An Investigation into the Etiology of 
Phthisis. 
BY 
HENEAGE GIBBES, M. D., 
Professor of Pathology in the University of Michigan ; 
AND 
E. L. SHURLY, M. D., 
Professor of Laryngology and Clinical Medicine in the Detroit College of Medicine. 
V. 
Tubercular Peritonitis. 
By HENEAGE GIBBES, M. D. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
August, 1890. Extracted from 
The American Journal of the Medical Sciences for August, 1890. 
AN INVESTIGATION INTO THE ETIOLOGY OF PHTHISIS. 
By Heneage Gibbes, M.D., 
PROFESSOR OF PATHOLOGY IN THF. UNIVERSITY OF MICHIGAN ; 
AND 
E. L. Shurly, M.D., 
PROFESSOR OF LARYNGOLOGY AND CLINICAL MEDICINE IN THE DETROIT COLLEGE OF MEDICINE. 
V. 
Tubercular Peritonitis. 
By Heneage Gibbes, M.D., 
There are some interesting points in this disease which deserve a 
short notice. In all the cases I have examined of tubercles in the omen- 
tum and mesentery the lesion consisted of an aggregation of small, round 
cells, generally surrounding a bloodvessel. Some of these nodules have 
a gray translucent appearance to the naked eye, and I have never been 
able to find any tubercle bacilli in them. Some, however, have a whitish 
opaque appearance, caused by the disintegration of their central portions ; 
in these I have invariably found tubercle bacilli. 
I have made a number of experiments on animals by feeding and 
inoculation to see whether I could produce these conditions artificially, 
but I have found I could not rely on so doing by any one method, 
although I have produced them often. I have found the appearances 
presented were of two kinds: 
1st. An immense number of small bodies, about the size of a millet-seed, 
studded the omentum and mesentery; they were translucent, and on 
making sections of them and staining with logwood they were found to 
be collections of small round cells with a patent bloodvessel running 
through them. 
2d. Numbers of rather larger bodies having a white opaque look and 
on section showing a number of similar small round cells at the periphery 
while the centre consisted of a granular debris resembling caseation. 
In the first kind I have never been able to find any tubercle bacilli; 
in the second they are almost always present, and generally in such num- 
bers as to give a distinctly red appearance to the centre of the nodule. 
I have not been able to find any recorded account of reticular tubercles 
in this situation. In connection with this so-called tubercular peritonitis 2 
GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
it is interesting to note the cases where laparotomy has been performed 
and has resulted in curing this condition. In several cases the abdomen 
has been opened under the impression that it contained an ovarian tumor. 
In one case, recorded by Sir Spencer Wells, the patient was alive and 
well twenty-two years afterward. Knaggs and Clarke, of Huddersfield, 
have recorded similar cases, also Lawson Tait. These cases have, how- 
ever, been open to the objection that it has never been proved they were 
actually tuberculosis—that is, the presence of tubercle bacilli had not 
been demonstrated. At the request of Dr. Bowditch the records of a case 
have been sent me by Dr. Henry O. Marcy, which remove this objection. 
The case is as follows : 
November, 1886, a woman, set. thirty, had been under observation 
in the hospital for some months, suffering from severe pain and emacia- 
tion, with uterus fixed. This was considered to be a case of old tubal 
disease. Dr. Marcy performed laparotomy and found disseminated 
tubercles in the mesentery and abdominal walls. A small portion was 
removed for examination. The abdominal cavity was washed out with 
a solution of bichloride of mercury 1 : 2000 and closed up. Examina- 
tion showed the miliary tubercles in the portion removed to consist of 
colonies of tubercle bacilli, and this was confirmed by subsequent culti- 
vation. Recovery followed with an improvement of all symptoms. In 
the following spring the patient sailed for Europe and in a letter dated 
August, 1887, she writes: “Am enjoying at present very good health, 
being able to work again.” 
This is, as far as I am aware, the only case where an examination has 
been made for the tubercle bacilli. Since the above was written I have 
received a very interesting paper, by Dr. William Osier, on “Tubercular 
Peritonitis,” in which is an account of a case where reticular tubercles 
were found by Dr. Councilman containing numerous tubercle bacilli and 
no caseation in the nodules. It however, agrees exactly with what 
I have found several times in artificial tuberculosis in animals where 
the mesentery and omentum have been affected. I have no doubt other 
cases will be recorded showing similar facts; in the meantime we have 
the evidence of one case that numerous nodules containing tubercle 
bacilli can exist in a serous membrane without setting up a condition of 
general tuberculosis. The cure of these cases by abdominal section in 
the present state of our knowledge seems very difficult to explain. Such 
a weak solution of mercury could hardly have any action on bacilli shut 
up in these nodules. 
Bovine Tuberculosis. 
By some authorities this disease is held to be identical with human 
tuberculosis—that is, by those who hold the view that tuberculosis is 
only such when the tubercle bacillus is present. Others consider the 
disease to be different in many respects, and extended observation obliges GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
3 
me to agree with their conclusions. In the first place, the ordinary 
chronic tuberculosis of cattle has nothing whatever in common with 
pulmonary phthisis in the human subject, except the presence of a 
bacillus which has the same chemical reaction to staining agents as the 
tubercle bacillus of Koch. It has, however, many features similar to 
those in chronic tuberculosis in man, and also many marked differences. 
On examining the lungs of a cow affected with tuberculosis the appear- 
ances presented under the microscope are those of reticular tubercle 
containing a large number of giant cells and also a number of large, 
so-called epithelioid cells; this reticular tissue is arranged round the mar- 
gins of large caseous masses, which, in the majority of cases, has under- 
gone calcification to a large extent. So far the disease resembles that 
found in the human lung, with the exception of the calcification, which, 
almost universally present in the bovine animal, is rare in the human. 
Another point, also, is the frequency with which large nodular masses are 
found in the pleura of cattle affected with this disease, which on exam- 
ination are found to be composed of reticular tubercles. All these 
reticular tubercular formations consist of aggregations of small tubercles 
which appear to have grown and degenerated in a similar manner to 
that already described as occurring in the human subject. 
So far the difference between the human and bovine disease is slight, 
and it is not until we treat sections of these lungs in a special manner to 
show the bacilli contained in them, that the difference becomes more 
marked. It is then seen that the bacillus itself differs in size from that 
found in human tuberculosis; it is much smaller. Klein (Microor- 
ganisms and Disease, 3d ed.) says they are nearly half, or at least 
one-third smaller. This may not seem an important point to many until 
they consider the extremely minute variations in shape and size which 
have been held, by some, to constitute a different species of microorganism 
and establish its connection with some form of disease. 
The next point of difference is in the distribution of the bacilli, and 
here it is very marked. The bacilli are found principally in the giant 
cells and so-called epithelioid cells, and their arrangement in the giant 
cells is peculiar; they are arranged circularly round the periphery of 
each cell. The so-called epithelioid cells are packed full of them, and 
they can be found in clumps where these cells have broken down. I 
have before pointed out that bacilli are not found in the giant cells of 
tuberculosis in the human lung; at least, such is my experience and it 
is supported by other observers. We then have a difference in the 
bacillus itself morphologically and also in its distribution and relation to 
the component parts of the tubercular growth, from that of the bacillus 
found in the human lung, their only point of resemblance being their 
reaction to certain staining agents. 4 
GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
The next point to be considered is, Do they affect animals in a similar 
manner to those taken from human lungs when inoculated ? 
To settle this point I have made a large number of experiments both 
in feeding and inoculating animals with tubercular material obtained 
directly from the lungs of animals affected with tuberculosis. 
The results I have obtained were the following. I will not give the 
experiments in detail, as they have been so numerous it would prove 
tedious. 
The effect of the inoculation of guinea-pigs with bovine tubercular 
matter is to produce in them a general tuberculosis in which all organs 
are more or less affected. There are two points, however, worthy of 
notice. 
I find throughout my P. M. notes of these cases, constantly occurring 
in the description of the microscopical appearances in the lungs and 
liver, the following remark: “ The tubercular process seems to have 
commenced in the interlobular tissue and extended from it into the organ.” 
Now this is exactly what I have found in many animals where this 
form of tuberculosis has occurred spontaneously, and it may have some 
significance. The second point is the freedom of the kidney from in- 
fection, and this applies to inoculation of human matter as well as 
bovine. I have never found the kidney affected except in those cases 
where pregnancy has allowed the disease to exist for a long time, months 
instead of weeks. 
It must be understood that I am now speaking of the results of inoc- 
ulation on guinea-pigs only. 
In monkeys I have never seen the kidney affected from inoculation 
with human tubercular material from any source. 
In inoculation experiments on rabbits with bovine tubercular material 
the results were very different. In every case a marked general tuber- 
culosis was produced with large masses of caseation containing numerous 
bacilli. An important point in connection with these animals is this: in 
every case inoculated with bovine tubercular material the kidney shared 
the fate of the other organs and presented to the naked eye a surface 
studded with tubercular projections, which on examination proved to be 
caseous and full of bacilli. 
There is still another point of difference between human and bovine 
tuberculosis which may have some significance in the further line of 
investigation we are carrying on, which will be the subject of future 
reports. 
I have mentioned before the fact that after eighteen years in spirit the 
tubercle bacilli in the human lung still retain their characteristic reac- 
tion. In the cow’s lung, hardened in the same manner, I have found 
that four or five years in spirit entirely removes this property and I GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
5 
cannot get any reaction from the bacilli. This, at any rate, is the case 
in several different specimens under observation. 
I think from the foregoing facts it will be granted that the morpho- 
logical difference in the bacilli and the marked difference shown by 
rabbits when inoculated with tubercular matter from these two diseases, 
justify us in considering that in the present state of our knowledge 
they cannot be classed as the same, the only identical point being the 
reaction of the bacillus to staining agents. 
Klein, in his work on Microorganisms and Disease, third edition, 
1886, says, page 170 : 
“ According to my own experience, extending over a very large number of 
cases of human miliary tuberculosis and tuberculosis in cattle, I cannot for 
a moment accept the statement that the bacilli found in the two affections 
are identical; for I find that in the two diseases their morphological charac- 
ters and distribution are very different. The bacilli of human tuberculosis 
are conspicuously larger tban those of the tuberculosis of cattle, and in many 
instances more regularly granular. .... The bacilli in the tubercu- 
lous deposits of cattle are always contained in the cells; the larger the cell 
the more numerous the bacilli.” 
Different Animals in which Bacilli have been Found Giving 
the Reaction of Koch’s Tubercle Bacillus. 
I have examined a number of animals that died with diseases of the 
lungs and other organs and have found in them bacilli that give the 
characteristic reaction of the tubercle bacilli, although the lesions in 
many cases differ from those found in either human or bovine tuber- 
culosis; and it may help in some degree toward the elucidation of the 
problem we are working at to give an account of these cases. 
Monkeys.—It is a commonly received idea that the quadrumana are 
very subject to tuberculosis. This is not the case; the majority of these 
animals that die in confinement are the subjects of bronchitis, broncho- 
pneumonia, acute pneumonia, pulmonary phthisis, or pleurisy. In 1883 
in conjunction with Mr. J. B. Sutton, I examined the lungs of a number 
of monkeys that died at the Zoological Gardens, and out of this large 
number only five were considered tuberculous. At that time I made the 
diagnosis of tuberculosis more from the presence of tubercle bacilli than 
from the actual microscopical appearances; extended observation since 
has made me very doubtful if a bona fide case of reticular tubercle ever 
occurs in any of the quadrumana. I have had several of these animals 
that have died from general tuberculosis as it appeared to the naked 
eye, cases where tubercles existed in every organ, where the omentum 
and mesentery were filled by them and immensely thickened, but careful 
examination has shown that in every one of these cases there was no 
reticular formation, only caseous degeneration of inflammatory products, 
and in this degeneration were large numbers of bacilli giving the reac- 
tion of Koch’s tubercle bacillus. 6 
GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
It is impossible to tell what these cases really are without a micro- 
scopical examination. I have lately examined the lungs of a monkey 
that had to the naked eye every appearance of tuberculosis. On hard- 
ening them, however, all these apparent tubercles had disappeared, and 
on making sections I found they were caused by a localized emphysema 
brought on by minute emboli. In a paper read by me at the Patholog- 
ical Society of London, January 15, 1884, I described a similar case 
occurring in a Beatrix antelope. 
Carnivora ( Viverridce, Felidae).—Amongst the animals belonging to 
these groups examined were felis eyra, paradoxure, civet cat. 
They had been fed on birds that were supposed to have died of tuber- 
culosis. The changes found were in the liver, a portion of the organ 
had undergone caseation seemingly after some inflammatory condition; 
there was no appearance of reticular formation, and bacilli giving the 
tubercular reaction were found in the caseated portions. 
Ursidje (Coatimondi, Bears).—These are the only animals, other 
than ruminants, I have examined where there was any resemblance in 
the morbid process to that in bovine tuberculosis. In the lungs 
there'were large masses of changed substance which consisted of a fibroid 
tissue with, in some cases, giant cells and numbers of the so-called epi- 
thelioid cells. These latter contained many tubercle bacilli. One bear 
had nodular growths in the pleurae. 
Camel.—I have examined the lungs of a camel supposed to be tuber- 
culous. The case, however, was one of acute pneumonia the consolida- 
tion of which had not undergone resolution but had remained in patches 
throughout the lungs. The outline of the air-vesicles could be clearly 
made out in the consolidated portions. Tubercle bacilli were so numer- 
ous in these parts that they were easily visible with the naked eye as 
red patches, principally at the edges of the affected parts. 
Birds.—I have examined a large number of birds that were consid- 
ered to be the subjects of avian tuberculosis, amongst others the domestic 
fowl, turkey, grouse, golden pheasant, South American ostrich, emeu. 
The appearances presented by the organs of these varied exceedingly, 
and I shall have to separate the rhea or South American ostrich and 
the emeu from the others. The first specimen I received was the liver 
of a rhea sent me by Mr. J. B. Sutton. On making sections and stain- 
ing them with logwood I found circumscribed areas surrounded by fibrous 
tissue containing a number of cells; these areas varied greatly in size 
and the larger ones had the centre filled with disintegrated cells. Outside 
these areas the liver structure was normal. On staining them for tuber- 
cle bacilli I found that these areas were made up of cells filled with 
bacilli giving the reaction of those found in phthisis. In the larger 
areas the cells had broken down and the bacilli were loose amongst the 7 
GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
debris. Between the affected parts a few cells could be seen containing 
the bacilli, but the majority were perfectly normal. 
Dr. Klein made a drawing from one of my specimens of this liver for 
his work on Microorganisms and Disease, and considers it to be leprosy. 
This to anyone who has worked on leprous tissue is manifestly wrong. 
Since then I have examined the organs of two rhea and some emeu and 
have found in them the samQ appearances, but in these cases I was able 
to examine all the organs : the result showed that everywhere the rela- 
tion of the bacillus to the tissue was the same; in the thyroid, the 
intestine, liver, etc., the various cells were full of bacilli in places, but 
they had exerted no influence on the surrounding cells, and only in 
exceptional cases had the irritation been sufficient to set up new fibrous 
formation round the affected cells. In the intestine, the appearance of the 
columnar epithelial cells crowded with these bacilli was very peculiar. 
In the grouse and pheasant (golden) the changes were very different; 
here the liver was the organ affected, and on staining sections with log- 
wood here and there patches of large cells were seen : these patches were 
composed of cells that stained very differently both with logwood and 
methylene blue ; those in the periphery took the stain well and showed 
one or more well-developed nuclei, while those toward and in the centre 
stained faintly or not at all. 
For a long time I was puzzled to account for the origin of these cells, 
but after carefully examining a large number of sections from various 
cases, I was able to satisfy myself that they were simply liver cells that 
had become hypertrophied. On staining sections with special stains I 
found that those cells which had taken the logwood or blue stain well, 
contained no bacilli, while those that had stained faintly or not at all 
with logwood or blue, showed with the special stain several red bacilli, 
resembling the tubercle bacillus. That is, the normal cells contained 
no tubercle bacilli, only those that were undergoing degeneration. It 
was an interesting question as to where these seed-eating birds had 
obtained the infection and I made many careful investigations of their 
food and surroundings, the earth in their runs and the worms contained 
in the earth, to see if any bacilli were present, but I could find none in 
any way resembling the tubercle bacillus. 
I have frequently found caseous masses in the liver of the domestic 
fowl which contained large numbers of bacilli staining similarly to the 
tubercle bacillus and resembling it somewhat in shape and size. 
Snakes.—I have examined the livers of several large snakes, such as 
boas and python, which had died of disease presumably from having 
been fed on tuberculous birds. 
The appearances presented were somewhat similar to those found in 
the rhea and emeu ; that is, the liver cells in certain patches were full of 
bacilli giving the characteristic reaction, and some of the larger of these 8 
GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
patches were surrounded by a small amount of fibrous tissue evidently 
formed by the irritation set up. All the intermediary portions of the 
liver appeared to be normal. The majority of these cases I received 
from Mr. J. B. Sutton, whose numerous papers on comparative pathology 
published in the Transactions of the Pathological Society of London are 
very valuable. I have also obtained several cases from sources in this 
country and England, but the supply is much too small for extended 
work. 
VI. 
Conclusions Drawn from the First Portion of the 
Investigation. 
By Drs. Gibbes and Shurly. 
We wish now to point out the deductions we have made from our 
investigations so far, and later on we shall give the results of a number 
of experiments now in progress, but which will take a considerable time 
before we can get reliable data from them. 
We consider that tuberculosis and phthisis pulmonalis cannot be 
classed as the same disease clinically, and in this opinion we are un- 
doubtedly upheld by the majority of men having large clinical experi- 
ence ; we also consider that the appearances presented by the lesions in 
the lungs after death are so different in these two diseases, that they are 
even more widely separated pathologically than clinically. 
It seems to us, then, that the position held by the bacillary theorists 
may be summed up in this way: To use an optical simile, rays 
coming from points as widely separated as tuberculosis, phthisis pul- 
monalis, lupus, bovine tuberculosis, scrofula, converge and come to a 
focus at a point, the bacillus tuberculosis. Here they immediately 
diverge, and when they have proceeded far enough—that is, to the 
post-mortem examination, they are found to be of different kinds, but 
each has its own identity. Our observations lead us to doubt whether 
all these rays do pass through the same focal point. 
We would suggest the follow ing classification of diseases of the lungs 
in which consolidation occurs : 
Acute Miliary Tuberculosis.—Of two kinds, differing clinically 
only in the occurrence in one kind of typhoid symptoms, causing it often 
to be mistaken for enteric fever. Differing, however, in toto in the 
morbid histology, the one form being genuine tubercle, the other a col- 
lection of numerous small foci of inflammatory action. 
Differing also in the distribution of Koch’s tubercle bacilli, which in 
the latter form are always found in large numbers, but in the former 
are often absent and never numerous. GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
9 
General Tuberculosis.—The clinical features varying according to 
the chronicity of the disease, but sufficient to a careful observer to dis- 
tinguish it from phthisis pulmonalis, and never following broncho-pneu- 
monia. Differing in its morbid histology, in that the consolidation is 
always formed by new growth, and not by inflammatory action, this 
new growth being characterized by its proneness to break down and dis- 
integrate, thus forming cavities; enough of the new growth, however, 
always being left in the wall of the cavity to determine its tuberculous 
character. 
Differing also from phthisis pulmonalis, in that many cases, even with 
large cavities, have been proved to be free from tubercle bacilli. 
Phthisis Pulmonalis.—An inflammatory disease of the lungs, dis- 
tinguished by rapid consolidation, which, however, may clear up if the 
process has not gone far enough to damage irretrievably the lung sub- 
stance, and notable for the frequency with which it follows broncho- 
pneumonia. Differing from tuberculosis in that there is no formation 
whatever of new tissue; from beginning to end the process is one of in- 
flammatory exudation, breaking down, or caseation, ending in the for- 
mation of cavities. Differing also from tuberculosis in the regularity 
with which tubercle bacilli are found in this disease, and their enormous 
numbers in the most acute forms. 
Chronic or Fibroid Phthisis.—This from the beginning is a 
chronic change acting on the fibrous or interstitial tissue of the lungs. 
It may follow from many causes, such as the inhalation of irritating 
particles, or the presence in the lung of a consolidation, such as that of 
croupous pneumonia, which has not undergone resolution. Arising from 
such various causes, the clinical features will vary accordingly. The 
pathological change, however, is always the same, an increased growth 
of fibrous tissue which contracts, and in so doing damages the lung sub- 
stance. Inflammatory action may, however, take place in a lung the 
subject of fibrous change which may be followed by caseation, and in 
this way the discrepancies in the accounts as to the relation of the 
tubercle bacillus to this disease may be accounted for. 
The above classification is suggested, and will, we think, bear more 
minute investigation. It is, in fact, the classification of the older 
writers, which has been set aside by the discovery of Koch’s tubercle 
bacillus, and we contend that this discovery is not sufficient, and cannot 
sustain the sweeping change that has recently been made in the views of 
many regarding these lung diseases. Koch himself laid down some 
axioms as necessary to be filfilled before a given microorganism could 
be accepted as the virus of a given disease. They are, as stated by Dr. 
Pye-Smith in the second edition of Fagge’s Practice of Medicine: 10 
GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
1. The malady must have such distinct and constant features, 
whether clinical or anatomical, as shall enable it to be identified. 
2. The microorganism must be itself distinguishable from all others 
by its size and shape, its staining properties, but above all by its mode 
of propagation in a pure cultivation (i. e., artificial separation from 
other organisms), and by the form, color, and general appearance of the 
colonies it produces, and its mode of growth, both in plate cultivation, 
in tubes, and in drop cultures. 
3. The organism thus identified must occur in the blood or tissues, 
not merely on the surface (cutaneous or intestinal), but below the epi- 
thelium, in the lymph-spaces or bloodvessels, in every case of the disease 
in question. 
4. It must not occur in the human body, except in cases of the par- 
ticular disease in question. 
It may, however, conceivably occur in other animals without giving 
rise to the same pathological symptoms, or in air or water—as of course 
it does occur in the test-tubes and plates of “ pure cultivations.” 
5. When a pure cultivation of the organism is introduced into the 
blood and tissues of an animal, the phenomena (clinical and ayiatomical) 
of the disease in question must be reproduced. 
6. From that animal a “pure cultivation” must be again capable of 
reproduction, from which another animal may be again infected, and 
so on. 
Now, taking the first canon, we would ask, Are the clinical and 
anatomical features distinct and constant? We have given data 
enough to show that they are not. Dr. Klein, in his description of the 
lesions in acute miliary tuberculosis, marks the sharp distinction into 
two forms. 
And yet we have Germain-See, in his work on Bacillary Phthisis, 
making the following statements : 
“1. The unity of phthisis, comprising all acute and chronic manifestations. 
There exists no dualism between tubercle and caseous pneumonia; no dis- 
tinction between tubercular phthisis and inflammatory phthisis.” 
“ 2. Analogy, even identity, of tubercular nodule with inflammatory nodule 
from the histological point of view.” 
This is exact science with a vengeance. 
Professor Hamilton, in his work on The Pathology of Bronchitis, speaks 
of disseminated catarrhal pneumonia. He says : 
“The most curious point about these deposits is that they have not the 
slightest tubercular structure, but in all respects are identical with what is 
seen in the second stage of catarrhal pneumonia; they are small isolated 
groups of air-vesicles filled with epithelial products, the group invariably 
caseating in the centre. Every one has exactly the same appearance ; there 
is not a vestige of any giant-cell structure; there is nothing of an interstitial 
character in the nodules. The whole process is one of catarrhal accumula- GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
11 
tion in the air-sacs, followed by necrosis of the mass; and the only difference 
between this and ordinary catarrhal pneumonia is in the fact of the nodules 
being small in size and isolated in character, and universally disseminated 
throughout the lung substance.’’ 
We have pointed out that these nodules always contain numbers of 
tubercle bacilli. 
In speaking of Koch’s axioms, Dr. Pye-Smith (loc. cit.) says: 
“The microorganism of tubercle is believed to be constant, specific, and 
pathogenic, but its relation to much of what is clinically and anatomically 
called tubercle in man is not fully established. Here the first of the above 
conditions is wanting.” 
Here, then, at the outset we find the tubercle bacillus not filling the 
first of the conditions established by its discoverer as essential to its 
position as the virus of the disease. 
Secondly, if we take the question of size, the bacillus tuberculosis is 
at once separated from that found in bovine tuberculosis, although the 
reaction to staining agents is the same. 
Next, in its staining properties it is not distinguishable from the 
lepra bacillus, from the numerous bacilli found in birds and other 
animals, the account of which has been already given, or from a form of 
micrococcus isolated by one of us from urine. These cannot be tubercle 
bacilli, as they do not produce the disease in the animals in which they 
are found. We shall have something to say on the mode of growth in 
cultivations later on. 
Thirdly, this canon is not fulfilled by Koch’s tubercle bacillus, as 
Koch himself has recorded cases where the disease existed and no bacilli 
could be found. We have shown that such has also been our experience 
in a number of cases. 
Fourthly, to answer this canon the particular disease must be accu- 
rately defined. 
Fifthly, we have proved that the induced disease by inoculation in the 
lower animals has no features similar either to reticular tubercle or 
caseous phthisis. 
We have then a microorganism which is considered by many to be 
firmly established as the virus of a disease, to establish which connec- 
tion its discoverer has laid down a set of rigid laws, and we find that 
this microorganism does not fill the conditions of any one of these 
laws. 
It may be asked how has the microorganism arrived at this anomalous 
position ? The answer is simple. This solution of the tubercular 
problem took a vivid hold on the imaginations of many men, the 
majority of whom had no special training for histological or pathologi- 
cal work. It was carried by acclamation, and any questioning of its 
position was received as little short of blasphemy. Even at the present 12 
GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
day there are some men who seem to consider it a personal insult to 
them to doubt the infallibility of the tubercle bacillus. We have, how- 
ever, been working for a number of years on this question, and we wish 
to bring before the medical profession our views founded on actual 
practical work, and we feel sure of fair criticism from those men who 
are capable of looking at both sides of a question. 
These diseases of the lungs cause such misery and such a large per- 
centage of deaths that any addition to our knowledge of their causation 
can only act beneficially on the human race. When we see the divided 
opinions concerning these diseases held by our best men, vre cannot but 
feel that the end is not reached yet, and when we consider the enor- 
mous amount of work that has been done in bacteriology generally, 
and especially in connection with tuberculosis, in the last ten years, we 
stand appalled at the very slight (if any) benefit we have derived from 
it. In our treatment of these diseases we cannot but think that the 
investigations have been made in the wrong direction. To think that 
men should be content to consider the virus of a disease found, and 
yet to remain without any further means of combating that disease 
after this discovery, would be an impossibility, and this is proved by 
the immense number of remedial measures brought forward, all to be 
faithfully tried, and all to fail. 
We cannot help thinking that the chemical side of the question has 
been almost entirely neglected. What have the chemists told us about 
caseation; of what is it composed; and is it in all cases an identical 
chemical substance? This is a most important question, and one that 
ought to be fully worked out. It would then be shown whether the 
substance produced by the disintegration of reticular tubercular 
formation is identical with that found after the breaking down of con- 
solidation following broncho-pneumonia. It is nonsense to assert that 
these are the same, and that they are caused by a specific microorganism 
we want chemical proof. 
We have lately had a case which was diagnosed during life as 
phthisis. There was a large amount of consolidation ending in the 
formation of cavities. A number of guinea-pigs were inoculated with 
sputum from this case, and the bacilli were so numerous that it was 
used for practical class demonstration. At the post-mortem examina- 
tion there were the usual appearances of phthisis pulmonalis, yet the 
microscope revealed the fact that the case wras one of croupous pneu- 
monia, the consolidation of which had not undergone resolution. Not 
one of the guinea-pigs inoculated developed the so-called tuberculosis. 
They all had large abscesses at the seat of inoculation, containing fluid 
pus, with numbers of tubercle bacilli, but in no case were the lungs 
affected. In one case there wrere some abscesses in the liver and spleen, 
and one guinea-pig is still living, seemingly unaffected, the inoculation GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
13 
abscess having healed. Whatever may be the true explanation of this 
case, the fact remains that sputum taken from a case where the lung is 
rapidly breaking down after croupous pneumonia, and which sputum was 
loaded with bacilli, did not produce the lesions in the guinea-pig that 
we may confidently look for when using sputum from a case of phthisis 
pulmonalis. 
We think that if the fact were universally admitted that cavities in 
the lungs were formed by two distinct methods we should be better able 
to treat these diseases—as one form that of the inflammatory kind, is 
distinctly amenable to treatment if taken early enough, and if the 
lesions in these inflammatory cases were recognized at an early stage 
we are confident that more cures of cases of phthisis would be re- 
corded, although the tendency of the present time is certainly in that 
direction. 
With regard to tuberculosis proper it is probably an incurable dis- 
ease, as is cancer, when occurring in an internal organ; at any rate, 
in the present state of our knowledge of these diseases, associated with 
the formation of new and alien tissue. 
It may be thought that we should express some opinion as to the 
part the bacillus tuberculosis plays in these diseases. Here we are 
met by a difficulty. It seems beyond a doubt that this microorganism 
is intimately associated with caseation, and we know that it is never 
absent from that degeneration when it follows phthisis pulmonalis; but 
we also find it in degeneration of tubercular new-growth. Now, the 
question arises, Are these the same bacilli ? 
We have shown that in bovine tuberculosis the bacillus has the same 
chemical reaction as that of Koch, and yet it is much smaller. We 
know from careful and repeated observations that the bacillus varies 
in size considerably in various cases of phthisis; more especially is this 
noticeable in cases of acute phthisis or galloping consumption. Here 
the bacilli are large, long, and contain numbers of so-called spores. 
In other cases the bacilli are much smaller and shorter. Another point 
we have observed is, that in scrofulous glands removed from the neck 
and placed in spirit, after some years the bacilli lose their power of 
reacting to the specific staining agent, and before this power is quite 
gone—that is when they have not been so long in spirit—they will 
stain fairly well, but the reaction completely disappears in twenty-four 
hours, although bacilli in sections of lungs kept many years in spirit 
took the same stain well and still retain it. We have already pointed 
out this peculiarity in the bacilli of bovine tuberculosis. There are 
several cases on record where the mesenteric glands have been found 
after death changed into masses of calcification. This is what we have 
already pointed out as occurring so often in bovine tuberculosis. We 14 
GIBBES, SHURLY, ETIOLOGY OF PHTHISIS. 
have a number of cases in which tabes mesenterica was directly traced 
to the ingestion of cow’s milk. 
Is it possible that tuberculosis, as we understand it, has any distinct 
relation to bovine tuberculosis, through infection from the milk of a 
tuberculous cow ? This has occurred to us as a possibility, and as such 
we bring it to the notice of the profession. We should then have two 
forms of tubercle bacilli, the one derived from an outer source, and pro- 
ducing tuberculosis, either directly or through some poisonous product, 
this might take place in a gland or other part. This gland, becoming 
caseous first, would after a time infect the whole organism, and this infec- 
tion would take varied forms, according to the situation of the part first 
infected, and its means of communication with the rest of the body. 
The other, a bacillus having a similar chemical reaction to the first, 
but associated in some way with caseation. It cannot be the cause 
of the disease here, as we find it in cases where we have bronchitis 
extending into the lungs, and causing broncho-pneumonia, the con- 
solidation so formed not clearing up, but breaking down, and con- 
taining numerous bacilli with specific reaction. To explain it by 
the theory that there is a specific and a non-specific broncho-pneu- 
monia seems to us to be a very lame way out of a difficulty. We do 
not give this idea as mere theory, but we have some facts which have 
induced us to consider the matter, and we are carrying on a series 
of investigations on these lines. There may be nothing in it, but wTe 
would ask the kind consideration of those men wrho are not wedded to 
the unity of phthisis on this point. 
As to heredity and contagion our work is still in progress, and it will 
take a much longer time than we have yet devoted to these questions 
before we can get reliable data to work on. In the meantime we would 
say that the results we have laid before the profession are those of honest 
work, and all we ask is fair and open criticism of this work by those 
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