithelial cellular layer out in the inter- 
 cellular lymph passages of the epithelium towards the 
 periphery. Nevertheless, there is no doubt that local 
 infection may come from bacilli in the sputum if there 
 is the slightest erosion. That, however, would not 
 
bear upon the origin of laryngeal tuberculosis, for 
 which we must have recourse exclusively to the blood 
 and lymph streams in the laryngeal mucous mem- 
 brane. 
 
 The question of the curability of laryngeal tuber- 
 culosis is now generally decided in the affirmative, that 
 is, in the»sense of the foregoing view of the curability 
 of pulmonary tuberculosis. It certainly is not often 
 the case that tuberculous ulcers of the larynx heal, 
 but I am very certain that it is possible, for I have 
 seen several cases quickly heal up under the influence 
 of a general quiescence of the tuberculous process, 
 and when the patients died (after some years from re- 
 newed outbreak of the tuberculosis) I was able to note 
 the firm scars of the ulcers. All experienced laryn- 
 gologists must have observed similar cases. 
 
 From all that has been said, it is evident that 
 aaany questions remain to be answered, before all the 
 conditions of the life, work, and death of the tubercle 
 bacillus become so well known that we shall be able 
 to extirpate this hereditary enemy of the human race. 
 But, thanks to the discovery of Koch, enormous pro- 
 gress has been made during the past six years in the 
 study of the etiology and pathology of tuberculosis. 
 The zeal with which the study is pursued and the 
 strict methods used guarantee further and steady ad- 
 vancement, and in it clinical medicine will as far as 
 possible take an active share. 
 
PART SECOND. 
 
 The Diagnosis of Pulmonary Tuberculosis. 
 
 CHAPTER I. 
 
 THE PARALYTIC THORAX-THE APICES 
 
 It is not my intention to recapitulate the entire 
 symptomatology of pulmonary tuberculosis. I shall 
 limit myself to some matters which are of practical im- 
 portance, especially for diagnosis. The reader will 
 perhaps find some new points of view valuable for 
 judging individual cases and for ascertaining thera- 
 peutic indications. I first select some of the symp- 
 toms made known by physical examination. 
 
 Let us consider the form of the thorax in pul- 
 monary tuberculosis. Long and flat and with scant 
 antero-posterior diameter, it produces the impression 
 that the arched walls have sunk in; that is, the vertical 
 diameter has been lengthened at the expense of the 
 sterno-vertebral diameter. This impression is intensi- 
 fied by the thin adipose and muscles and by the slight 
 elevation of the wall in inspiration. The phrase 
 "paralytic thorax" aptly expresses the condition. 
 
- 3' — 
 The prominence of the clavicles is partly due to the 
 meagerness of the soft tissues and becomes very 
 marked by the sinking in of the chest wall orer the 
 shrunken apices. The prominence of the shoulder- 
 blades is likewise caused by the scantiness of the fat and 
 the thinness and atony of the trapezeus, rhomboideus, 
 latissimus dorsi, and serratus muscles; but it becomes 
 very pronounced when there is simultaneous kyphosis,* 
 that is, excessive curvature of the upper thoracic ver- 
 tebrae with compensatory lordosis* of the lower thor- 
 acic and lumbar vertebrae — a condition found very 
 frequently in long chests. 
 
 The flatness of the thorax and the smallness of 
 its antero-posterior diameter can be clearly seen on 
 lateral inspection when the patient's arms are elevated. 
 Diagrams drawn by means of Woillez's cyrtometer 
 make it still more evident. This instrument is first 
 accurately adjusted to the thorax and then, after its 
 removal and fixation, the circumference of the chest 
 is, by its means, marked out on a large sheet of paper, 
 on which the diameters have been drawn. The result 
 is an imaginary cross-section of the thorax which very 
 clearly shows the difference between the normal and 
 the paralytic forms. Several such sections are here- 
 with presented, but necessarily on a reduced scale — a 
 fact that is to be regretted, because the actual propor- 
 
 * Kyphosis is an exaggerated condition of the nornaal 
 dorsal curve; lordosis is an excessive lumbar curve; and a 
 lateral curvature of the spine is called scoliosis. — Tr. 
 
— 32 — 
 
 tions would be very instructive. They are made on a 
 plane through the spinous process of the ninth thor- 
 acic vertebra and the base of the processus xiphoi- 
 deus, and all are from patients between twenty-five 
 and forty years of age. The woman (Fig. i) and the 
 man (Fig. 2) were cases of advanced phthisis. The 
 normal thorax (Fig. 3) was that of a healthy, low- 
 sized, stoutly-built butcher. For purposes of compari- 
 son, an emphysematous thorax is presented in Fig. 4, 
 in which the length of the sterno-vertebral diameter i& 
 to be noted. Allowance must be made for the thin- 
 ness of the chest walls, which, of course, makes the 
 paralytic thorax more pronounced; but, as the cyrtom- 
 eter is always tightly applied, the discrepancy from 
 this cause cannot be reckoned as more than 1.5 cm. 
 (.6 inch). The principal difference between the nor- 
 mal and the paralytic thorax consists in the diminu- 
 tion of the sterno-vertebral diameter and its propor- 
 tion to the transverse diameter. 
 
 It is of little use to give absolute measurements 
 of the sterno-vertebral diameter in the normal thorax 
 because the size of the thorax varies considerably 
 within the limits of health. One may, however, say 
 that in men of medium size (170 to 175 cm. i. e. 66 to 
 68 inches) the antero-posterior diameter should not 
 be less than twenty centimeters (7.8 inches); in 
 phthisical men, it may be as small as eighteen centi- 
 meters (7 inches); and in phthisical women, it may be 
 be reduced even to fifteen centimeters (5.9 inches). 
 
— 33 — 
 
 Riihle very properly points out that the paralytic 
 thorax in fat persons who become tuberculous may be 
 concealed at first glance by the amount of adipose 
 
 FIG. I. 
 
 Consumptive woman, 28 years old. 
 
 Narrowing of left side. 
 
 FIG. 2. 
 
 Consumptive man, 2!; vears old. The 
 
 soft tissues very much emaciated. 
 
 FIG. 3. 
 
 Monn&l thorax, thick mu«cles 
 
 a man 32 years old. 
 
 From FIG. 4. 
 
 Expanded thorax of an emphysematous 
 patient, 40 years old. 
 
— 34 — 
 tissue. But even in such cases, and especially if there 
 is progressive emaciation, one may by close observa- 
 tion ascertain its presence. 
 
 That the paralytic thorax may be found in tall, 
 rapidly grown individuals who are entirely healthy 
 and not tuberculous, is certain. Doctors who examine 
 recruits for military service have opportunity often 
 enough to see such cases. Still its occurrence in 
 health is a rarity and ought always excite suspicion of 
 a tuberculous disposition. 
 
 In the physical examination, the closest attention 
 should be paid to the apices of the lungs. Since they 
 are, in far the greatest number of cases, the locality 
 where the bacilli first lodge, it is to be expected (and 
 experience justifies the expectation) that they should 
 manifest the earliest physical signs of the disease. 
 The anatomical conditions are most favorable for their 
 examination inasmuch as the apex proper lies above 
 the first rib, the clavicle and the upper edge of the 
 scapula, that is, to a certain extent outside the thor- 
 acic skeleton and projecting above it. Hence it is 
 possible to accurately mark out the borders and to 
 ascertain to what extent the apices contain air. A 
 sharp outlining of the inflated apices towards the 
 larynx, cervical muscles and vertebral column presents 
 no difficulty to anyone moderately skilled in topo- 
 graphical percussion. Approximately correct results 
 can be had by using the finger to percuss, but the 
 
— 35 — 
 limits can be accurately defined by the use of my 
 ivory wedge-shaped plessimeter. It is 
 intended for outlining organs and es- 
 pecially for determining the borders 
 of the apices. The instrument (of 
 which a side view, actual size, is given 
 in Fig. 5) is to be applied with its nar- 
 row end (2 mm. or .08 inch, wide) 
 to the skin whilst the percussion is 
 made on its broad end (17 mm. or 
 
 .6 inch). 
 FIG. 5. ' 
 
 On physical grounds which it would take too long 
 to detail, I recomend that percussion be always made 
 from above downwards. Starting from the neck, the 
 edges of the expanded apices should be located, and 
 the boundaries between the dull note of the muscles 
 and bones, the tympanitic note of the larynx and the 
 note of the apices should be marked with pencil or 
 ink. In this way one moves gradually from the 
 larynx to the vertebral column. The boundaries on 
 both sides being thus determined, both apices should 
 be compared with regard to their capacity. Percus- 
 sion of the supra-clavicular depression should be made 
 from behind towards the front, otherwise the clavicle 
 will be in the way, and the finger cannot be firmly ap- 
 plied m the depression. Corresponding parts of the 
 supra-clavicular grooves should be compared in this 
 manner. In health, the external, middle and innermost 
 parts of these grooves return different notes, the in- 
 
- 36 - 
 
 nermost being most intense and the outermost least 
 so. Consequently great care must be taken to com- 
 pare, in patients, only like parts with each other. 
 Similar precautions must be used in percussing and 
 comparing the supra-spinous regions and the spaces 
 between them and the vertebral column. Results will 
 be more reliable, the more firmly the finger is applied 
 and the more equally percussion is made on it with 
 the middle finger of the right hand. The plessimeter 
 does not fit well into the supra-clavicular grooves and 
 the hammer does not give nearly as fine results as the 
 simple finger; hence their use for those parts is not 
 recommended. 
 
 The height of the two apices is surprisingly 
 similar, as is evident from simple inspection. But if 
 one desires to express the height in figures, it is best 
 (in view of the peculiar configuration of the parts) to 
 measure along the edge of the trapezius from the top 
 of the apex to the outer border of the acromion, the 
 arms of the patient being allowed to hang down. The 
 uniformity is all the more wonderful, as it depends on 
 the configuration not only of the neck and upper 
 chest, but also of the scapulae. Measurements from 
 the tip of the lungs straight down to the clavicles are 
 not reliable. The complete equality of the height of 
 two apices in health naturally causes any departure 
 from the normal proportion in one of them to be very 
 suspicious. Hence the great value of a comparative 
 determination of the height of the apices in the begin- 
 
— 37 — 
 ning of tuberculosis as well as in its later stages. In 
 the Natural Science Association meeting at Frankfurt, 
 in 1867, I showed to the Section of Medicine, both by 
 photographs and by demonstration on the living sub- 
 ject, the great diagnostic value of these things. I 
 fear, however, that the medical fraternity was not 
 sufficiently impressed with the importance of ascer- 
 taining the height of the apices. I should not omit 
 to mention that Prof. Seitz (then at Giessen) had 
 already in 1862 called attention through one of his 
 pupils to the importance of determining this height by 
 percussion. 
 
 As to the clinical value of a considerable varia- 
 tion in the height of the apices, I will say that flatness 
 of one or both is usually found with large or small . 
 infiltrations at the apex. The shrinkage which causes 
 the flatness occurs in the new connective tissue, which 
 is a product of reactive interstitial pneumonia. As 
 the infiltrate softens and degenerates, together with 
 the alveolar tissue of the infiltrated lobules, the young 
 cicatricial tissue replaces it step by step. In the be- 
 ginning the defect of tissue is pretty considerable, but 
 it is compensated for by thickening of the pleura and 
 by vicarious distension of the neighboring air-contain- 
 ing pulmonary tissue. The apex suffers most diminu- 
 tion of height when the cicatrix is widespread and 
 ramifying and contains no considerable cavities. In- 
 deed, a considerable flattening of the apices may 
 result favorably in this manner, namely, in cicatriza- 
 
- 38- 
 
 tion and healing, and that all the sooner, if there are 
 no physical signs of cavities. A few schematic figures 
 will illustrate the usual course of nature's curative 
 process in apical tuberculosis. Fig. 6 represents the 
 condition of infiltration; Fig. 7, the advanced soften- 
 ing and cicatrization, with vicarious distension of the 
 adjoining air-holding tissues; and, finally. Fig. 8 shows 
 the arching over of the contracted cicatrix by the 
 compensatory emphysema of the neighboring parts. 
 
 
 FIG. 6. 
 
 FIG. 7. 
 
 FIG. 8. 
 
 In this last stage of simple cicatrization and 
 diminution of the apex, there are usually as yet only 
 very slight dullness to be noticed on percussing, and 
 a heightened or weakened vesicular murmur with 
 prolonged increased or diminished bronchial expira- 
 tion, but no rales — a sign that there are probably no 
 progressive process and no open cavities to keep up 
 softening and secretion. 
 
 To a certain extent, the flatness of the apex may- 
 be finally compensated for by an increased emphysema 
 of the upper lobes, which are more and more raised 
 up over the cicatrix. This compensation occurs 
 especially when the sunken upper part of the thorax 
 is gradually enlarged by strong inspiration, as has 
 
— 39 — 
 been observed in pulmonary gymnastics after cicatriza- 
 tion following apical tuberculosis. Here the scaleni 
 muscles count as special factors. The enlargement 
 of the upper part of the thorax must be accompanied 
 by compensatory emphysema of the parts surrounding 
 the cicatrix and by a corresponding elevation of the 
 apices. Such elevations of earlier depressions can be 
 followed clinically with sufficient exactitude. The 
 emphysema around the cicatrix might be characterized 
 as a sort of protective measure against new settle- 
 ments of bacilli, for experience teaches that emphy- 
 sematous pulmonary tissue is not a favorable soil for 
 bacilli cultures. 
 
 We thus see in what manner the process of spon- 
 taneous cure occurs. Frequent exceptions to this 
 course are found. Frequently one or more cavities 
 are met with in the cicatrix. These are filled with 
 firm, inspissated, cheesy secretion, or, communicating 
 with the bronchi and secreting for a long time, they 
 may finally, through progressive cicatrical contraction, 
 end in solidification. Such cavities in the cicatricial 
 tissue, either enclosed or still secreting, are less favor- 
 able, inasmuch as they furnish a suitable soil for the 
 development of the bacilli, whilst bacilli in the firm 
 cicatricial tissue have only a counterfeit existence. 
 The cheesy deposits in the cicatrix are usually rich in 
 bacilli and often may undergo softening even at a late 
 period and lead to a local renewal of the trouble or to 
 a general infection of the system. Such caseous foci 
 
— 4° — 
 and small caverns are volcanoes which may remain 
 quiescent during long years or even during the entire 
 life. Often enough, however, an eruption takes place 
 unexpectedly and to the great surprise of the physi- 
 cian, especially if he have known nothing of the 
 earlier changes and if the patient have reached an ad- 
 vanced age. Acute tuberculosis of old people is com- 
 moner than is usually supposed, and the post ?nortem 
 almost always shows remains of the old tuberculous 
 process along side of the new eruption. The exist- 
 ence of such a volcano may be clinically inferred, if 
 the sputum continues to show bacilli, although the in- 
 dividual may otherwise seem entirely restored, and if 
 the dulness of the percussion note over the apex does 
 not fully clear up, as is wont to be the case in simple 
 cicatricial contraction with arching over of the emphy- 
 sematous neighboring tissue. 
 
 There are families in which this benevolent form 
 of tuberculosis (if I may so term it) is hereditary, and 
 in which, consequently, healing of the tubercle focus 
 in the apices and roots of the lungs forms the rule. In 
 the members of such families we may observe the de- 
 velopment of the apex trouble at first unilaterally and 
 usually with repeated hemoptyses, and we may after- 
 wards trace the clearing up of the dulness and the 
 contraction of the apex. Then after a long time the 
 other apex takes its turn and we find the same retro- 
 grade processes in the same sequence. 
 
 If the original tuberculosis which caused the 
 
— 41 — 
 shrinkage of the apices was not recognized at the 
 proper time, it may be worth while, in order to judge 
 later events (such as the occurrence of a relapse) or 
 to explain special tuberculous affections (as of the 
 vertebrae or genito-urinary tract, or tuberculous dis- 
 eases in the offspring), to examine the apices as to 
 height and air-contents. Many cases of clear tuber- 
 culosis in children, whose parents are apparently 
 healthy and have never been seriously sick, will be 
 explained by such a cicatrized apex in one or other of 
 the parents. If we inquire more closely into such 
 cases we will generally obtain some useful data for 
 the anamnesis, as, for example, that the person when 
 young suffered for a long time with " catarrh," or 
 used to spit blood, or had pleurisy or " intermittent 
 fever which quinine didn't help," etc. 
 
 A careful examination of the apex is also very 
 important as regards the question oi primary laryngeal 
 tuberculosis. It has been repeatedly maintained that 
 the tubercle bacillus may gain admission through the 
 laryngeal mucous membrane as well as the lungs. 
 Cases have been cited where tuberculosis of the larynx 
 existed without the slightest trace of it being found in 
 the thorax. I have seen, however, many cases which 
 at first produced the impression of primary laryngeal 
 tuberculosis, but in which closer investigation of the 
 apices showed cicatricial remains of older processes. 
 So far I have not seen any really convincing case of 
 pure primary tuberculosis of the larynx, but, on the 
 
; — 42 — 
 
 contrary, 1 have met frequent cases of sub-acute or 
 chronic laryngeal tuberculosis joined with latent or 
 entirely healed tuberculosis of the shrunken apices. 
 
CHAPTER II. 
 
 SPUTUM— BACILLI- ELASTIC FIBRES— MYELIN 
 CELLS— HEMOPTYSIS. 
 
 Since Koch's discovery, the microscopical examina- 
 tion of the sputum holds the first place in diagnosis. 
 Formerly, in order to diagnose the process of decay, 
 it was required to discover histological elements of 
 the pulmonary tissue in the sputum. However, the 
 demonstration of elastic fibres arranged as in lung 
 structure shows at most only a condition of disturb- 
 ance, and is not pathognostic of tuberculosis. Koch's 
 discovery gave to the microscopic examination of 
 sputum a much more distinct significance, namely, 
 where puhnonary tuberculosis exists, tubercle bacilli will 
 be found in the expectoration. Even should they be 
 scarce, repeated examinations will bring some to light. 
 It may to-day be stated as one of the best established 
 diagnostic axioms that where tubercule bacilli are found 
 in the sputum, tuberculosis exists; on the other hand, 
 that where pulmonary tuberculosis exists, bacilli will ap- 
 pear in the sputum; and finally, that in lung affections 
 where skilled examinations exhibit no tubercle bacilli, 
 tuberculosis can be excluded. At present, however, 
 there are several exceptions to these propositions, 
 namely, acute miliary tuberculosis, in which bacilli 
 have not yet been demonstrated in the sputum, and 
 
— 44 — 
 obsolete apical tuberculosis, where the callous con- 
 nective tissue has completely encapsulated the bacilli. 
 Thus we see the great importance of the bacilli 
 for diagnosis. A single morphological element de- 
 cides it. Still we must bear in mind the fundamental 
 axiom of diagnosis: Never base a diagnosis on any 
 single cause but always on the totality of the symptoms. I 
 do not mean to call in question in the slightest the 
 pathognostic importance of tubercle bacilli in the 
 sputum. In the hands of an expert in bacteriological 
 investigation, a preparation showing bacilli gives 
 absolute warrant for diagnosis. But the investigator 
 must be entirely familiar with the proper method of 
 demonstrating them. Simple as is the method in 
 vogue of Ehrlich-Weigert or Ziehl-Neelsen, the search 
 for and recognition of bacilli require the same ex- 
 perience and care that are necessary in other investi- 
 gations, if the result is to be trustworthy. An error 
 from inexperience is here more serious, because it 
 concerns a matter in itself decisive of a grave diag- 
 nosis. I have seen strange things in the practice of 
 colleagues who though otherwise very capable had 
 not mastered microscopical technique and in con- 
 sequence made wonderful diagnoses by means of the 
 microscope. Physicians should be very cautious in 
 their conclusions, and in doubtful cases should have 
 their results verified by some scientific authority, as a 
 pathological or clinical institute.* 
 
 * See Appendix for method of examining sputum for 
 bacilli. — Tr, 
 
— 45 — 
 
 We now approach the question of the relation be- 
 tween the number of bacilli in the sputum and the 
 pathological changes which the lungs have undergone. 
 May we infer favorable changes from a decrease in 
 their number, and unfavorable ones from their in- 
 crease ? This question can generally be answered in 
 the affirmative. Numerous bacilli in the sputum de- 
 note rapid softening and usually coincide with fever, 
 night-sweats, etc.; few bacilli, on the contrary, are 
 found in chronic tuberculosis and pertain to secretions 
 from cavities. A gradual numerical decrease of 
 bacilli (for example, during a course of climatic treat- 
 ment) indicates curative changes and will usually be 
 accompanied by corresponding improvement in appe- 
 tite and weight, freedom from fever, cessation of 
 night-sweats, etc. There are some exceptions to this 
 general statement. Few bacilli are found in progres- 
 sive softening, if the focus of softening is still separate 
 from the bronchi; and on the other hand numerous 
 bacilli appear in old inactive cavities if their walls 
 should be irritated, for example by any external agent, 
 and their secretion be thereby increased. 
 
 Koch's discovery has given a degree of certainty 
 to the diagnosis of pulmonary tuberculosis that can be 
 affirmed of but few diseases. Furthermore, this cer- 
 tainty that tuberculosis is really present in individual 
 cases has improved our knowledge of its curability. 
 The pessimistic standpoint of the old school has been 
 shaken by nothing so much as by Koch's doctrine 
 
- 46 - 
 
 which has taught us to recognize many apparently 
 harmless cirrhoses of the lungs as really tuberculous 
 and to trace out their cures. It is consequently not 
 at all justifiable to declare a patient lost in whose 
 sputum bacilli are discovered. Rather we should ap- 
 proach the treatment of tuberculosis with much 
 greater assurance, because our knowledge of thera- 
 peutic measures has been so extraordinarily increased 
 and because the hope (which formerly found only 
 timid expression) that the disease could be really 
 cured has been fully verified. The fact that this cer- 
 tainty of diagnosis may be had at the very beginning 
 of the disease has given greater distinctness to thera- 
 peutic indications and better foundation to the expec- 
 tation of cure. 
 
 Finally, we are able (and this is of utmost value) 
 to exclude tuberculosis in chronic lung troubles on 
 account of the continued absence of bacilli from the 
 sputum. The diagnosis of simple chronic inflamma- 
 tion of the bronchi and pulmonary tissue, peribron- 
 chitis nodosa, anthracosis, cirrhosis and bronchiectasis, 
 pulmonary syphilis and neoplasms of the lungs is ren- 
 dered easier by the exclusion of tuberculosis; indeed, 
 in many cases it only then becomes possible. So that 
 the clinical investigation of these obscure pulmonary 
 diseases (for example, pulmonary syphilis) has been 
 directed into new paths by the clearing up of the sub- 
 ject of tuberculosis. 
 
 I shall now mention some other things which are 
 
— 47 — 
 found in the microscopical examination of the sputum. 
 Of these I first consider elastic fibres. No importance 
 should be attached to single elastic fibres. They con- 
 stitute a pathognostic sign of tuberculosis only when 
 they present under the microscope the connection and 
 arrangement which they have in pulmonary tissue. 
 This hint will enable us to avoid errors which may 
 arise from accidental admixture with the sputum of 
 bits of meat, or shreds of tendons and connective 
 tissue which may have remained caught in the teeth. 
 The importance of elastic fibres when found in the 
 histological arrangement characteristic of lung tissue 
 is, however, always great. As already said, they indi- 
 cate only a destruction of the tissues; but when tuber- 
 cle bacilli are also found in the sputum, it speaks for 
 progressive tuberculous softening and against a sta- 
 tionary condition. To distinguish that is sometimes of 
 great value. 
 
 When the elastic fibres are but sparingly present, 
 the search for them requires much patience and per- 
 severance. Fenwick's method is recommended as the 
 best. This consists in boiling the sputum with eighteen 
 per cent, caustic soda and then mixing it with three 
 or four times its volume of water; it should be placed 
 in a conical glass and allowed to stand for twenty-four 
 hours, after which the elastic fibres will be found in 
 the deepest layers of the sediment. 
 
 The pigment cells and myelin cells, which are also 
 found in the sputum of tuberculous persons, deserve 
 
- 48 — 
 
 especial notice. In 1872, in his paper on "Pneumonia^ 
 Tuberculosis and Consumption," Buhl expressed the 
 opinion that these large pigment-bearing nucleated 
 cells and myelin cells are, if numerous, an infallible 
 sign of beginning desquamative pneumonia — the initial 
 inflammatory stage (according to him) of tuberculous 
 phthisis, and that the quantity of myelin, either free 
 or enclosed in cells, stands in a direct relation to the 
 length of the phthisical process. In the beginning, 
 this view created much perplexity, but it is now, I 
 think, generally considered as refuted. I have long 
 since observed that the sputum of persons who are 
 continually in a hot, dusty atmosphere contains many 
 large pigment cells, fat granules and myelin forms, 
 without the lungs being at all diseased. I have also 
 had repeated occasion to verify after death the in- 
 tegrity of the lung tissue in men who had during life 
 plentifully furnished such sputum. They are mostly 
 persons whose calling or circumstances daily expose 
 them to a hot, smoky atmosphere, as bakers, smiths, 
 bar-room loungers and others. 
 
 At my suggestion. Dr. Panizza at one time sub- 
 jected the whole question to a thorough clinical and 
 experimental investigation, and the result confirms my 
 view as to the unimportance of these morphological 
 elements for the diagnosis of tuberculosis. Myelin 
 and fat granule cells, with or without pigment granules, 
 are found in all lung and bronchial affections, but 
 most constantly and numerously where there is super- 
 
— 49 — 
 ficial irritation of the breathing surfaces, such as is 
 caused by a heated, smoky atmosphere. Of five hun- 
 dred healthy and sick men whose sputa were examined 
 by Panizza, pigment-bearing cells and myelin forms 
 were found in eighty-six per cent, of the healthy, only 
 the sero-mucous morning sputum being examined. 
 When the examination was limited to special classes, 
 as smiths, cabinet-makers, cooks, etc., an abundance 
 of these cells was found in ninety per cent, of them. 
 Even after such persons had been in the hospital for 
 a long time the cells, though somewhat decreased in 
 quantity, did not entirely disappear. Panizza was 
 also often able to establish the integrity of the lung 
 tissue in some of the patients who had died of other 
 diseases. Consequently the occurrence of myelin and 
 pigment in the sputum must be considered a phenom- 
 enon compatible with health; though when very 
 numerous these elements indicate in general an irri- 
 tated condition of the breathing surfaces. 
 
 As to the origin of myelin and myelin cells, 
 Panizza was led by his researches on the respiratory 
 mucous membrane of the living frog to the view that 
 myelin is identical with mucm which is insoluble in 
 water but swells up in it. According to him, this 
 mucin is a secretion of the beaker cells lying between 
 the ciliated epithelial cells and it is poured out abun- 
 dantly on slight irritation, as, for example, by the ad- 
 mission of water. At first spherical shaped, it presses 
 by amoeboid movements up on the surface and seizes 
 
— 5° — 
 the pigment granules which are lodged there, and then, 
 having acquired a delicate enclosing membrane, it is 
 pushed outwards as myelin and pigment cells by the 
 movement of the cilia. 
 
 It is not to be disputed that where there is con- 
 tinual irritation of the respiratory apparatus, as in 
 trades associated with dusty atmospheres, the alveolar 
 epithelial cells may also take up pigment and appear 
 in the sputum as large pigment-bearing myelin cells. 
 But there is no conclusive reason for ascribing all 
 such elements in the expectoration to the prolifera- 
 ting alveolar epithelium. At any rate, it is much 
 easier to suppose that the largest part of the dust 
 particles remain clinging to the surface of the mucous 
 membrane and are there taken up by cellular elements 
 or elements which later receive the cell form. 
 
 To be sure, this does not settle the very interest- 
 ing question of the origin of pigment-bearing and 
 myelin cells. That question, and in fact the entire 
 subject of bronchial secretion and expectoration, need 
 further investigation and elucidation. I have been 
 constrained, however, to show that the presence in the 
 sputum of abundant pigment-bearing and myelin cells 
 and free myelin has no pathognostic significance for 
 pulmonary tuberculosis; but that it is to be considered 
 in a general way as an indication of an irritated con- 
 dition of the breathing surfaces. 
 
 Some remarks may be here added on hemoptysis. 
 It is to be considered as established that the first 
 
— 51 — 
 
 hemorrhage in tuberculosis does not come from 
 healthy lung tissue but from diseased lobules; and the 
 view that a primary hemorrhage may start up phthisis 
 can be considered as definitely set aside. The patho- 
 logical conditions in a tuberculous lung which lead to 
 hemorrhage may be very different. From a clinical 
 standpoint I would distinguish two principal classes: 
 First, hemorrhages which are due to progressive 
 changes and above all to softening consequent on 
 coagulation necrosis; and secondly, such as arise from 
 a pronounced retrograde tendency of the local affec- 
 tion. Whilst hemoptysis at the beginning of tuber- 
 culosis and at the advent of secondary outbreaks is 
 serious, its significance, even though frequently re- 
 peated, is very slight when there is a decided tend- 
 ency to healing. In the former case, softening and 
 decay of the tissue is the essential cause; in the latter 
 on the contrary, the bleeding is due to the disturb- 
 ance of the circulation caused by the cirrhotic shrink- 
 age of the tissues and to the most trifling changes in 
 the walls of cavities. From this point of view, one 
 may say with some degree of authority that habitual 
 blood-spitters are not the worst cases for treatment, 
 but rather that they belong to a favorable class, pro- 
 vided, however, that there is a general retrograde 
 tendency. 
 
CHAPTER III. 
 
 FEVER— IDIO-MUSCULAR TETANUS— CONTRAC- 
 TION WAVES. 
 
 Since the thermometer has come into use as an 
 indispensable domestic guide, at least among all half- 
 way cultivated families, we are pretty well informed 
 as to the course of fever in tuberculosis. Sick people 
 generally take their temperature more frequently than 
 is necessary. Every slight disturbance, every discom- 
 fort causes a resort to the thermometer. That is of 
 advantage to medical observation, so long as the dis- 
 ease has not progressed very far; but in the later 
 stages it is bad, inasmuch as the permanence of high 
 temperature produces a depressing effect on the pa- 
 tient. Hence it is advisable, in advanced stages, to 
 limit or entirely suspend the taking of temperature. 
 
 The significance of fever in tuberculosis is always 
 very great. Constant high temperature denotes a 
 progress of the bacillary and inflammatory process; 
 whilst continued apyrexia corresponds to a retro- 
 gressive tendency of the disease. The cause of the 
 fever is always to be sought for in the local changes: 
 on one hand, in the multiplication of bacilli, the re- 
 active inflammation of the lung tissue and in the fever- 
 exciting products of both; on the other hand, very 
 probably also in the absorption of products of decay 
 
— 53 — 
 from the focus of softening and in the chemical pro- 
 ducts of secondary colonies of cocci, about the bear- 
 ing of which on local and general disturbance in pul- 
 monary tuberculosis, we in fact know very little. 
 Viewed in their extremes, we may compare the con- 
 tinuous fever of acute infiltrations with the fever of 
 pneumonia, and the erratic or regularly occurring ex- 
 acerbations of the late stages with that of septic in- 
 fection. Between these extremes lie many inter- 
 mediate forms, among which the slight febrile excite- 
 ment, which often lasts for months, is least clearly due 
 to the local changes. In general, we may observe in 
 this disease, just as in severe fevers, a remission 
 entirely or almost down to normal in the morning and 
 an exacerbation towards mid-day or in the afternoon. 
 Leaving aside the higher degrees of absorption 
 fever, the fever curve of tuberculosis generally cor- 
 responds to the curve of protracted acute and sub- 
 acute infectious fevers; but there is not the same 
 regularity of movement, such as is observed, for ex- 
 ample, in typhus. This is best shown by hourly ob- 
 servations continued during the twenty-four hours. 
 Just as in the curve of typhoid fever, so here double- 
 crested curves are usually marked, corresponding to 
 the late forenoon and the afternoon, whilst after six 
 o'clock p. M. the temperature declines to the morning 
 minimum. In many cases, the twenty-four hours' 
 curve shows only one crest in the afternoon, or more 
 rarely in the forenoon. Triple-peaked curves are 
 
— 54 — 
 
 found very seldom, and then one of the crests corre- 
 sponds with midnight. 
 
 The more the symptoms are those of absorption 
 fever, the greater will be the difference between the 
 temperature of the remission and the exacerbation. 
 The higher the latter, the lower the former — not only 
 down to normal, but often a degree or two below it. 
 To explain this access of fever, we must suppose, as 
 in the septic fevers, that either the absorption of pyro- 
 genic matter into the circulation occurs with some 
 regularity and calls forth an explosive reaction of the 
 organism, or else that as soon as it has sufficiently 
 accumulated in the blood, it causes an excitation of 
 the nerve centre for temperature and produces a sort 
 of cumulative effect. Although, as appears from what 
 I have said, we cannot assign a distinctive type to the 
 fever of tuberculosis, it is still worth while to impress 
 on our minds the usual manner of its course. 
 
 I wish next to speak of an interesting phenome- 
 non which was long held to have a diagnostic value, 
 and which occurs usually, if not exclusively, in tuber- 
 culous phthisis. I mean the so-called idi'o-muscular 
 contraction* which owes its origin to the abnormal 
 
 * From the Greek z'iSzoS, peculiar. This phenomenon, 
 first observed by Graves and Stokes, was described by Tait, in 
 the Dublin Journal of Medical Sciences (Vol. LI I, p. 316), and 
 called by him " Myoidema." To elicit it, the percussion must 
 be immediate, /. <■. , without the interposition of plessimeter or 
 finger. — Tr. 
 
— 55 — 
 mechanical irritability of the emaciated muscles. If 
 we^strike firmly with the percussion hammer or the 
 tip of the finger on the pectoral muscle of an emaci- 
 ated consumptive near the sternum, we do not get 
 that rapid movement through the extent of the fasci- 
 culus of the muscle which occurs in health, but instead 
 a. rather hard muscular tumor, corresponding to the 
 size and form of the percussing body, appears and 
 quickly disappears. This brief circumscribed tetanus 
 may be combined with the normal muscular move- 
 ment, but such a combination is not constant. It may 
 be simultaneously elicited at different parts of the 
 muscle, or even of the same fasciculus, by using all 
 the fingers in percussion. 
 
 In many consumptives, besides this idio-muscular 
 tetanus, another notable phenomenon occurs. When 
 the tumor forms, very superficial and delicate contrac- 
 tion 7vaves pass from it on each side across the muscle. 
 They run perpendicular to the long axis of the fasci- 
 culus and mark the extent of the irritation or force 
 applied. They are best seen if one draw the handle 
 of the hammer firmly and quickly across the muscle 
 parallel to the sternum. Two delicate waves, cor- 
 responding in width to the length of the streak, are 
 formed, one moving towards the sternum and the 
 other towards the humerus, and both gradually de- 
 creasing in size. If two or more such lines are drawn 
 parallel to one another, each will give off two lateral 
 waves; and it is noticed on close observation that, 
 
- 56 - 
 when any two opposing waves meet, they do not die 
 out but they pass on, one over the other. The more 
 advanced the phthisis and the more wasted the adipose 
 tissue and muscles, the more clearly and constantly 
 will this phenomenon be elicited. 
 
 The phenomenon of myoidema was long known 
 to physiologists, but frequent observation of it in con- 
 sumptives first led the English surgeon, Lawson Tait, 
 to think it was a pathognostic sign of phthisis, and in 
 fact of the softening stage. Later observers have 
 verified its occurrence in advanced phthisis without, 
 however, giving full assent to Tait's opinion of its 
 pathognostic significance. In conjunction with two of 
 my pupils, Dr. von Millbacher and. Dr. Stadelmann, I 
 have subjected the matter to a close investigation. 
 Our conclusions were briefly the following: 
 
 1. The idio-muscular convulsion occurs only 
 when the adipose tissue is completely wasted and the 
 muscles are extremely emaciated. It can consequently 
 be elicited in all patients in whom these conditions 
 are verified and of course especially in consumptives 
 in whom emaciation is usually very great. We found 
 it to occur in other diseases which cause great emacia- 
 tion, as in the fourth or fifth week of abdominal 
 typhus, in cases of neoplasms, etc. 
 
 2. For demonstrating the phenomenon, only 
 those muscles are suitable which lie upon osseous 
 structures against which they can be firmly com- 
 pressed by the stroke. The muscle best adapted is 
 
— 57 — 
 the broad pectoralis major, but we found it in other 
 muscles with a hard back-ground, as, for example, 
 thesupra-spinatus, deltoideus, extensor digitorum com- 
 munis, tibialis anticus, etc. 
 
 3. We succeeded a few times in eliciting a weak 
 tumor formation in men apparently healthy but very 
 emaciated. 
 
 4. The histological changes on which the phe- 
 nomenon depends are a high degree of atrophy of the 
 adipose and cutis, and simple atrophy and fatty de- 
 generation of the primitive fasciculus. But also pro- 
 liferative changes in the internal perimysium and con- 
 nective tissue, as well as proliferation of nuclei in 
 the sheaths of smaller vessels and thickening of the 
 adventitia of larger vessels, play a part in it. On post 
 mortem examinations, von Millbacher found the " tied 
 fasciculi of Fraenkel " {umschniirten Biindel) abund- 
 ant in muscles which during life had exhibited the 
 phenomenon in a marked degree. Besides prolifera- 
 tion of the nuclei in the connective tissue and vascular 
 sheaths, he always found, in the neighborhood of ves- 
 sels with thickened walls, fasciculi bound around 
 either partly or completely with connective tissue. 
 Often, in fact, the proliferated connective tissue 
 sheaths of both were directly proportioned to each 
 other. 
 
 5. These anatomical changes impel us to rank 
 this abnormal muscular irritability (which is obviously 
 independent of nerve influence) with the excessive 
 
- 58 - 
 
 irritability of muscles entirely withdrawn from nerve 
 influence by cutting or degeneration of the nerves and 
 involved in atrophic and interstitial proliferative 
 changes. However, the two cases are essentially 
 different. In motor paralysis, the nerves are degen- 
 erated down to their end-plates; here they are well 
 preserved. In the former, the muscles are not subiect 
 to the will; here they are capable of function, even 
 though they may be weak. There the reaction of 
 muscles and nerves to the electric current changes 
 with the succession of appearances which represent 
 the reaction of degeneration,"^ and the entire muscle, 
 or, at least, entire fasciculi of it, slowly respond with- 
 out forming a contraction tumor; here only the part 
 of the muscle which is directly affected undergoes a 
 brief tetanus and sends out superficial waves, a thing 
 that never occurs in the reaction of degeneration in 
 excessively irritable muscles. 
 
 6. Though the analogy between the reaction of 
 simple emaciated muscles and that of paralyzed mus- 
 cles is not tenable, we do find an important relation- 
 ship between the phenomenon under consideration and 
 the physiological condition of exhausted or moribund 
 muscle. Years ago Schiff noticed in the exhausted 
 
 * The reaction of degeneration, as described by Erb, con- 
 sists in the loss of both galvanic and faradic irritability by the 
 nerves, whilst the muscles lose only faradic irritability, but 
 their galvanic irritability is always changed in quality and 
 sometimes increased. — Tr. 
 
— 59 — 
 or dying muscles of mammals precisely the same ap- 
 pearances which we observe in the emaciated muscles 
 of consumptives. There can consequently be scarcely 
 a doubt that in the atrophied muscles of consumptives 
 we have to deal with a phenomenon of exhaustion and 
 dissolution which occurs the more readily, the more 
 atrophied the external tissues are. 
 
 Though this does not explain the intimate changes 
 in the disease, we are justified by this physiological 
 parallel, as well as by clinical observation, in conclud- 
 ing that this idio-muscular contraction has nothing to 
 do with tuberculosis itself; that it is merely a phe- 
 nomenon connected with emaciation and going hand 
 in hand with the general waste of the tissues; and 
 that consequently it has no diagnostic significance. 
 
CHAPTER IV. 
 
 VITALCAPACITYOFTHE LUNGS— BODY WEIGHT. 
 
 I will next briefly refer to two appliances which 
 are valuable for diagnosis, for the continued study of 
 a case, and for determining the line of treatment, and 
 which I think have not been sufficiently appreciated 
 by physicians, namely, the spirometer and the scales. 
 
 In speaking of the spirofneter I shall not consider 
 the physiological side of the subject of lung capacity 
 but shall limit myself to some practical questions. 
 
 Spirometry is seldom used by physicians, partly 
 because it is thought that its results depend too much 
 on the patient's skill and practice to have exact and 
 constant value, and partly because we have no ab- 
 solute standard of vital capacity in health. These 
 views, however, are not verified in practice. There 
 are of course many clumsy men, especially in the 
 lower walks of life, who are unsuited for examinations 
 in which they themselves must co-operate with the 
 physician. But their number is very much reduced if 
 pains are taken to instruct them. In my hospital 
 wards we have by patience and practice generally suc- 
 ceeded in making spirometric measurements; though 
 we also noted that clumsiness in this matter prevails 
 more among women than among men. 
 
 As regards the second objection, namely the im- 
 possibility of assigning an absolute value to vital 
 
— 6i — 
 
 capacity in health, it is true that such an impossibility 
 exists because the amount of vital capacity depends 
 on very different factors. Among these, stature is the 
 most important inasmuch as a constant proportion 
 exists between vital capacity and size of body, though 
 different in the two sexes. The other factors, for ex- 
 ample, circumference of chest, length of flanks, weight, 
 age, trades, etc., do not affect vital capacity to such an 
 extent as stature. Accidental factors, such as a full 
 stomach, intestinal flatus, position of body, etc., can 
 always be removed. Guided by four years' experience, 
 I advise that only the relation between the volume of 
 expired air and the stature should be taken as a 
 standard in estimating vital capacity. Both can be 
 easily ascertained and the proportion between them 
 needs only a moment's calculation. Hutchinson, the 
 inventor of the spirometer, and Winternich calculated 
 the vital capacity in units of linear measurement, that 
 is in inches and centimeters. 
 
 I have endeavored to establish a sort of boundary 
 line between normal and sub-normal vital capacity, 
 and I have found that the minimum proportion in 
 health is one to twenty for men (/. e. one centimeter of 
 height to twenty cubic centimeters of vital capacity) 
 and one to seventeen for women.* These limits have 
 of course only an approximate value, but that does not 
 
 * Denoting height in inches and capacity in cubic inches, 
 the proportion will be for men i to 3, and for women i to 2.6 
 — Tr. 
 
— 6a — 
 
 much matter in practice because in the pathological 
 conditions which come before us we have usually to 
 deal with wide variations. Furthermore, the chief 
 value of spirometry does not consist in absolutely 
 determining the vital capacity but rather in noting 
 the variations of vital capacity in the same individual 
 during a lengthened period of time. Consequently, 
 the procedure is less valuable for primary diagnosis 
 than for noting changes in the respiratory function 
 during a course of observation and treatment. 
 
 The pathological conditions of the respiratory 
 organs which diminish vital capacity are very numer- 
 ous. They include all acute and chronic affections of 
 the lungs, pleurae, heart and thorax, and affections of 
 the abdominal viscera which narrow the thoracic 
 space. Hence spirometry serves only to corrob- 
 orate the results of other methods of examination. 
 Among the changes which most influence vital capa- 
 city I may name (in addition to pulmonary tuber- 
 culosis) adhesions of the pleurae following pleuritis, ad- 
 hesion and lifting of the diaphragm, pulmonary em- 
 physema, cirrhosis of the lungs and bronchitis. 
 
 We may then say in general: When the propor- 
 tion of stature to vital capacity falls below one to 
 twenty in a man or one to seventeen in a woman, we 
 may infer a considerable disturbance of the respira- 
 tory organs, the nature of which is to be determined 
 by other methods; if, however, we should find a pro- 
 portion of, say, one to twenty-five in a man or one to 
 
twenty-two in a woman, such a disturbance would be 
 a priori improbable. 
 
 The absolute value of these data may be illustrated 
 by an example. An unusually tall and slender youth 
 of twenty-five years, the son of a father who had died 
 of phthisis, was brought to me by his anxious mother 
 to learn whether his emaciation, 'pallor and sickly ap- 
 pearance were due to aay pulmonary trouble. The 
 physical examination resulted negatively. Still, 
 isolated rales in the upper lobes in connection with 
 the anaemia, the "paralytic thorax," the poorly de- 
 veloped muscles, the cardiac palpitation, and the tend- 
 ency to perspire at any vigorous muscular effort, made 
 the case suspicious as one of quickly developing tuber- 
 culosis. The spirometric examination gave for a 
 height of 1 86 cm. (74 inches) a vital capacity of 5,000 
 ccm. (305 cubic inches), or a proportion of i to 27 
 (i to 4.1 in inches and cubic inches). This rendered 
 the exclusion of tuberculosis more certain and gave 
 definiteness to the therapeutic indications. Three 
 months later the vital capacity was found to be the 
 same, and the measures adopted in the interim 
 (shower-baths, sea-baths, mountain climbing and 
 bodily exercise) had produced a gratifying effect on 
 the general nutrition, the muscular strength, the color 
 of the skin and mucous membrane, and also on the 
 cardiac palpitation. 
 
 A contrast to the above is furnished in the follow- 
 ing case. A young man belonging to an apparently 
 
- 64 - 
 
 healthy family had not long ago an attack of hemop- 
 tysis, and since then he has had a dry cough without 
 expectoration. Otherwise he seems not much affected. 
 Physical examination showed a scarcely appreciable 
 difference in the apices and at the same place isolated 
 rales and prolonged respiration. The pleurae were 
 free, and the position of the diaphragm and the move- 
 ment of the edges of the lungs normal. The spirom- 
 eter gave for a stature of 175 cm. (or 68 inches), a 
 constant vital capacity of 3,200 ccm. (or 195 cubic 
 inches), or a proportion of i to 18 (i to 2.8). This 
 made the diagnosis of beginning tuberculosis pretty 
 certain. A few months later we found tubercle bacilli 
 in his sputum. 
 
 The relative value of spirometry is shown best in 
 cases where definite changes are noted in the respira- 
 tory apparatus and where repeated tests are made dur- 
 ing a long course of observation. 
 
 If even a slight increase in vital capacity appear 
 during a course of climatic or other treatment, it is 
 valuable for prognosis and will be usually found to 
 correspond with improvement in other directions. 
 But a rapid or slow decrease is an ominous confirma- 
 tion of other unfavorable appearances. I will also 
 cite a case in illustration. 
 
 In a young woman, twenty-eight years of age, with 
 an inherited weak constitution (tuberculosis was shown 
 only in her maternal uncles and aunts), an undoubted 
 tuberculosis of the apices, bacilli in the sputum, etc.,. 
 
-65 - 
 
 the spirometric test gave a constant vital capacity 
 of 2600 ccm. (128 cu. in.) for a height of 160 cm. (63 
 inches), that is a proportion of i to 15.6 (i to 2.5). 
 She passed the winter at Meran, where she was almost 
 entirely free from fever, and where she took regular 
 exercise in climbing. Her appetite improved; she 
 gained 6 kgrms. (13 lbs.) in weight, and the next year 
 possessed a constant vital capacity of 2700 ccm. (164 
 cu. in.), that is a proportion of i to 17 (i to 2.6). 
 Four years have since passed and she is still healthy, 
 the dullness over the apices has almost completely 
 disappeared, and bacilli are no longer found in the 
 sputum. 
 
 Of course I could furnish a far greater number 
 of cases which contrast with this favorable one and in 
 which the vital capacity steadily decreased. The de- 
 crease may be very great, partly through progressive 
 infiltration, partly through fever, muscular weakness, 
 etc. Often in advanced cases we do not get a higher 
 proportion than i to 8 (or i to 1.2). Nevertheless, 
 where vital capacity rapidly and notably diminishes, 
 we should not infer that the tuberculous process is 
 spreading unless the physical examination also indi- 
 cates it, and unless we can also exclude diffuse bron- 
 chitis, pleuritis, high fever, etc. 
 
 The scales are another apparatus valuable as an 
 aid in diagnosis and prognosis. They have been long 
 used in hospitals and health resorts for diseases of 
 the chest, but seem to be but little employed in private 
 
 6 EB 
 
— 66 — . 
 
 practice. The knowledge of the patient's weight has 
 a relative, not an absolute value. Abstracting from 
 the extreme loss of weight which occurs in the last 
 stage of consumption, we would be still less justified 
 in making our diagnosis merely from the fact that a 
 patient weighs 50 or 70 kilograms (i 10 or 154 lbs.) than 
 we would be from a knowledge of his absolute 
 vital capacity. In the latter case we have at least the 
 stature with which to compare the volume of expired 
 air. The size of the body cannot, however, serve as a 
 standard by which to judge whether the average 
 weight is normal or abnormal, for there are people 
 who have diseased chests and whose weight is consid- 
 erable on account of their large bones, and, on the 
 other hand, there are slender delicate persons who are 
 entirely healthy in spite of light weight. Hence, 
 weight has no absolute worth for diagnosing or ex- 
 cluding tuberculosis, except in so far as its variations 
 upwards or downwards may speak for or against the 
 supposition of that disease. 
 
 But weight becomes an useful guide when it is 
 tested at regular intervals in a patient, as is done in 
 sanitariums for chest diseases and in many hospitals. 
 After the diagnosis of tuberculosis has been settled, 
 the scales will inform us whether the process is ad- 
 vancing or receding, whether fever is present or not, 
 and whether the assimilation of food is sufficient. 
 
 Even the maintenance of a steady weight, after 
 having recouped a previous loss, is a favorable sign as 
 
- 67 - 
 
 it probably speaks against a progressive tendency of 
 the disease. Steady loss of weight is always a bad 
 omen, and worse in proportion to its rapidity, for it 
 shows that the general economy is breaking down 
 under the iniiuence of the fever. On the contrary a 
 steady even though slow increase, especially in con- 
 nection with other local and general signs of improve- 
 ment, indicates a disappearance of the fever and a 
 better condition of the appetite and assimilation. I 
 need scarcely say that no physician will be misled by 
 an increase of weight produced by oedema of the 
 limbs. Thus, if the patient were in the country or at 
 a health resort, the scales wpuld keep the family phy- 
 sician informed as to the course of events in the same 
 way that the spirometer would. Every decrease of 
 weight below the equilibrium warns the patient that 
 something is wrong and causes him to seek the advice 
 of his physician. On the other hand, every increase 
 in weight tells him that his condition is satisfactory, 
 increases his confidence in his treatment and strength- 
 ens his fidelity in following it. Tabulated or graphic 
 statements of the regular weighings are of great inter- 
 est to the physician and enable him and the relatives, 
 even when the patient is at a distance, to form a 
 pretty correct judgment as to the course of the treat- 
 ment. The record of weighings sent by. the patient is 
 a sort of supervising report on the issue of the thera- 
 peutic efforts. 
 
 The above points are all important, and deserve 
 
— 68 — 
 
 the notice and study of the readers. Every physician 
 knows how helpful, nay necessary, an exact diagnosis 
 is in the beginning of tuberculosis. Here as else- 
 where is true that memorable saying of Van Swieten: 
 "Qui bene diagnoscit, bene medebitur."* 
 
 *A correct diagnosis is half the cure. Literally, he who 
 diagnoses correctly will treat well. — Tr. 
 
PART THIRD. 
 
 The Ther/peutics of Pulmonary Tuberculosis 
 
 CHAPTER I. 
 
 PROPHYLACTIC TREATMENT — HYGIENE — 
 
 CHOICE OF EMPLOYMENT— PRECAUTIONS 
 
 AGAINST CONTAGION— HYDROTHERAPY. 
 
 The discovery of the bacilli as the cause of tuber- 
 culosis has given us a new standpoint for its treat- 
 ment, but so far has had no other important result. 
 The first thought was of course to direct all thera- 
 peutic efforts against them, and the hope was ex- 
 pressed by many that some remedy might be dis- 
 covered which would, without injuring the body, limit 
 or destroy their growth or vitality. This hope of 
 sanguine investigators has not yet been fulfilled, and 
 there is but little prospect that it will ever be realized. 
 However, modern medicine teaches more clearly than 
 ever before that one should not play the prophet, and 
 consequently I shall not disturb with doubts the hopes 
 of those who look for the ultimate extinction of tuber- 
 culosis in the human race. Though we have no 
 specific remedy for the disease, we can still do much 
 
— 70 — 
 
 for its treatment, especially in the domain of dietetics, 
 by an intelligent and well-planned manner of living 
 adapted to the needs of the individual constitution. 
 
 I will take as the starting point of my remarks an 
 expression of Graves, cited by Hermann Weber: " It 
 would be a great help if we knew how to make a per- 
 son consumptive, for by pursuing the opposite course 
 we would be able to prevent phthisis." The desire 
 expressed in these words has been fulfilled by modern 
 research, the real cause [materia peccans) has been 
 laid bare, and the conditions which favor its acquisi- 
 tion have been recognized. An abundance of facts 
 and observations have been accumulated concerning 
 the causes which chiefly favor the development of the 
 disease, whether an hereditary tendency be present or 
 not. I have already described these causes in Part 
 First, and shall now limit myself to designating the 
 points of view to which their consideration necessarily 
 gives rise. I shall begin with the observations made 
 there, concerning the development of tuberculosis in 
 healthy inmates of prisons, convents and hospitals. 
 The Sisters of Charity, whom we see all day long in 
 our hospital wards going about their blessed work with 
 utmost zeal and devoted self-sacrifice, show us very 
 clearly how tuberculosis is acquired and what injurious 
 influences favor its development. The continual 
 breathing of confined air, little or no outdoor move- 
 ment, much work, monotonous diet, little recreation 
 and much night-watching are the principal causes. Ex- 
 
— 71 — 
 
 perience also teaches us that mental agitation, spiritual 
 struggles, cares, etc., contribute to diminish the body's 
 power of resistance to the disease. 
 
 How does the disease develop ? What precur- 
 sory symptoms herald it ? Here, as among the 
 prisoners described by Baer, the beginnings are 
 scarcely noticeable. We find rather a picture of 
 anaemia with muscular weakness and anorexia. Cough 
 and impaired respiration are not necessarily present. 
 Yet the physical examination will show infiltration. 
 Baer found such lingering infiltrations, followed by 
 rapid decay, in prisoners subjected for a long time to 
 unaccustomed hard labor or much penal dieting, or to 
 the influence of great grief or deep sorrow. 
 
 In marking out a line of prophylactic treatment, 
 we must bear in mind those conditions which favor 
 the development of the disease. They show us clearly 
 what must be avoided. Instead of sitting in a room, 
 there must be outdoor movement; instead of straining 
 and incessant action in a confined place, there must 
 be regular but not excessive outdoor muscular work, 
 with intervals of rest; instead of limited diet, there 
 must be good and varied food corresponding to the 
 work and consisting of albumenoids, fats, and carbo- 
 hydrates; there must be. light stimulating drinks, at 
 least seven hours of sleep, and frequent visits to the 
 country with complete freedom from all duties. Per- 
 sons whose means permit it may extend this anti- 
 tuberculous manner of living by trips to the mountains 
 
— 72 — 
 
 or on the ocean where the air is absolutely pure and 
 free from dust and bacilli, or by taking such forms of 
 exercise as will necessitate deep inspiration in a pure 
 atmosphere, such as mountain climbing, rowing, trap- 
 eze practice, etc. The essential thing is the deep inspir- 
 ation of pure air conjoined with outdoor muscular exer- 
 cise. The Pommeranian laborers and drivers have 
 only plain food, hard work and little sleep all through 
 the summer; but they do not become consumptive. 
 On the contrary, they thrive remarkably well in the 
 fresh air, for they always enjoy enviable appetites, 
 tireless strength, sound sleep and the best of spirits. 
 Consequently, to prevent phthisis, it is necessary t» 
 avoid close and impure air and to take sufficient out- 
 door exercise, moving around or working. 
 
 The question presents itself, why are not prison- 
 ers put at outdoor work ? Why are they packed 
 together in close working rooms and impure atmos- 
 pheres? It has been found practicable to keep the 
 insane at rural employments and to watch over them; 
 why should it not be possible in the case of prisoners? 
 Why not allow prisoners to indulge in athletic and 
 other physical exercise ? Surely it is not the intention 
 of the law that the criminal, whose removal from so- 
 ciety is necessary for its safety, shall become sick and 
 die! The penal code aims to punish and improve, 
 not to make sick and slay. Yet, as things now are 
 and always have been, a sentence of five, ten or twenty 
 years* confinement, or for life, means a sentence to a 
 
— 73 — 
 very great risk of consumption. Certainly the hygiene 
 of prisons has been immeasurably improved, and in 
 consequence those terrible epidemics of typhus, scor- 
 butus, dysentery, etc., which once decimated them 
 have disappeared. Tuberculosis alone remains and 
 its mortality statistics are enormous — three or four 
 times more than among the general population. 
 
 During the years from 1825 to 1842, twelve out 
 of every thousand prisoners in the great English peni- 
 tentiary at Millbank died of phthisis, while during the 
 same years the mortality in the city from that cause 
 was only 4.37 per thousand. Two hundred and five 
 deaths occurred in the penitentiary during those years 
 and eighty of them were due to phthisis. Besides 
 that, ninety persons were liberated on account of ad- 
 vanced tuberculosis. In the Prussian prisons, the pro- 
 portion is about the same. At Plotzensee,* from 
 1873 to 1882, one hundred and thirty-nine prisoners 
 died of whom ninety-one or 65.4 per cent, died from 
 phthisis, and besides, forty consumptives were liber- 
 ated. Almost all prisons give a like proportion.! Such 
 a mortality from consumption, in spite of relatively 
 good hygienic arrangements and a relatively small 
 total mortality, is something awful. Yet these figures 
 are not high enough, for post mortem examinations of 
 convicts who had died from other diseases showed in 
 
 * Pl5tzensee is a penitentiary near Berlin. — Tr. 
 f See Appendix for statistics of American penitentiaries. 
 — Tr. 
 
— 74 — 
 most cases a more or less developed tuberculosis. 
 Baer states as the result of his experience as prison 
 physician that it is an exception to find in the post mortem 
 of prisoners the lutigs free from tuberculosis. 
 
 In estimating the danger of consumption in 
 prisons, there is another thing to be noted. The 
 highest mortality from tuberculosis is not found in 
 collective prisons and houses of correction, where the 
 deteriorated atmosphere of working rooms and dormi- 
 tories is breathed by the prisoners in common, but 
 in prisons conducted on the cellular system. And 
 this is so notwithstanding that under the latter system 
 the healthy prisoners are entirely separated from the 
 diseased ones, that the volume of air furnish'ed the 
 prisoners is much larger than in the collective system, 
 and that the atmosphere is better and the floors and 
 walls much cleaner. Hence, the ubiquitous nature 
 of the tubercle bacilli being understood, the infection 
 depends essentially on the deprivation of outside air 
 and outdoor work. That the diet is monotonous and 
 often innutritious cannot be denied; and psychical 
 causes also, such as ennui, lonesomeness, repentance, 
 longing after freedom, etc., must not be undervalued. 
 I believe that with a plentiful supply of air and suit- 
 able outdoor work in moderation not only the 
 appetite and sleep would be better, but the disturbed 
 and depressed spirits would be notably improved. 
 These considerations deserve the attention of law- 
 makers. The causes of the disease are clear, and the 
 
— 75 — 
 evil cannot begotten rid of without changing the man- 
 ner of working and increasing the supply of fresh air. 
 After the immense advances made in prison hygiene 
 during the last fifty years, no one will deny the possibil- 
 ity of changing the existing rules in the direction 
 indicated. 
 
 What has been said of the prison applies, mutatis 
 mutandis, to all trades and avocations which bring to- 
 gether a number of persons in crowded, unhealthy 
 rooms and deprive them of fresh air and freedom. 
 Statistics of the French and English armies show that 
 the ratio of mortality from consumption quickly de- 
 creases at the beginning of wars or military man- 
 oeuvres, and at once increases on return of the soldiers 
 to the barrack life of peace. The German army owes 
 its small mortality from this cause, not only to the 
 careful selection of recruits and the excellent sanitary 
 condition of the barracks, but especially to the regular 
 summer and winter marches and other outdoor physi- 
 cal exercises. 
 
 The case of cloister-like seminaries, orphanages 
 and educational institutions is similar. The more the 
 free exercise of youth is limited in such institutions, 
 -the more frequent is tuberculosis, as Fourcault has 
 shown by a number of most convincing examples. A 
 state supervision of hygiene in seminaries and similar 
 institutions, especially in girls' boarding schools, seems 
 to be urgently necessary. The youth of Germany 
 enjoy too little freedom and outdoor exercise. At 
 
- 76 - 
 
 school, especially in the intermediate schools, an ex- 
 cessive and pedantic care for order and discipline 
 limits the enjoyment of fresh air in the intervals be- 
 tween the classes. At home, when supper is over, the 
 pupils must at once set about preparing their lessons 
 for the morrow. There are, of course, gifted pupils 
 who can prepare their lessons in an hour and then 
 have time for play, walking, music, etc.; but the aver- 
 age pupil if industrious must devote the most of his 
 free time after dinner or supper to study, so that he 
 seldom or not at all gets out of doors. How many 
 children perish every year on account of this un- 
 natural way of living ! Contemplate the pale, thin 
 boys and girls as, tired and exhausted, they leave the 
 school at the close of their studies. Compare them, 
 relaxed and over-worked, with English boys and girls 
 whose every minute of free time, in or out of school, 
 is given up to ball playing, climbing, wrestling, rowing, 
 etc. What a difference in the color of the skin, the 
 bright glances, the active movements ! I know of 
 prominent intermediate schools where the forenoon 
 recess consists of only seven or eight minutes out of 
 doors, and even then the pupils are not allowed to 
 romp or play, but must walk about sedately and con- 
 verse. 
 
 Dr. Hermann Weber, of London, one of the most 
 prominent and most esteemed German physicians in 
 foreign countries, and one well acquainted with Eng- 
 lish manners, pointed out the difference in physical 
 
— 77 — 
 training among pupils in Germany and England in a 
 paper read before the Third Congress of General 
 Medicine at Berlin. In a series of essays, lately pub- 
 lished, on the Hygiene and Climatic Treatment of 
 Phthisis, he has again urgently insisted on the neces- 
 sity of careful attention to the physical training and 
 outdoor exercises of growing youth. Medical atten- 
 tion in Germany has hitherto been taken up with the 
 hygiene of schools in relation to myopia. It is indeed 
 time that it should be directed to a sufficiency of 
 recreation, the choice and supervision of games, the 
 estimation of each pupil's vital capacity, a systematic 
 noting of his weight in relation to size, and finally to 
 his muscular power. Such regular investigations 
 (which ought to be made every three months) would 
 furnish valuable information for the training of youth. 
 The school would become a channel of instruction for 
 parents regarding the improvement of their children's 
 constitutions. A half day every quarter devoted to 
 such purposes would make no great inroad in the 
 school work but would be invaluable in its results for 
 the physical development of the pupils, especially of 
 any with weak constitutions or with a direct disposi- 
 tion to tuberculosis. The physical development of 
 children belonging to these two classes should receive 
 the unremitting attention of the family physician. 
 Every catarrh, every swollen gland, every skin affection, 
 every trouble, though apparently unimportant and 
 hardly worthy of notice in a child free from an heredit- 
 
- 78 - 
 ary disposition, must receive careful attention and 
 treatment. Even if no such disturbances occur, the 
 physical training of children exposed by inheritance or 
 otherwise to tuberculosis must be constantly super- 
 vised. We should insist on the boy or girl spending 
 at least several hours every day out of doors. We 
 should mark out the regular exercises which should 
 include ball playing, turning, skating, rowing, bicycling, 
 hill-climbing, etc. All this applies not merely to 
 vacations, when of course it is understood, but to 
 the school term when every day is spent in the impure 
 air of the school or bent over books at home or in 
 class. 
 
 The selection of an employment suited to persons 
 disposed to tuberculosis ought to be left to the physi- 
 cian. Unfortunately his opinion is not often asked or 
 followed. In general, one may say that such persons 
 should avoid employments which do not allow mus- 
 cular activity and which require them to stay in close 
 rooms. Pursuits which keep them continually in the 
 open air and allow abundant activity to the muscular 
 and respiratory systems should be chosen. The fol- 
 lowing may be named as being least dangerous: Mili- 
 tary service, farming, gardening and sea-faring. Of 
 the learned professions, theology and medicine are 
 recommended, the former because of the country pas- 
 torates which it offers, and the latter because the 
 whole world is open to the doctor. In the case of 
 girls, sewing and embroidery should be forbidden, 
 
— 79 — 
 and bodily exercise, walking, mountain-climbing, etc., 
 recommended. 
 
 These are not theoretical deductions, but they are 
 the lessons of experience. I might cite cases from 
 my own experience which would show the eminent 
 importance of a right choice of employment for per- 
 sons predisposed to disease, but I know of no case 
 so striking as one mentioned by Weber, and which I 
 reproduce here, presuming on his friendly permission. 
 •A teacher of languages and his wife, both sprung 
 from tuberculous families, died of phthisis under 
 Weber's treatment, one shortly after the other. Of 
 their seven children, one had died previously of tuber- 
 cular ineningitis basilaris. The other six, ranging in 
 age from one to twelve years, were healthy except the 
 youngest boy, who was somewhat rachitic. Still, the 
 inherited constitutional vice of these poor orphans 
 was as bad as could be imagined. After the death of 
 the parents, all the children were taken by well-to-do 
 relatives who resided in a hilly district of Silesia, and 
 there they received a rational physical training such 
 as I have indicated above. What was the conse- 
 quence ? 
 
 The eldest son remained healthy as long as he 
 devoted hirhself to an open air life. But in his twenty- 
 third year he plunged into the study of philology. 
 He worked at it day and night, wholly gave up taking 
 physical exercise, and spent most of his mealtimes in 
 his study. In eighteen months he died of "galloping" 
 
— 8o — 
 
 consumption. The second son became a farmer and 
 enjoyed the best of health until his twenty-ninth year. 
 He then found that his business was not profitable 
 enough, and began to work in a mercantile house^ 
 where he was shut up most of the day in a poorly 
 ventilated office. Besides, he studied industriously 
 at home. After two years of this intense " city work,"^ 
 he began to suffer from repeated hemoptyses and died 
 after hardly two years' duration of the disease. The 
 third son became a cavalry man, leads an active rational 
 life, and is a strong and fine-looking man. The 
 fourth child, at that time a girl of five years, is now 
 the wife of a country clergyman in a healthy part of 
 Silesia. She has no children and is perfectly healthy. 
 The next son, who was rachitic in childhood, has be- 
 come a strong man. He is a farmer in Manitoba,. 
 America, and the sixth child (the youngest girl), who- 
 lives with him, is also strong and healthy. 
 
 This very instructive history shows how beneficial 
 open air life is even in the presence of a pronounced 
 family tendency to consumption, and how sternly in 
 the same condition, the violation of hygienic laws is- 
 avenged. The history covers a period of thirty years^ 
 but we cannot say that it has reached its end. Un- 
 favorable circumstances, care, troubles, especially a 
 sudden change from an open air life to an indoor one,, 
 may cause the latent tuberculosis to develop or the ex- 
 isting disposition to yield to direct infection. Such 
 cases occur often enough in practice. Persons die of 
 
— 8i — 
 
 quick consumption in their fiftieth or sixtieth year, al- 
 though they have previously been always healthy or 
 at most had suffered from " catarrh " in their youth or 
 later years. The post mortem shows in the lungs of 
 such patients old remains of a healed tuberculosis in 
 the form of crooked scars at the apices which enclose 
 cheesy or calcareous lumps or small cavities or are en- 
 tirely indurated. That these scars are really remains 
 of a healed tuberculosis is undeniable, for industrious 
 investigation has discovered isolated tubercle bacilli 
 in them or in the old, pigmented, cheesy-hard bronchial 
 glands. Such cases account for tuberculous diseases 
 in children which seemed inexplicable because the 
 parents were always supposed to be perfectly healthy: 
 The early tuberculosis of the latter was either entirely 
 overlooked or else was euphemistically described to 
 the patient and his family as chronic catarrh, slight 
 bronchitis, etc. If one has an opportunity to care- 
 fully examine these cases he may be able, even after 
 the lapse of years, to diagnose the healed phthisis 
 with tolerable certainty, on account of the flattened 
 apices and the slight difference in the intensity of the 
 percussion note and in the quality of the respiratory 
 sound. That is a very important point for a doc- 
 tor engaged in life insurance examinations. 
 
 We now approach a part of the prophylactic 
 treatment, the importance of which is perhaps greater 
 or mayhap less than would be on the moment im- 
 agined. I mean the avoidance of tuberculous contagion. 
 
It necessarily follows from Koch's doctrine that 
 tuberculosis is contagious, and the preventive treat- 
 ment must be regulated from the same standpoint. 
 Clinical experience, however, has not verified an 
 actual contagion from man to man, and the re- 
 sults of the general congresses organized in France, 
 England and Germany have not favored, so far as 
 can be seen, the view of a direct contagion. 
 
 Notwithstanding that, it is advisable, when one 
 parent is phthisical, to deal with the matter plainly 
 and to insist that the patient shall not kiss spouse or 
 children, that the sputa shall not be cast on the carpets 
 but shall be suitably disposed of and disinfected, that 
 the soiled handkerchiefs shall be separately disinfected, 
 and that the room with all its carpets, curtains and 
 furniture shall be frequently cleaned and always kept 
 ventilated. If at all possible the sick person should 
 occupy a separate room or certainly at least a separate 
 bed. Such precautions, I admit, are onerous, distaste- 
 ful, and in a manner penal. They create in the 
 healthy members of the family an aversion to the pa- 
 tient, a dread of being infected, and are so opposed to 
 familiar feelings and customs that they cannot be suc- 
 cessfully enforced in practice. Still, if the father and 
 mother are at all reasonable, these stringent precau- 
 tions will benefit the children. Children seem to become 
 infected, especially in the first years of life, by fre- 
 quent kisses of a consumptive mother, or by the con- 
 tamination of their food with her saliva, or by the air 
 
— 83 — 
 
 of her sleeping room. The physician must appeal 
 to her maternal devotion and, by placing clearly be- 
 fore her eyes the danger to her child, make her realize 
 that she holds its life and health in her hands. The 
 maternal heart will unconsciously concentrate all its 
 tenderness on the babe's well-being. Of course a 
 tuberculous mother should not nurse her babe, and 
 great care should be taken to avoid tuberculosis in 
 the selection of a wet-nurse for it. So far, bacilli have 
 not been found in the milk of consumptive women, but 
 it is only a question of time until they will be demon- 
 strated, for the infectiousness of milk from tuberculous 
 cows, even where the udders are not tuberculous, has 
 been fully established by experiment. 
 
 The danger of infection by milk of tuberculous 
 cows (especially if the udders should be ulcerated) is 
 not absolutely very great, for it is calculated that at 
 most only* two per cent, of cattle are tuberculous. 
 However, when we reflect that the consumer has usu- 
 ally no control over the source of the milk, that he 
 seldom knows the condition of the herd that supplies 
 it, or whether it is the product of one sick cow or a 
 part of the mixed milk of the entire herd, the danger 
 is still considerable. Hence, before using, all milk 
 should be sterilized by boiling. Five minutes' boiling 
 will be sufficient, and the mistress of the house should 
 herself attend to it. As to infection from using the 
 meat of diseased cattle, the strict supervision of the 
 slaughter-houses guards against that. Butter and 
 
- 84 - 
 
 cheese made from the milk of tuberculous cows may 
 also be infectious, but the danger from their use by a 
 growing child with good digestion is much less than 
 the danger to a babe from use of the milk. Besides, 
 they are articles that may easily be dispensed with, if 
 any anxiety is felt. 
 
 The precautions against infection to be adopted 
 by healthy persons (Sisters, nurses, etc.) in charge of 
 the sick will be apparent from all that has been said. 
 Plenty of fresh air and outdoor exercise should inter- 
 vene between the periods of nursing. Ample sleep is 
 required. Delay in the sick-room should be as brief 
 as possible, and there should be an adjoining room, 
 well ventilated and with open windows, for the use of 
 the attendants. The linen, and especially the hand- 
 kerchiefs of the sick, should be placed after use in a 
 five-per-cent. solution of carbolic acid, and afterwards 
 washed separately from other soiled clothes. The 
 floors of the sick-room should be often wiped with 
 moist corrosive sublimate wool; the furniture and 
 cushions should be taken out of doors once a week 
 and be beaten and brushed; and the doors, walls, and 
 carpets should be rubbed with bread. The dishes 
 and vessels used by the patient in eating or drinking 
 should also be kept separate. These precautions will 
 enable nurses and relatives in attendance on tubercu- 
 lous patients to avoid personal risk of contagion with- 
 out in any way detracting from the carefulness of their 
 attendance. The chief thing is to have regular and 
 
- 85 - 
 
 sufficient fresh air and active outdoor exercise. Pa- 
 tients are selfish and apt to resent the absence of the 
 attendant, so that the physician may have to exercise 
 his authority in the matter. The maintenance of the 
 nurse's health and ability to work is for the ultimate 
 advantage of the patient. The doctor should deter- 
 mine how many hours each day the wife or daughter 
 of the patient should take air, for they will usually be 
 averse to do of their own accord anything that might 
 savor of neglect or indifference. It is his duty to 
 think not only of the patient but also of the attend- 
 ants whose unceasing work often injures themselves 
 without being of any real benefit to the patient. In- 
 deed, the care for the healthy should often take 
 precedence of that for the sick. 
 
 Over the male and female religious orders who 
 take care of the sick, and their work, we, as doctors, un- 
 fortunately have no influence. They are entirely regu- 
 lated by the rules of the order and the commands of the 
 superior, and they are often worked beyond their 
 strength by the demands made on them by suffering 
 humanity. Many a blooming life would be preserved, 
 many an individual maintained in health and well-doing, 
 and certainly sickness and death would be diminished 
 by one half, if medical warnings were heeded and if 
 considerations of health were more regarded than the 
 rules of the order. Hundreds of these admirable and 
 devoted beings perish every year, without benefit to 
 humanity, crushed under the wheels of an inflexi- 
 
— 86 — 
 
 ble machinery. Say that the supply of nurses is not 
 adequate to the constantly increasing demands and 
 that this leads to overwork. I reply that each indi- 
 vidual's capacity for work has its limits, and that these 
 limits are usually exceeded by the superior from the 
 worthy motive of extending to as many suffering peo- 
 ple as possible the benefits of a well regulated system 
 of nursing. The remedy should be placed entirely in 
 the hands of the physician. It consists in care for 
 the maintenance of health in the nurses, and that will 
 result in the greater benefit of the patients. No one 
 will consider that the merit of those noble men and 
 women who voluntarily resign the pleasures of earth 
 to devote themselves to their suffering fellow-beings is 
 in the least diminished by attention to their own 
 health and strength. On the contrary, every intel- 
 ligent man will praise a religious order which seeks 
 and obeys competent advice for the maintenance of 
 the health of its members and so preserves their lives 
 and usefulness. 
 
 I now proceed to some other points of prophy- 
 laxis, which I judge especially important for the pro- 
 tection of persons who are disposed or at least exposed 
 to tuberculosis. I have already said that the chief 
 thing necessary is an abundant inspiration (deepened 
 by outdoor muscular action) of an atmosphere as free 
 as possible from dust and bacilli. This is best attained 
 by a sojourn in the mountains and by mountain-climb- 
 ing, or on the ocean or sea coast with rowing and 
 
— 87 — 
 
 Other exercises. Few persons, however, can afford 
 such changes of locahty which may need to be pro 
 longed for months, or perhaps even for years. An 
 excellent substitute for persons who can afford it is a 
 visit to the country, more or less distant from the 
 great cities, where there will be opportunity for young 
 men to hunt, row, ride bicycles, and practice athletic 
 exercises, and for young women to indulge in gym- 
 nastics, ball, nine-pins, and running games. Every 
 minute of favorable weather should be passed out of 
 doors. 
 
 What are called Vacation Colonies have been estab- 
 lished by humane societies and individuals so that 
 poor children, especially such as are scrofulous or 
 anaemic, or have an inherited tendency to disease, 
 may enjoy the psychic and hygienic benefits of a 
 country sojourn. These institutions are eminently 
 practical and deserve to be introduced as widely as 
 possible. The influence of such a visit on the health 
 of weak children growing up in poverty, in narrow 
 damp houses and with scant food, is most excellent, 
 and many a sinking constitution is strengthened and 
 directed into normal paths. Physicians should strive 
 in their respective circles of practice to interest as 
 many as possible in such noble works of humanity. 
 Children's Homes or Asylums erected on the sea-side 
 attain the same end and are of utmost benefit for 
 scrofulous and weakly constitutions. But they can 
 only benefit a limited number of individuals, while the 
 
Vacation Colonies can reach a far greater number. 
 Every city and town could organize them, and in 
 course of time we might expect that hundreds of 
 thousands of poor little ones would every year enjoy 
 their benefits. 
 
 For grown up youth whose station of life is estab- 
 lished, such as clerks, mechanics and employes gen- 
 erally, it is of course more difficult to supply the indis- 
 pensable fresh air and outdoor exercise, because 
 almost all their time is claimed by their work. Such 
 young people ought to join athletic societies, bicycle 
 clubs, etc., which will furnish both fresh air and ex- 
 ercise, and drill and strengthen the entire respiratory 
 system. That is, at any rate, incomparably better than 
 to seek the bar-room at the close of work and to spend 
 hours in a hot and smoky atmosphere. The sputa of 
 bar-room loungers (which Panizza and I examined 
 largely) showed by the abundance of cells, coal par- 
 ticles and myelin that the respiratory organs are sub- 
 jected in such places to a continuous even if slight 
 irritation. Such a condition, joined to incomplete ex- 
 pansion of the lungs, favors the disposition to take up 
 bacilli. On the contrary, gymnastic exercises (even 
 in doors, provided the dust is kept down with tan- 
 bark) are a great benefit not only for the lungs and 
 muscles of respiration but for all the functions of the 
 body. 
 
 I cannot conclude this chapter on prophylaxis 
 without referring to hydrotherapy which occupies a 
 
very important position both for the prevention and 
 for the cure of tuberculosis. Winternitz, to whom 
 principally we owe scientific hydrotherapy, has pub- 
 lished his experience relating to its use in this disease 
 in a brief essay entitled " Studies of the Pathology 
 and Hydrotherapy of Pulmonary Phthisis," which I 
 strongly recommend to the reader's special study. 
 My experience of the " hardening " method where 
 there is an hereditary or acquired disposition agrees 
 fully with his. Water at a suitable temperature is the 
 best, simplest, most general, and most available agent 
 for strengthening and " hardening " a weak body or 
 one disposed to catarrhs and colds. Even a simple 
 rubbing down of the entire body with a large moist 
 cloth after getting up in the morning accustoms the 
 skin to sudden cooling off. At first the cloth should 
 be wrung out of lukewarm water and later on cold 
 water may be used. The practice drills the vaso- 
 motor nerves of the peripheral arteries to prompt re- 
 action. It acts centripetally as a thermic irritant to 
 the central nervous system, stimulating and refresh- 
 ing it, and indirectly on the innervation and function 
 of the respiratory, circulatory and digestive systems. 
 At first, water of about 24° R. (86° F.), is to be used, 
 and the cloth should be well wrung out. On each 
 succeeding morning the temperature of the water may 
 be reduced ^° R. (i^° F.). Winternitz does not con- 
 cede that a milder effect is produced by the use of 
 lukewarm water than by cold water. But in this 
 
— 90 — 
 
 point my experience differs from his, possibly because 
 his was derived from his water-cure establishment 
 whilst mine is drawn chiefly from private practice. It 
 is not at all a matter of indifference, I can say posi- 
 tively, whether one order a sensitive body rubbed 
 with cloths wrung out of water at 12° R. (59° F.) 
 or 24° R. (86° F.) temperature. Nervous and weak 
 persons shrink from the cold applications and more 
 readily submit to the warmer ones. It is very import- 
 ant that the friction should be brief, only a minute 
 long, and that the cloth should be well wrung out 
 (not "wringing wet" as in sponging or splashing). 
 The aim is to produce a thermic and mechanical 
 irritation of the superficial nerves and vessels, 
 not to deprive the body of any considerable heat. 
 This latter effect would be produced if the cloths 
 were wet with cold water. To attain the desired 
 end, very low temperatures are not needed and it is 
 seldom necessary to go below 15° R. (66° F.). 
 
 In weak constitutions where appetite and assimi- 
 lation are poor, I order from one-half to one pound of 
 cohimon salt and one-quarter liter (about 8 fl § ) of 
 caustic potash to be added to the water after the third 
 week, so as to make an artificial salt bath.* This 
 produces a more lively and lasting irritation of the 
 
 *The German word is Soole. It means a saturated solu- 
 tion of salt, either from natural salt wells or made artificially. 
 — Tr. 
 
— 91 — 
 
 nerves, and, like mineral baths, improves the assimila- 
 tion and nutrition. Such friction baths can be used 
 in private practice everywhere and amongst the poor- 
 est people. They entail no expense and conflict with 
 no duties, because they are taken immediately after 
 arising, and the patient at once dresses and can go about 
 his work. Unless the patient is very weak, I do not 
 permit him to return to bed after the rubbing. It 
 would be much better if he would at once take some 
 outdoor exercise if the weather permit, and return 
 after an hour to his breakfast. Very delicate persons, 
 especially women, may be allov/ed a cup of warm tea 
 or coffee before the friction bath, but all others should 
 be fasting. 
 
 Patients who have no one to assist them with the 
 rubbing may improve matters by using a large towel, 
 or they may substitute a douche bath for the friction 
 bath. This rain or douche bath is not so effective, 
 because its stimulation is not so intense nor does it 
 reach the entire surface. However, it is still an ex- 
 cellent method of hardening and invigorating the 
 body. 
 
 Local frictions with cogniac in which salt has 
 been dissolved are practiced in some sanitariums for 
 chest diseases, but I do not attribute any particular 
 effect to them. They miss the essential thing, that is, 
 the sort of shock which is produced by wrapping the 
 body in a wet cloth or sheet, and which innures the 
 surface to sudden cold or dampness, produces prompt 
 
— 92 — 
 
 action of the superficial vessels, and hardens the sen- 
 sitive nerves of the skin. 
 
 Should a more thorough treatment be desirable, 
 the patient may be sent to a water-cure establishment. 
 This is necessary, however, only in persons who are 
 deficient in will power. Most persons have firmness 
 enough to persevere for months and years in such 
 friction baths in their homes and with the help of their 
 relatives or servants. This simple procedure, which 
 may be varied in various ways, is one of the best with- 
 in reach of the physician. It overcomes sensitiveness 
 to changes of temperature, wind and dampness, and 
 renders excessive clothing unnecessary. It overcomes 
 constant slight perspiration, eternal nasal and bron- 
 chial catarrhs, rheumatic disposition, etc., and gives to 
 the body a freshness and elasticity which can be pro- 
 cured in like degree only by mineral and sea baths. 
 Its great advantage in being used at home, without 
 expense and for months and years if needed, recom- 
 mends it especially for people of moderate means. 
 
 The natural mineral and sea baths are, for those 
 who can afford to go to them, an excellent agent for 
 invigorating and strengthening the constitution and 
 especially the sensitive respiratory surfaces. Their 
 effect is due to various causes. In the sea baths, we 
 have the chemical and thermic influences of the cold 
 salt water, the mechanical irritation of the waves,, the 
 rapid movement of the air which is both free from 
 dust and bacilli and rich in water and salt, and the 
 
— 93 — 
 outdoor life. All these agencies affect the nervous 
 system and through it all the organic functions, stimu- 
 lating and invigorating all, and especially the appetite, 
 assimilation and respiration. The lungs are impelled 
 to deep inspiration, and their epithelial cells are 
 strengthened by the quick motion and other favorable 
 conditions of the air. The influence of mineral baths 
 is analogous, especially those situated in moun- 
 tain districts and, like Reichenhall and Kreuth,* 
 rich in special curative agencies. In addition to 
 the direct effects of such baths, the constant climbing 
 of the hills in the pure air improves and deepens 
 respiration. Systematic exercise in mountain climbing 
 is one of the most beneficial practices for various 
 chronic lung troubles, and its results are more effec- 
 tive and permanent the higher the level at which the 
 patiept resides, the purer and thinner the air, the 
 lighter the atmospheric pressure and the less there is 
 of rain, wind or fog. 
 
 * Reichenhall and Kreuth are Bavarian Alpine resorts. 
 The former has salt baths, "pine needle" baths, and an 
 establishment for the whey treatment; the latter has sulphur 
 baths. — Tr. 
 
CHAPTER II. 
 
 DIRECT TREATMENT— HYGIENIC- CLIMATIC- 
 DIETETIC— MEDICINAL. 
 
 All the important curative agencies mentioned in 
 the preceding chapter are valuable not only for deal- 
 ing with an inherited or acquired disposition to tuber- 
 culosis or scrofulosis, but also for the treatment of 
 phthisis after it has become manifest and is proven by 
 the presence of tubercle bacilli in the sputum. It is 
 hardly necessary to repeat that the bacillus and its 
 products and effects in the lungs must always occupy 
 the foremost place in our studies. After it has once 
 gained admission into the organism, the aim of all our 
 treatment must be to combat and destroy it. Unfor- 
 tunately there seems at present no prospect of accom- 
 plishing that aim in a visible time. Fraentzel, dne of 
 the most deserving and indefatigable investigators in 
 this department of medicine, candidly admits that the 
 result of all the experiments thus far made at the bed- 
 side and in the bacteriological laboratories is to show 
 our inability to destroy bacilli or cocci domiciled in 
 the pulmonary tissues by medicines whether admin- 
 istered in gaseous form or by atomization. 
 
 The best remedies, the remedies which medical 
 experience shows to have produced the best results in 
 the beginning of pulmonary tuberculosis, are still the 
 physical ones — air, climate, exercise and water. Diet 
 occupies only a secondary place. 
 
— 95 — 
 
 Considering the importance of a definite and per- 
 severing treatment, all thought and effort should be 
 directed to the selection of a proper course in the be- 
 ginning of the disease, when hope of cure is still justi- 
 fiable. Hereditary disposition, physical constitution 
 of the patient and his entire family, age, sex, tempera- 
 ment, mental endowments and condition, tractable- 
 ness and firmness, social rank and employment, 
 financial circumstances — all these factors vary in dif- 
 ferent cases, and all affect the selection. But mani- 
 fold as may be the differences in individual cases, the 
 curative agencies already mentioned are of funda- 
 mental importance for all and should never be 
 omitted. 
 
 The fresh air treatment occupies the first place. 
 To a certain extent, it can be employed in all condi- 
 tions of life, though of course modified according to 
 circumstances, and consequently more or less limited 
 in its effects. The simplest way is to keep a window 
 open day and night, or to remain constantly out of 
 doors, sitting or lying as preferred, and protected in 
 bad weather by some simple shelter. In addition to 
 this, the patient should practice deep inspiration, which 
 may be done by climbing any hill or mountain near 
 his house, or by regular gymnastic exercises, such as 
 the use of bars, swinging ropes, etc. It is true that 
 pulmonary hemorrhage may occur in such exercises, 
 but I can scarcely believe that it is more frequent in 
 consequence of a stronger expansion of the lungs than 
 
- 96 - 
 
 otherwise. Mountain health resorts, which are acces- 
 sible to persons of means, are also a form of the fresh 
 air treatment. Such resorts for persons with pulmon- 
 ary troubles are numerous and excellent. They are 
 found in all high-lying districts from the Lower Alps 
 to the elevated vallies of the Grissons, and all produce 
 good results. Their success seems to depend not so 
 much, if at all, on elevation of site as on the purity of 
 air and the exercise of the lungs. 
 
 When I designate deep inspiration of pure moun- 
 tain or sea air, accompanied by vigorous action of the 
 respiratory and other muscles as the most essential 
 part of treatment, I mean that bacilli and cocci do not 
 thrive well in a constant current of pure air through- 
 out the lungs, and that further settlements of them 
 are' prevented by the energetic action of the lungs and 
 by the renewal of the air. High temperature and 
 stationary condition of the air favor the bacilli, and 
 hence good ventilation and low temperature must be 
 beneficial to the patient. I will not decide whether 
 other causes may not also contribute to the effect, as 
 for example the improvement in the pulmonary circu- 
 lation produced by the deep inspiration, and the freer 
 expectoration of infectious matter resulting from the 
 increased action of the lungs. Hence warm climates 
 are, in my opinion, less beneficial than cool ones, pro- 
 vided, however, that other atmospheric conditions,, 
 such as stillness of the wind, sunshine, etc., are favor- 
 able, and that the patient can be constantly in the open 
 
— 97 — 
 air. This opinion is confirmed by the excellent re- 
 sults obtained at Gorbersdorf, Davos* and the elevated 
 vallies of the Grissons, the Andes and the Cordilleras, 
 where the patients can be much out of doors even in 
 the winter. It is further confirmed by the immediate 
 and rapid benefits derived from polar journeys and by 
 the fact that tuberculosis is scarcely to be found 
 among the peoples of Iceland, the Hebrides, the 
 Faroe islands, the Shetland islands, and the northern 
 districts of Norway. 
 
 The question as to the respective merits of public 
 spas and private sanitariums is one of methods, not of 
 principles. It is certain that the strict discipline of a 
 sanitarium has the advantage of avoiding many dangers 
 (such as pleasure parties, colds, indigestion, etc.), to 
 which the guest at a watering place is exposed through 
 ignorance, thoughtlessness or lack of self-control. 
 There is besides a better guarantee for regularity of 
 exercise and better precautions against taking cold. 
 On the other hand, sensitive people find something 
 abhorrent about sanitariums and feel much better in 
 public watering places. If patients will patiently and 
 
 * Gorbersdorf . is situated in Prussian Silesia, 1,840 feet 
 above the sea. Dr. Hermann Brehmer (who is still living) 
 established there a celebrated sanitarium for , consumptives. 
 It was the first erected at an elevation exempt from bacilli. 
 Davos is in the canton of the Grissons in Switzerland, 5,940 
 feet above the sea. It is a favorite summer and winter resort 
 for persons with pulmonary and nervous trouble. — Tr. 
 
perseveringly follow the directions of their physician, 
 they will obtain satisfactory results in the latter resorts. 
 Of this I have had plenty of evidence among my pa- 
 tients at Reichenhall, Meran,* and other mountain 
 resorts. 
 
 In the selection of a health resort, some authors 
 attach great importance to the moisture of the* atmos- 
 phere. But as far as actual experience goes, we 
 must say that a dry climate with little rain and fog is 
 generally more suitable for tuberculous persons than a 
 moist one. As regards winds, provided the purity of 
 the air is the same, the still atmosphere of high-lying, 
 sunlit vallies is to be preferred, because there is far less 
 danger of taking cold when out of doors or climbing 
 the hillsides. The condition of the atmosphere as re- 
 gards its supply of ozone, or its poverty in oxygen or 
 (as in the upper Alps) its slight pressure, does not 
 affect the therapeutic value of health resorts. The 
 celebrated pine woods of many places, as for example 
 in the Black Forest, to the aromatic exhalations of 
 which a sterilizing influence on the diseased lung sur- 
 faces is ascribed, possess also the inestimable advant- 
 age of a dry, warm and wind protected situation, ex- 
 cellent for the prolonged enjoyment of the open air. 
 
 *Meran is a winter resort situated in Southern Tyrol, 
 about HOC feet high. Fully 10,000 visitors go there each 
 season (from September to June). The grape, whey and milk 
 treatment are practiced and there are also pneumatic chambers. 
 — Tr. 
 
— 99 — 
 
 It is impossible to give in this short treatise all 
 the details of climatic treatment. It would be well if 
 physicians could personally visit and investigate the 
 most important watering places and climatic resorts. 
 
 Finally, I take up that part of the treatment 
 which enters the daily practice of the physician and 
 which is consequently of great importance, no less to 
 him than to his patient. It includes dietetics and the 
 treatment of the fever which accompanies tuberculosis 
 of the lungs. The treatment of other disturbances 
 and complications is reserved for the third and last 
 chapter. 
 
 The diet of tuberculous patients should be regu- 
 lated according to the stage of the disease, the rapid- 
 ity of its course, and the condition of the constitution. 
 In the initial stage, when nutrition is as yet not essen- 
 tially impaired, but the excitability of the heart and 
 the tendency to congestions are considerable, it is ad- 
 visable to decrease the albuminoids and to correspond- 
 ingly increase the carbohydrates and fats. Vegetable 
 diet has a slightly laxative effect and is beneficial in 
 proportion to its amount of vegetable acid alkalies, as 
 in fresh vegetables, fruits, etc. For this reason the 
 grape cure and the whey cure conjoined with moun- 
 tain air are excellent in the first stage. Raw and 
 cooked fruits, cider and the like are also appropriate. 
 Stimulating foods and drinks like tea, coffee and al- 
 cohol (which should be allowed only moderately and 
 in the form of beer) are unsuitable on account of the 
 
excessive irritability of the heart. The koumiss and 
 kephir* treatment are good in the first stage if the 
 patient can visit the steppe of Samara, or, at least, 
 stay out of doors entirely. Cod-liver oil is also useful 
 if the patient has good digestion. 
 
 In the later stages, when the constitution is 
 undermined by the fever and the appetite has failed, 
 it is difficult to adequately nourish the patient on ac- 
 count of the anorexia. If the fever is continuous, it 
 must be met as will be hereafter explained. If it is 
 slight and confined to certain hours, nutriment should 
 be given as far as possible when it is not present, 
 even though the patient should have to force himself 
 to eat. I am sure that want of appetite and dyspepsia 
 do not always depend on the fever, but that, like the 
 night sweats, they may be purely a nervous disturb- 
 ance and consequently accessible to direct treatment. 
 Too much reliance should not be placed on medicines, 
 though the simple and aromatic bitters with or with- 
 out iron are often helpful. We should rather lay 
 
 * Kephir, or kefir, is a liquor made from the milk of a 
 cow or mare by the addition of a special ferment. The fer- 
 ment is contained in the grains of a plant which grows in the 
 Caucasus. There are three grades of kefir, according to the 
 time, one two or three days, taken in its preparation. The 
 first or young kefir is used in pulmonary troubles. It has a 
 laxative effect. The third or strong has a constipating effect 
 and is used in abdominal disorders. In the beginning two or 
 three glasses are to be taken daily and gradually increased to 
 six or seven. — Tr. 
 
stress on fresh air, especially mountain air, outdoor 
 exercise, entire freedom from business cares, and a 
 good, plentiful and varied diet. In choosing a health 
 resort for consumptives, the kitchen is not the least 
 important thing to be considered, for, even with 
 slight appetite, better nutrition will be secured by 
 abundance and variety of well-prepared food than by 
 a scanty, monotonous and plain bill of fare. 
 
 Instead of relying upon the allurement of a well 
 laden table, Debove has, in cases of anorexia, resorted 
 to compulsory over-feeding either by the use of an oeso- 
 phageal tube or by overcoming the patient's resist- 
 ance. Our own experiments have shown that this 
 plan of " sur-alimentation " produces brilliant but only 
 temporary results in many cases. After several weeks, 
 the excessive quantity of food, out of proportion to 
 the gastric and intestinal juices, creates disturbances 
 of digestion, flatulence, nausea, diarrhoea, etc. The 
 treatment must be discontinued, and in many people 
 its resumption at once brings on a recurrence of the 
 disturbances especially where the assimilation is bad 
 and the muscular action is insufficient. 
 
 The fattening treatment of Weir Mitchell is more 
 sensible and more permanent in its results. The 
 nutriment is, indeed, supplied during complete rest of 
 the body, but assimilation is aided by judicious mas- 
 sage in lieu of voluntary muscular action. This passive 
 condition produces in many cases a good effect upon 
 the general economy, and not onJy results in an in- 
 
crease of fat but also tones up in a surprising manner 
 the general nervous and muscular system. I would 
 recommend this treatment in cases of beginning or 
 even advanced tuberculosis where there is little or no 
 fever and where the constitution and appetite do not 
 improve on account of the excessive nervous irrita- 
 bility. Such neurasthenic patients, especially of the 
 gentle sex, often improve wonderfully under the en- 
 forced rest in spite of their tuberculosis. 
 
 As to drinks, alcohol has more and more during 
 the last ten years acquired and deserved a prominent 
 place in the treatment of tuberculosis. I do not re- 
 commend strong alcoholic drinks like wine and 
 cogniac in the early stages of the disease, and in ex- 
 citable constitutions, irritable heart, tendency to 
 hemoptysis, etc. In such cases I allow only light beer 
 in moderation and cider, or else I exclude all alcohol 
 and permit only milk. The milk diet often produces 
 excellent results when the stomach is good, but daily 
 investigation must be made to forestall any gastric 
 disturbance. In the later stages of the disease, 
 alcohol is invaluable. It is used in almost all sani- 
 tariums and health resorts and in relatively large 
 quantities, one to one and a half liters (about three 
 pints) of wine and fifty to sixty grams (about two 
 fiuidounccs) of cogniac each day. It invigorates the 
 nervous system, gives a pleasant feeling of warmth 
 and strength which is of value in the open air treat- 
 ment especially during cool weather, increases energy 
 
— I03 — 
 
 and endurance in exercising, produces quieter sleep 
 and diminishes the night sweats. It produces these 
 effects in various ways. It seems to me to act rather 
 by stimulating the central nervous system and conse- 
 quently the separate functions than by its inhibitory 
 influence on assimilation (its " labor-saving effect ") or 
 by its action on the heart. That is shown by its effect 
 on the psychical and intellectual functions and by the 
 diminution of night sweats which are due to weakness 
 of the nerve center of the sweat glands. 
 
 The quality of wine may be regulated by the pa- 
 tient's taste, but the fiery red wines, the Valletelino, 
 Burgundian and red Hungarian wines suit better than 
 light white wines. The kind and quantity of alcohol 
 must be determined according to the individual case. 
 Where the intestinal tract is very sensitive and there 
 is a tendency to diarrhoea, with or without the presence 
 of intestinal tuberculosis, an excellent evening drink is 
 mulled wine, that is, red wine boiled with some cinna- 
 mon, sugar and cloves. The high temperature of the 
 wine and the aromatic additions to it produce a very 
 pleasant and anti-diarrhoeic effeet on the intestinal 
 mucous membrane. The excellent "berry wine" 
 (Beerenwein) or " forest wine " (Waldwein) from the 
 factory of Fromm & Co., of Frankfort, is well adapted 
 for making mulled wine, as its tannin is least brought 
 out in that form. The " berry wine " is also highly 
 recommended when slightly warmed, but not boiled. 
 Delicate patients should not drink cold wines, and in 
 
— I04 — 
 
 fact red wines do not taste well when cold. Cogniac 
 should be given (one or two tablespoonfuls) chiefly 
 in the evening and in the form of cold or hot 
 grog. Many patients have an idiosyncrasy in regard 
 to it and cannot drink it. It gives them palpitation 
 of the heart or causes sleeplessness, etc. In such 
 cases, arrac, rum, brandy or whiskey should be tried, or 
 wine alone be used. 
 
 The fever, which unfortunately too often presents 
 a most difficult problem, will be met in the beginning 
 of the disease and in slight cases of relapse by the 
 open air treatment and the dietetic regulations. Phy- 
 sicians at health resorts have frequent opportunity to 
 witness the satisfactory antipyretic effects of the air 
 treatment. Patients who at home kept their rooms 
 for weeks at a time on account of the fever are soon 
 freed from it at Reichenhall, Bozen,* Meran or San 
 Remo. They quickly recover from its effect and not 
 seldom escape it through an entire winter. Unfortun- 
 ately this simple and pleasant therapy is not always 
 sufficient, at least not in advanced cases. Then alco- 
 hol, which possesses a certain degree of antipyretic 
 power, must be used. The antipyretics also (say what 
 one will against them) are indispensable. The best of 
 these are atitipyruie and aritifebi-ine. Though they 
 may help but little in progressive cases with high 
 
 *Bozen is a town in Tyrol, noted as a winter resort. San 
 Remo (made famous by the sickness of the ill-fated and noble 
 Emperor Frederick) is situated on the Riviera of Genoa. — Tr. 
 
— I05 — 
 
 fever, they are nevertheless indispensable on account 
 of the sense of well-being which they produce. In 
 moderate fever, they are often very satisfactory especi- 
 ally when long used, because patients are enabled to 
 go out more into the open air, and the appetite and sleep 
 improve. During the past few years I have preferred 
 antifebrine. I give it in capsules, three or four times 
 in the twenty-four hours in doses of 0.3 grams (4.6 
 grs.). When the fever occurs at a definite time, de- 
 noted by chill or shivering, we may attempt to abort 
 it by giving at one dose 0.6 gram (9.2 grs.) two or 
 three hours earlier and following that during the after- 
 noon or night by two doses of 0.3 gram. Some sherry 
 or marsala is recommended to be taken after the drug. 
 
 In many cases, it is best to check further develop- 
 ment of the fever by treating the slight relapses as is 
 done in intermittent cases. For this purpose the 
 patient should carefully take his temperature regularly 
 three or four times a day, and his weight should be 
 ascertained every two or three days. In that way he 
 will be able bo correctly distinguish the fever attacks 
 from simple discomforts and dyspeptic disturbances, 
 and so use the antifebrine at the right time. In some 
 the fever disappears only with a change of locality. 
 Lukewarm or warm baths gradually cooled, with 
 or without the addition of salt, and matutinal frictions 
 with saline waters are also beneficial. 
 
 Creasote, first warmly advocated by Bouchard in 
 1877, and after him used with success by Reuss, Som- 
 
— io6 — 
 
 merbrodt and Fraentzel, may be tried, especially in 
 fresh cases with little or no fever. It is said to de- 
 crease cough, mucous secretion and fever, to increase 
 appetite and weight, and to dissipate the phenomena 
 of consolidation. Although many cases do not im- 
 prove and many patients cannot endure the drug, still, 
 according to those authors, the greater number are so 
 much benefitted that a long-continued trial (from 
 three months to a year) ought to be made in suitable 
 cases and especially in persons whose employment or 
 poverty will not permit recourse to the systematic 
 open air treatment. On account of its disagreeable 
 taste, the drug should be given in capsules, each con- 
 taining (according to Sommerbrodt's prescription) 
 0.05 gram. (.75 gr.) creasote and 0.2 (3 grs.) tolu bal- 
 sam. One or two capsules should be taken after each 
 principal meal with a tablespoonful of water. After 
 two months, it should be discontinued for a month. 
 The entire course should last a year or longer. Bou- 
 chard's original prescription, adopted by Fraentzel, 
 was: 
 
 5 Creasote, 13.5 ( 3 iijss). 
 
 Sherry wine, ^ litre (fl | xxv). 
 
 Rectified spirits, 200.0 ( % vij). 
 
 Tincture of gentian, 30.0 (§j). 
 M. Sig. — A tablespoonlul to be taken in a glass of water 
 two or three times a day. 
 
 Menthol has lately been recommended by A. and 
 S. Rosenberg as an anti-parasitic remedy. It may be 
 
— loy — 
 
 taken internally six times a day in doses of one to 
 one and a half grams (15.4 to 23 grs.) or by inhalation 
 with Schreiber's apparatus, using fifteen or twenty 
 drops of a twenty-per-cent. oily solution several times 
 a day. Confirmation of its good results is still lack- 
 ing. 
 
 Other antiseptic drugs have been tried in the 
 form of gaseous or atomized inhalation, without, how- 
 ever, having produced any great results. Such are 
 pine and beech tars, oil of mountain pine,* turpentine, 
 oil of eucalyptus, etc. Though a directly curative 
 effect has not been established for these inhalations, 
 they are to be recommended for impregnating the at- 
 mosphere of the patient's room, especially of his sleep- 
 ing room. They certainly have a real, though slight, 
 antiseptic effect, and they reach the diseased parts of 
 the lungs which harbor the bacilli and are exposed to 
 the inroads of secondary colonies of cocci. 
 
 Arsenic is another drug recommended for tuber- 
 culosis. It was long used in France, England and 
 Russia, and has lately been recommended on theoreti- 
 cal grounds by Dr. Hans Buchner. In practice, how- 
 ever, its claims are not confirmed, at least not as a 
 specific. As a tonic for the nervous system, it seems 
 
 * Oleum pini pumilionis, Hancke, also called ol, tem- 
 p'inum, or krummholzcel. It is distilled from the young 
 branches of the mugho or mountain pine, from which "Hun- 
 garian balsam " is obtained. A refined form of it has been 
 lately introduced, called pumiline. — Tr. 
 
— io8 — 
 
 to hare produced good results in many cases of torpid 
 phthisis. I have no personal experience as to the 
 results of carbonic acid inhalations or of Bergeon's 
 gas enemata (prepared from carbon dioxide and hydro- 
 gen sulphide). I fancy that both methods, like so 
 many other remedies for consumption, will be soon 
 forgotten. 
 
CHAPTER III. 
 
 SECONDARY TUBERCULOSIS-COMPLICATIONS 
 —LARYNX— INTESTINES— ANAL FISTUL/E. 
 
 For the treatment of secondary tuberculosis and 
 some complications which occur, I shall limit myself 
 to what I have tested in my private practice, used in 
 my clinics and recommended in my consultation prac- 
 tice. 
 
 Pubnonary hefnorrhage is to be treated by laying 
 from above downwards two ice bags on the anterior 
 chest wall, including the apices, and by subcutaneous 
 injection of a solution of sclerotic acid* (i.o gram to 
 5.0 of distilled water, 15.4 grs. to 75 Tl]j), using a 
 syringeful every hour. The place of the injection 
 should be vigorously kneaded on account of the pain, 
 or morphine may be injected. The solution of sclerotic 
 acid is much better for subcutaneous injections than 
 the solution of extract of ergot, which is more painful 
 and may cause abscesses. I use the ergot for simul- 
 taneous internal use, and continue it beyond the dura- 
 tion of the hemorrhage in order to prevent relapses 
 and to quiet the anxious spirits of the patient. For 
 inhalations, liquor ferri sesquichlorati of the strength 
 of 2.0 to 200. (Ti]j 32 to 3 vi-vii) is used. It is not 
 
 * Sclerotic or sclerotinic acid is one of the most active 
 constituents of ergot. It is a yellowish brown, tasteless, in- 
 odorous substance, with a slight acid reaction. — Tr. 
 
supposed that the nebulized liquid reaches the bleed- 
 ing spot in the pulmonary tissue and acts there as a 
 styptic, but I explain its excellent results by a reflex 
 contraction of the pulmonary vessels being caused by 
 its marked astringent action on the mucous membrane 
 of the upper air passages. Hence I only allow brief 
 inhalations (one or two minutes), but repeated fre- 
 quently, say every half hour. Morphine, either sub- 
 cutaneously or internally, is strongly recommended 
 to check the tendency to cough. Every cough tem- 
 porarily alters the condition of the pulmonary circula- 
 tion, and the patient dreads to cough lest it should 
 bring on another hemorrhage. Between whiles, I re- 
 quire the patient to take deep breaths, which help re- 
 markably to stop the bleeding. As soon as he has 
 overcome his dread of danger from this deep inspira- 
 tion, I instruct him to breathe strongly for a longer 
 time. It not seldom happens that this procedure 
 finally stops very obstinate and recurring hemorrhages. 
 Tuberculous ulcers of the larynx, pharynx^ and 
 tongue can rarely be cured. Chronic circumscribed 
 laryngeal ulcers are the most tractable. The exten- 
 sive ulcerations of the last stage make the prognosis 
 positively bad and require only a palliative treatment 
 with anaesthetics, especially cocaine and the bromide 
 salts. In chronic laryngeal ulcerations of the early 
 stage, I am opposed to strong remedies, especially to 
 caustics like lunar caustic. I recommend instead mild 
 antiseptics like boracic acid, potassium chlorate, crea- 
 sote, lactic acid, or menthol. 
 
In intestinal tuberculosis, the fight against the diar- 
 rhoea must be incessant. It and the accompanying 
 discomfort in the abdomen are best controlled by 
 opium; but for prolonged use the astringents, as tan- 
 nic acid, nitrate of silver, and especially the milder 
 astringents, Colombo, rhatany and kino, or the anti- 
 zymotics as naphthalin in keratin-coated pills * are 
 preferable. Besides, warm spiced wines, especially 
 mulled wine and the " berry-wine " described above, 
 also rye flour soup [roggenmehl suppe) and oatmeal 
 with dry or moist warm applications to the abdomen 
 are recommended. 
 
 A very painful complication for the poor patient 
 is the fatal periproctitis with formation of complete or 
 incomplete anal fistula;. There can be no question 
 but that the inflammation of the peri-rectal connective 
 tissue is due to the tuberculosis, especially to intestinal 
 tuberculosis, for Schuchardt and Krause have found 
 tubercle bacilli in the granulations of the fistula, and, 
 even where bacilli were not found, the infectiousness 
 of the granulation tissue was proved by successful in- 
 oculation m the anterior chamber of a rabbit's eye. 
 On account of the rarity of tuberculous ulcers of the 
 rectal mucous membrane, we must suppose that the 
 
 * Keratinirten Plllen. The word refers to a special coat- 
 ing prepared from horn {Kspai). It is not soluble in the acid 
 juice of the stomach, and consequently enables the antiseptic 
 to produce the desired effect in the intestines, in the alkaline 
 juice of which it is soluble. — Tr. 
 
112 
 
 periproctal connective tissues become infected from 
 faeces containing bacilli through some small erosion or 
 tear caused by long retention of the excrement. It is 
 not possible at present to show that the periproctal 
 bacillary process develops by way of the circulation, 
 independently of changes in the rectal mucous mem- 
 brane and analogous to the formation of fistulous 
 ulcers in the scrofulous. It is much easier to suppose 
 an infection direct from the contents of the rectal 
 cavity — a view which Schuchardt advocates in his 
 latest publications. 
 
 The success of the radical treatment of such 
 fistulse by incision, scraping or cautery is an additional 
 and encouraging evidence of the curability of local 
 tuberculosis. It condemns in a striking manner the 
 old teaching that they should be left alone, because 
 after the operation tuberculosis would at once develop 
 in other organs. Tuberculous rectal fistulae should be 
 operated on radically and as early as possible. Tuber- 
 culosis will ensue in other parts just as seldom as it 
 would after extirpation of tuberculous glands or after 
 the operation for a knee-joint fungus in the early- 
 stages. , I have had under observation for a long time 
 several cases of chronic tuberculosis in which fistulae 
 were operated on some years ago without causing any 
 development of the disease. 
 
 The treatment of pulmonary consumption covers- 
 a wide territory and I have been able to touch only 
 some of its points. I would also gladly have dealt 
 
— 113 — 
 
 with tuberculosis of the glands, serous membranes, 
 brain, kidneys, skin, bones and joints, but I must have 
 regard to the size of this book and will defer them to 
 another occasion. 
 
 9 KB 
 
APPENDIX. 
 
 A. TUBERCULOSIS IN AMERICAN PRISONS. 
 
 In reply to requests, sometimes twice or thrice 
 repeated, I received reports from the penitentiaries 
 named below. The figures bear out the author's 
 
 
 PENITENTIARIES. 
 
 („ou- 
 victs 
 Rec'd 
 
 Total 
 Annual 
 Popula- 
 tion. 
 
 Daily 
 Aver- 
 
 Total 
 No of 
 
 U'lnb 
 from 
 Phthi- 
 
 Per- 
 cent- 
 
 
 
 during 
 
 age. 
 
 D'ths 
 
 sis. 
 
 age. 
 
 
 
 Year. 
 
 
 
 
 
 
 
 California: 
 
 
 
 
 
 
 
 I 
 
 San Quentin(i888). 
 
 597 
 
 >8i7 
 
 
 32 
 
 15 
 
 46.8 
 
 2 
 
 Folsom (iS88). 
 Illinois: 
 
 166 
 
 771 
 
 539 
 
 7 
 
 4 
 
 57-1 
 
 3 
 
 Joliet (i88S>. 
 
 647 
 
 1946 
 
 1321 
 
 45 
 
 35 
 
 77-7 
 
 4 
 
 Chester (1S87). 
 
 373 
 
 1114 
 
 782 
 
 16 
 
 6 
 
 37-5 
 
 
 " (1888). 
 
 344 
 
 1091 
 
 763 
 
 15 
 
 4 
 
 26.6 
 
 
 Michigan: 
 
 
 
 
 
 
 
 5 
 
 Jackson (18S6). 
 Minnesota: 
 
 293 
 
 1030 
 
 774 
 
 4 
 
 2 
 
 50.0 
 
 6 
 
 Stillwater (1887). 
 
 208 
 
 59s 
 
 398 
 
 4 
 
 2 
 
 50.0 
 
 
 (1888). 
 
 214 
 
 626 
 
 426 
 
 4 
 
 I 
 
 25.0 
 
 
 Missouri: 
 
 
 
 
 
 
 
 7 
 
 Jefferson City (1887). 
 
 686 
 
 2321 
 
 
 20 
 
 5 
 
 25.0 
 
 
 " (1888). 
 
 786 
 
 2399 
 
 
 19 
 
 2 
 
 10 5 
 
 
 New York: 
 
 
 
 
 
 
 
 8 
 
 Sinff Sing (1887). 
 
 851 
 
 2383 
 
 iS°4 
 
 16 
 
 7 
 
 43-7 
 
 9 
 
 Auburn 
 
 416 
 
 1500 
 
 1146 
 
 32 
 
 17 
 
 531 
 
 lO 
 
 Clinton " 
 
 Pennsylvania: 
 
 374 
 
 913 
 
 61 2 
 
 6 
 
 4 
 
 66.6 
 
 II 
 
 Eastern (1887). 
 
 560 
 
 1 691 
 
 
 27 
 
 21 
 
 77-7 
 
 12 
 
 Allegheny (1887). 
 
 262 
 
 968 
 
 686 
 
 8 
 
 4 
 
 50.0 
 
 
 (1888), 
 
 266 
 
 963 
 
 664 
 
 4 
 
 2 
 
 50.0 
 
 
 Texas: 
 
 
 
 
 
 
 
 I.^ 
 
 Huntsville (i838). 
 
 
 
 
 28 
 
 9 
 
 32.1 
 
 startling statements. The percentage of deaths from 
 phthisis in Chicago during 1887 was 8.77 of the total 
 mortality. In many of the prisons it is from five to 
 ten times higher. Naturally the criminal classes are 
 more liable on account of their dissipated and vaga- 
 
— 115 — 
 bond lives to consumption and other diseases. But, 
 since tuberculosis is in all probability (nay, certainly) 
 contagious, regard for the welfare of society if not for 
 the health of the convicts should compel an earnest 
 effort to diminish or destroy the danger from such 
 prolific breeding places of the disease. 
 
 I. The physician at San Quentin says: "Whilst the 
 climate of Folsom is warm and dry and preeminently suited to 
 prolong the life of a consumptive, the moist climate of this 
 place militates against and causes death in a short time. An- 
 other thing is that the men who are sent here from the southern 
 country are mostly Mexicans and Indians and have the germs 
 of scrofula and consumption in their blood on coming, which 
 soon develops itself and through confinement they lose their 
 hold on life and soon die." Besides the 15 prisoners who 
 died of phthisis, 6 others died of scrofula. 
 
 2 One death at Folsom was from pneumonia, and there 
 remained in the hospital at the time of the report i patient with 
 phthisis. 
 
 3. In Joliet, there was i death by suicide and i from 
 pneumonia. Among 1460 cases treated in the hospital during 
 that year, 244 were for diseases of the respiratory system. 
 
 4. During 2 years, 9 cases of phthisis were treated in 
 the Chester hospital. In 1887, there was also i death from 
 acute tuberculosis, i by accident and i by suicide; in 18S8, 3 
 from pneumonitis, i from tuberculosis of mesenteric glands, 
 and I by suicide. These two cases of clear tuberculosis raise 
 the percentage to 43 7 and 33 3; but for the sake ot comparison 
 I have considered only "phthisis" or "consumption" in 
 the table. The physician says very properly, in reference to 
 "the marked prevalence of tubercular disease in its varied 
 forms," that "had the same people been left to the vices, 
 excesses and deprivations characteristic of their lives on the 
 
— ii6 — 
 
 outside of prison, there is no doubt that fully twice as many 
 would have died of this disease during the same period, as 
 did here. The record shows many of them to have been 
 men who had long been confined in prison; others were in an 
 advanced stage of the disease when admitted and consequently 
 could not have lived long, in or out of prison." 
 
 5. Of the prisoners received during the year at Jack- 
 son 276 were in good and 17 in poor health; 43 had lost one 
 or other parent by consumption; i death was due to stabbing. 
 The 2 who died of phthisis had been respectively 6 months 
 and 25 years in prison. 
 
 6. Among the deaths at Stillwater in 1888, i was due 
 to accident, i to suicide, and i to scrofula. All the pa- 
 tients who died from disease were diseased when they entered 
 the penitentiary. The physician says: " It may appear 
 strange that we have so heavy a percentage of deaths from 
 consumption, but to successfully treat consumption or those 
 predisposed to the disease requires surroundings that are not 
 to be found in an institution of this kind." 
 
 7. The physician of the Jefferson City penitentiary re- 
 ports that in 1887, he treated 21 cases of phthisis and 2 of in- 
 testinal tuberculosis, and in 1888 i of acute phthisis and 11 of 
 phthisis pulmonalis. Among the deaths in 1887 was i from 
 intestinal tuberculosis and in 1888 i from traumatic pneumonia. 
 The warden's report shows three deaths not noted by the phy- 
 sician, viz., I from apoplexy, i "died in cell," and i killed by 
 guard. The percentage of phthisis is surprisingly low. 
 
 8. Of the 851 new convicts received during the year at 
 Sing Sing, 598 were in good health and 253 were "partially 
 disabled." The percentage of deaths on the total number of 
 convicts is 0.67, and on the daily average 1.06. Of those 
 who died of phthisis the shortest confinement was 2 months, 
 and the longest 26 months. 
 
 9. The physician at Auburn says: " The mortality has 
 
— 117 — 
 
 been abnormally large as compared with former years. 
 Convicts have been transferred to this prison during the past 
 year in the last stages of consumption, who were carried from 
 the cars to the hospital, unable to walk or help themselves 
 and who died shortly afterwards." There were also 3 deaths 
 from scrofula, i from pneumonia, and 2 by suicide. The 
 terms of imprisonment of the victims of phthisis ranged from 
 3 to 42 months, being over i year in 11 cases. The previous 
 health of only 2 is reported as fair, the rest being poor or 
 very bad; the previous habits of f^ were temperate, of 2 
 moderate., and of 9 intemperate. 
 
 10. There was also i death from hemoptysis at 
 Clinton. The confinements were respectively 3, 25, 31, and 
 43 months. 
 
 11. Of all the reports which I have examined, that of 
 the Eastern penitentary of Pennsylvania, situated at Phila- 
 delphia, is the most interesting. The report of Dr. W. 
 DufEeld Robinson, the physician in charge, is complete. It 
 shows that of the 560 convicts received during the year, 345 
 were in unimpaired and 215 in impaired physical health; 59 
 were consumptives; 121 were from families in which con- 
 sumption was strongly hereditary (313 deaths from that dis- 
 ease having occurred in their immediate families). Of the 
 total convict population in 1887 (1691), 126 were consump- 
 tive and the average number of these under treatment 
 was 66. Of the 21 who died from consumption, 10 were 
 unable to give a reliable family health history, and 11 
 gave a family history of consumption. All but 2 of the 
 21 were afflicted with the disease on their admission, their 
 health being rated as: bad 11, poor i, impaired 4, and fair 5 
 The length of confinement ranged from 4 to 90 months, most 
 of the cases being between i and 2 years. There was i 
 death by suicide. Dr. Robinson says: " In those convicts 
 in whom it is found on reception that there is a strong 
 
— ii8 — 
 
 hereditary tendency to consumption or that it already exists, 
 appropriate care to prevent its development or progress is 
 taken by securing for the convict appropriate work, medica- 
 tion, and special gymnastic exercises for the benefit of the 
 lungs." He justly says: "With the exception of the simple 
 treatment of disease the work of the medical officer of the 
 penitentiary is of so distinct a character and requires such 
 special study and experience to secure accuracy in his inter- 
 view and investigation work as to be almost a distinct pro- 
 fession." This penitentiary is the only one in the United 
 States conducted on the cellular or solitary system. What- 
 ever may be said in behalf of that system from a monetary 
 or disciplinary standpoint, the fearful ratio of mortality from 
 phthisis would indicate that it is not to be recommended from 
 a sanitary point of view. 
 
 12. The total cases of phthisis treated in the hospital at 
 Alleghany during 1887 were 14, of whom 5 were returned to 
 cell, 2 discharged from prison and 3 remained sick. During 
 1888, thev were 19, 15 being returned to cell and 2 remaining 
 sick. In 1887, there was i death from hemoptysis. Those 
 who died from phthisis had been confined respectively 32, 64, 3. 
 30, 49 and 61 months. The physician says: " It would seem 
 that the regularity of prison treatment seems to prolong life 
 when suffering from a pronounced type of disease." 
 
 13. There are 8 convicts now in Huntsville prison with 
 symptoms of phthisis. 
 
B. HOW TO LOOK FOR TUBERCLE BACILLI IN 
 SPUTUM, 
 
 The following procedure, which I have translated 
 from Kunze's Grundriss der Praktischen Median, is 
 Ehrlich's method somewhat modified: 
 
 Press a little of the suspected sputum between 
 two cover-glasses so as to get a very thin layer. Dry 
 the cover-glasses separately, either by moving them 
 through the air or holding over a flame, or by passing 
 a few times through the flame. This fixes and dries 
 the preparation. Place some drops of aniline oil in a 
 reagent glass half filled with water, shake, and filter 
 into a watch glass. Add several drops of an alcoholic 
 solution of fuchsin or methyl violet to the contents of 
 the watch glass till they are markedly colored. Warm 
 this mixture till it begins to smoke. Place the cover- 
 glass with the dried sputum, face downwards, on the 
 warm liquid and let it float for from three to five min- 
 utes. Remove and rinse in alcohol, acidulated with 
 nitric or hydrochloric acid, until very slight traces of 
 color remain; then rinse in ordinary alcohol (70 or 80 
 per centj. Dry the cover-glass as before by holding 
 above a flame, clean it where necessary, add a little 
 pure glycerin, and set under the microscope. An en- 
 largement of 400 diameters will show the bacilli if 
 present. 
 
HtEMATIC 
 HYPOPHOSPHITES, 
 
 DARKE, DAVIS & COMPANY invite attention to their prepara- 
 tion of hypophosphites. 
 
 In the debilitated conditions in which the preparations of the 
 hypophosphites are usually prescribed, minute doses often exert 
 a more favorable influence than the large dose which the physician 
 is tempted to prescribe. 
 
 In cases of nervous exhaustion especially, recuperation is neces- 
 sarily slow, and medication to be successful must be based on the 
 maxim, festina lente. 
 
 This combination of remedies is one adapted to a great variety 
 of diseased conditions. It is likely to prove useful wherever there 
 is debility or depraved nutrition, but it is especially appropriate 
 in cases of anaemia and nervous prostration, in consumption, and 
 in scrofulous and tubercular affections. 
 
 The advantages of this preparation over others of a similar 
 nature in the market are its greater purity, assimilability, medic- 
 inal efBcacy, nutritiousness, and the additional fact that it is not 
 a proprietary product. Its careful comparison by physicians with 
 all other preparations of hypophosphites is solicited in the belief 
 that such a test cannot fail to demonstrate its superiority. 
 
 PARKE, DAVIS & COMPANY, 
 
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