DISEASES OF THE LUNGS. 
CROUPOUS PNEUMONIA. - HYPOSTATIC PROCESSES. - EMBOLIC 
PNEUMONIA-FAT EMBOLISM-HYPEREMIA AND (EDEMA. 
-ATELECTASIS.-EMPHYSEMA.-GANGRENE.-NEW 
6ROWTHS.-PULMONARY CONSUMPTION - 
TUBERCULOSIS. 
BY 
FRED'K C. SHATTUCK, M.D., 
Visiting physician to the house of the good Samaritan; physician to out-patients, mass. 
GEN. HOSPITAL, AND CLINICAL INSTRUCTOR IN AUSCULTATION AND PERCUSSION 
IN THE HARVARD MEDICAL SCHOOL. 
OF BOSTON, CROUPOUS PNEUMONIA. 
281 
CROUPOUS PNEUMONIA. 
BIBLIOGRAPHY. 
Liebermeister: Handbuch der Pathologie und Therapie des Fiebers, Leipzig, 
1875. Peacock: Report on Cases of Pneumonia. St. Thomas' Hospital Reports, 
Vol. V., 1875.-Fismer : Deutsches Archiv fur klin. Med., Bd. XI., p. 433.- 
Friedreich: Volkmann's Sammlung der klinischen Vortrage, No. 75.-Leichten- 
STERN: The same. No. 82.-Bristowe: Theory and Practice of Medicine, London, 
1876. -Sturges : The Natural History and Relations of Pneumonia, London, 
1876.-Wiedermann: Zur Lehre von der Lungenentziindung. Deutsch. Archiv 
fur klin. Med., Bd. XIV., p. 389.-Flint: Pneumonic Fever; Transactions of the 
N. Y. State Medical Society, 1877.-Cohnheim : Vorlesungen uber allgemeine 
Pathologie, 1877.-Leyden : Die Ausgange der Pneumonie. Berliner klin. 
Wochen., 1879, Nos. 20 and 21.-Wells: Analysis of 100 Cases of Pneumonia. 
Cincinnati Lancet and Clinic* 1879, II., p. 241.-Strauss: Note sur un casd'erysi- 
pele des Bronches et du Poumon. L'UnionMedical, Oct., 1879.-Ritter: Pneumo- 
typhus. Deutsch. Archiv fur klin. Med., Dec., 1879, p. 53.-Hamburger: Unter- 
suchungen uber croupose Pneumonie. Inaugural Dissert., Strassburg, 1879. 
The two leading peculiarities of Jurgensen's article on this subject 
are his vigorous advocacy of the theory that pneumonia is an infectious 
disease, and the view that a fatal result is generally due to failure of the 
heart. In the second edition of v. Ziemssen's Encyclopaedia, with en- 
larged experience and basis of facts, he emphasizes these views, as well 
as the various conclusions to which statistical analysis had led him in the 
first edition; but makes no very material changes. During the last few 
years, attention has been reawakened from widely different quarters to a 
class of cases of pneumonia characterized as " asthenic," "adynamic," 
"bilious," "typhoid," "pythogenic," "endemic," "epidemic," "con- 
tagious," "erysipelatous," and the like; and the burning questions in 
relation to this disease are to-day: I. Is pneumonia an infectious 
disease, or is it a simple inflammation? II. Is there an asthenic, etc., 
form of pneumonia, distinct from the ordinary or less severe form; or is 
there but one form, the manifestations of which differ only according to 
the intensity and concentration of the exciting cause and. the power of 
resistance of the patient? 
To the consideration of these two questions, and an attempt to indicate 
the light which has been thrown on their solution since 1873, it is pro- 
posed largely to limit this report. 
I. A better and more widespread understanding of the part played in 
the causation of disease by bad hygiene, or, as Simon graphically puts it, 
filth, has naturally prepared the way for the reception of the doctrine of 
the infectious nature of pneumonia; and there is no doubt that Jurgensen's 282 
CROUPOUS PNEUMONIA. 
views on this point have gained many adherents since their promulga- 
tion. They have been strongly adopted by Sturges and Flint among 
others. The latter calls the disease "pneumonic fever," as does Bern- 
heim (Leqons de Clin. Med., 1877, p. 17 et seq.), and says that name 
is as appropriate as the term enteric applied to typhoid fever. He derives 
his grounds from the morbid anatomy, etiology, clinical history and 
treatment of the disease; and states them so clearly that, in view of the 
great and well-deserved respect which is universally accorded to Dr. 
Flint's opinion on medical questions, a very brief abstract of them can 
hardly be out of place. 
MORBID ANATOMY. 
It is not easy to reconcile the large quantity of the exudation ; its 
probable derivation from the branches of the pulmonary artery; its com- 
plete removal without injury to the air vesicles; its gradual and sometimes 
successive extension over one or several lobes, and the partiality of the 
disease for the lower lobes, especially the right, with the deduction that 
the products in pneumonia are the result solely of a local inflammatory 
condition. 
Neither local affections of the lungs, bronchial tubes, nor pleura, nor 
violence applied to the chest ever give rise to acute lobar pneumonia; 
and here it may be added that Heidenhain (Virchow's Archiv, Bd. 70, 
p. 441) could not succeed in exciting croupous pneumonia in dogs and 
rabbits artificially. The inhalation of hot and cold dry air through a 
canula in the trachea had absolutely no effect on the lungs or the height 
of a thermometer in the trachea; bpt moist cold and heated air caused 
lobular pneumonia. Sommerbrodt ( Virchow's Archiv, Bd. 55), in con- 
nection with experiments on the relation of blood in the air-passages to 
phthisis, found that microscopically local spots of croupous pneumonia 
resulted from the introduction of a solution of the chloride of iron into 
the lungs. Jurgensen and Schilppell repeated his experiments carefully 
on dogs, and found that even anatomically the product differed from that 
of croupous pneumonia. In short, croupous pneumonia has never up to 
the present time been produced artificially. 
''Pneumonia," Dr. Flint continues, "as is well-known, is not in- 
frequently an intercurrent affection in the course of other essential fevers, 
namely typhus and typhoid fevers, measles, diphtheria, etc. In these 
instances the determining cause must be constitutional, and yet, as the 
affection is only an occasional complication, the determining cause in- 
volves something which does not necessarily pertain to these fevers. 
This something, it is reasonable to conclude, is pneumonic fever. 
Hence it follows that pneumonic fever may be associated with other 
febrile diseases. The blending of different fevers may be considered at 
the present time as a well-established pathological doctrine. An ex- 
ample with which all of us are familiar is the typho-malarial fever." 
ETIOLOGY. CROUPOUS PNEUMONIA. 
283 
A specific cause is not as yet demonstrable, but the same remark is 
also true of malarial and other essential fevers. The prevalence of the 
disease at certain seasons of the year; the relative immunity of some 
climates over others; the fact that it has, at certain times and places at 
the South, been known to prevail to an extent entitling it to be called 
endemic, and the fact that at different times and places the disease has 
varied as regards its phenomena and rate of fatality, are all adduced as 
etiological arguments in favor of the specific nature of the affection. 
Are not the same arguments equally potent in favor of the existence 
of bronchitic and pharyngitic fever? 
CLINICAL HISTORY. 
The disease is generally ushered in by a well-marked rigor followed 
by fever and a rapid and pronounced rise in the temperature, which 
fever cannot be symptomatic merely, for the reason that often no 
physical signs can be obtained until several days have elapsed; that 
the pulse and temperature afford no indication of the extent or extension 
of the disease; and that defervescence often takes place decidedly before 
it is possible to detect any change in the physical signs-in other words, 
that defervescence is not determined by conditions which relate to the 
local lesion. In fact it is a self-limited disease. The analogy to typhoid 
fever, which in several points of view is apparent, is further shown by the 
frequent occurrence in pneumonic fever of what are known as typhoid 
symptoms. It is true that they occur in various diseases, but they are 
far more frequent in pneumonic fever than in any other disease, except 
typhoid and typhus fevers. They cannot be attributed to the interrup- 
tion of the respiratory function, for they are rare in such diseases as 
pleurisy, capillary bronchitis, and asthma ; but are undoubtedly due to 
the fever, irrespective of the pulmonary affection. 
Pneumonic fever, again, has no immediate tendency to relapse; in a 
large number of cases recorded by Dr. Flint relapse is not noted in a 
single instance, nor does he recall such an occurrence in any unrecorded 
case. It never persists in a chronic form; clinical experience shows that 
it does not eventuate in phthisis, and if death does not take place from 
the disease, its complications, or its accidents, recovery follows without 
any risk of the persistence of the local affection in a chronic form. 
TREATMENT. 
The influence over the disease of antipyretic remedies-quinine, 
salicylic acid compounds, and cold water-speaks also in favor of the doc- 
trine of essential fever. 
Dr. Flint has seen the disease rendered abortive in a certain propor- 
tion of cases by 20-40 grains of quinine daily, and when this result has 
not followed, the disease is often favorably modified in a greater degree 
than by smaller doses. 
Finally he defines the affection as " a fever characterized anatomically 284 
by an abundant exudative deposit in the air-vesicles of a single lobe, or 
of two, and sometimes three lobes of the lungs with, in general, circum- 
scribed bronchitis and dry pleurisy. It is a fever which rapidly reaches 
its maximum of intensity, and has a short course, the duration averaging 
about eleven days. It proves fatal chiefly in consequence of associated 
diseases, complications, or accidents, and the mode of dying is by asthenia. 
It is non-communicable, and depends on a cause, or causes, specific in 
character, the nature of which is at present unknown, but having rela- 
tions to season and climate. It sometimes aborts spontaneously; and it 
is in some instances arrested by remedies. If not arrested it may be 
favorably modified, its duration abridged, and the danger to life dimin- 
ished by treatment addressed, not to the pulmonary affection, but to the 
fever." 
It will be observed that Flint's arguments are essentially the same as 
those of Jilrgensen, though they are more elaborate as well as more con- 
cise. In the presentation of the other side free use is made of critiques 
on Jurgensen and Sturges which appeared in the Brit, and For. Med.- 
Chir. Review for January, 1877, and on Sturges in the Edin. Med. Jour. 
for the same month and year. 
Both authors-and presumably Flint-follow Hirsch and v. Ziemssen, 
of Berlin, who propounded his views in 1858, based largely on the London 
mortality returns of sixteen years (1840-56). Buchan and Arthur Mitchell 
(Journal of the Scottish Meteorological Society, July 1874-75, p. 190) 
have investigated the same subject on the basis of thirty years of the 
same returns and have not found v. Ziemssen's views in any way sup- 
ported. On the contrary, they have found the mortality curve for 
pneumonia to be very steadily marked from year to year, and to be essen- 
tially the same as that from bronchitis. The pneumonia curve also 
differs in toto from those of typhus and typhoid, or even simple con- 
tinued fever, as well as from that of pleurisy, the curve of the latter being 
somewhat analogous to that of rheumatism and pericarditis. There is, 
therefore, nothing in these statistics-the most perfect in the world and 
extending over a longer period than any others-that lends the slightest 
support to the theory that pneumonia is a specific fever of any kind, or 
indeed anything else than an inflammation pure and simple. Prior to 
1869 all fevers were classed together in the London mortality returns, 
and between 1840 and 1856 typhus fever prevailed in that city more or 
less. We know that typhus and typhoid have a very different seasonal 
mortality, that both of them differ very materially from that of pneu- 
monia, and, therefore, how much value to attach to the curve figured on 
page 29 of the translation of volume V. 
It is true that in pneumonia the fever often abruptly ceases before the 
local lesion is resolved; in a healthy subject this is by no means the rule, 
but, be that as it may, the rapid cessation of a frequently very high tem- 
perature with the continuance of the local lesion often for a very long time 
is a daily occurrence in embolic pneumonia, which is purely a local 
process and could not possibly be supposed to have even the most remote 
CROUPOUS PNEUMONIA. CROUPOUS PNEUMONIA. 
285 
connection with any form of specific fever; and, indeed, it requires but a 
slight acquaintance with pyrexial processes to discover that the period of 
convalescence or repair is never pyrexial, or, as Bur don-Sanderson has 
stated, " does not form part of the febrile process." 
As for Flint's assertions that pneumonia never persists in a chronic 
form, and that it never leads to phthisis, it can only be said that many 
other first-rate authorities do not agree with him. One of the causes of 
interstitial pneumonia is claimed to be a croupous exudation which did 
not undergo absorption. Jurgensen himself says that this sequence, 
though not common, cannot be doubted by a physician of large experi- 
ence (2d Ed. v. Ziemssen's Encyclopaedia). 
As was hinted above, many of the arguments for the specific nature 
of pneumonia have a very wide application, and speak quite as strongly 
for the specific nature of bronchitis, pharyngitis, and some other affec- 
tions. Very likely they do partake of this nature at times, but there 
can be no question that they are very often simple inflammations. So with 
pneumonia; may it not be that the disease is sometimes an essential fever, 
sometimes a simple inflammation? Further than this I do not see how 
we can go at present. We have had a pathology of the humors and of 
the solids; we now bid fair to have a pathology of the specifics. 
Klebs (Arch. f. Exp. Path., Bd. IV.7 p. 420) figures and describes 
an organism, monas pulmonale, which he found in the ventricular fluid 
of patients who died of pneumonia, and in the sputa during life, and by 
injecting which in rabbits he has produced lobular pneumonia, with 
which was associated meningitis, nephritis, etc. He thinks that this 
explains the frequent association of pneumonia and erysipelas with the 
above affections, as well as pleuritis and pericarditis. These observa- 
tions are as yet entirely lacking in confirmation by others, and caution 
is never more imperative than in connection with these low forms of life. 
That pneumonia may apparently be set up by sewer gas is shown by a 
striking outbreak (Med. Times and Gaz., April 4th and June 20th, 
1874), quoted nearly as abstracted in the Irish Hospital Gazette for Nov. 
1st, 1874. 
Sewer-Gas Pneumonia.-On Saturday, March 14th, the parish sewer 
in the road nearly opposite a first-class boys' school, at East Sheen, near 
London, was opened by order of the sanitary authorities for the purpose 
of inserting a ventilator protected by a chatcoal screen. The headmaster 
remonstrated, and backed up his own objections by a certificate signed by 
several eminent medical men, including Sir William Jenner, two of whose 
sons were students at the school. Sir William Jenner especially mentioned 
the danger of pneumonia in connection with the probable escape of sewer- 
gas in the vicinity of the school. The authorities persisted in their 
scheme with a trifling modification. March 20th, a high tide in the 
Thames blocked up the mouth of the sewer, and the compressed gases 
forced an opening through the ventilator. The rooms of the school fac- 
ing the road were filled with a foul-smelling sewer air. Next morning, 
a boy sleeping in one of these rooms was taken seriously ill with pneu- 286 
CROUPOUS PNEUMONIA. 
monia; on the evening of the same day two other boys and two servants 
became similarly affected. One of the servants ultimately died. The 
school wasjjroken up, and the authorities were ordered to remove the 
ventilator and close the opening on the evening of the 21st, after which 
all smell ceased, and no additional cases of illness of any kind occurred 
in the house. For fifteen years previously, no illness attributable to 
bad drainage had occurred, and competent inspectors pronounced the 
sanitary arrangements of the house excellent. 
The fact that pneumonia was predicted lends additional interest to 
the above report. We are not given to understand that the cases pre- 
sented any peculiar clinical features. 
II. What is the position of the severe form of pneumonia called 
typhoid, asthenic, adynamic, nervous-does it differ etiologically from 
the common form or not ? Jurgensen puts this cpiestion (2d Ed. v. 
Ziemssen's Encyclopaedia), discusses it briefly, and answers: "Person- 
ally I do not hesitate to express my firm conviction that there is but 
one pneumonic poison; it is just as with roses: either each kind of rose 
forms a species, or there is but one species including many varieties." 
Laennec (De 1'auscultationmediate, 4th Ed., Vol. I., p. 595) observed 
and described an affection which prevailed among the conscripts of 1814, 
and was called by him epidemic pneumonia. A remarkable epidemic 
of contagious pleuro-pneumonia started in Canada during the war of 
1812, and spread through the United States far into the South, though 
all facts of this kind seem to have been lost sight of under the universal 
prevalence of the doctrine of the simple inflammatory nature of the dis- 
ease, until Hirsch formed a chronological list of similar epidemics 
occurring between 1521 and 1858. 
Within a few years the subject has been brought prominently for- 
ward by Liebermeister, Friedreich, Fismer, Leichtenstern, and others; 
and our knowledge has been enriched by the report of carefully observed 
and most interesting local outbreaks which are worthy of being dwelt 
upon at some length. 
In the' American Journal of the Medical Sciences for January, 1876, 
Rodman describes a series of cases observed by him in the prison at 
Frankfort, Ky., at a time when there was but little pneumonia about, 
and it was only among the prisoners that this form of the disease 
occurred. Between January 1st and February 24th, 1875, 16 cases of 
ordinary pneumonia occurred in the prison, one of which was fatal. 
About the last week in February, it was evident that the type of the dis- 
ease had radically changed, and the number of cases was greatly increased. 
The whole number of cases of pneumonia from January 1st to July 1st 
was 118; of these, 98 were of a peculiar type, and 25 of the 98 were fatal. 
The disease is said to have resembled closely ordinary pneumonia, both 
as to physical signs and post-mortem appearances, though it is mentioned 
that the sputa were generally either pure blood or a dirty brownish-black 
in color. 
Pain was not a prominent symptom, and in many cases the lung-con- CROUPOUS PNEUMONIA. 
287 
solidation was revealed only by physical exploration. The pleura was 
implicated oftener than in simple pneumonia, and in several cases cir- 
cumscribed empyema was found. The bowels did not seem to be much 
affected, but the dejecta were excessively offensive. The liver was en- 
larged, and, in fatal cases, filled with dark syrupy blood; no mention is 
made of the spleen or kidneys. Men died with hepatization of but 
a single lobe, and the disease was very treacherous as regards prognosis. 
The average temperature seldom ranged as high as in ordinary pneumo- 
nia. The patients might seem better as regards the pulse, respiration, 
temperature, cough, and expectoration; but take a sudden change for the 
worse and die. Carbonate of ammonia, on which previous experience 
has led Dr. Rodman to rely greatly, proved useless; and much better 
results seemed to follow the administration of quinine, and the tincture 
of the chloride of iron, with liberal diet and free stimulation. Conva- 
lescence was very protracted. 
The cell-house is 310 feet long, 43 feet wide, and 75 feet high, and 
contains 648 cells, each of which contains cubic feet of air; and the 
cells, like the cell-house, are very poorly ventilated. Feb. 1st, 694 men 
were confined in these cells, and daring this month the number of pris- 
oners received was so much in excess of those discharged, that by 
March 1st 735 men occupied these same cells. There are six tiers of 
cells on each side of the house, but those next the roof, 108 cells, cannot 
be used, it being almost certain death for any one to sleep in them, espe- 
cially in summer. It was consequently necessary to double the men in 
some of the cells, and this was done in the uppermost tiers. The strong- 
est cells are near the floor, and are reserved for the whites, who are more 
apt to escape than the negroes. Every man takes a night bucket with 
him to his cell, only intended to be used in case of emergency; but rather 
than wait their turn at the privy, 400 of the men will use their buckets 
in the cells between dark and daylight in spite of severe penalties. The 
basement tier was comparatively free from bad odors, and there was less 
sickness there than in any other part of the house. The odor increased 
with each tier, and, when the top was reached, the stench was almost 
unbearable by one unaccustomed to it. Of the 25 who died, 24 were 
negroes (occupying the upper cells) and 14 were new prisoners, reck- 
oning those as new who were received aftei' January 1st. The new pris- 
oners were to the old numerically as one to four. These facts show the 
causative agency of the bad air, and illustrate the greater susceptibility 
of a stranger over a native, so to speak, to zymotic poison. We are all 
familiar with the frightful ravages caused by the importation of measles 
into the Fiji Islands not many years since. We shall have further evi- 
dence to bring on this point later. 
Overcrowding and consequent intensification of the poison seems to 
have been the exciting cause of this outbreak, for the condition of the 
men was in other respects precisely the same as during the time that the 
pneumonia presented no distinctions from the ordinary type. Rodman 
states that twice before in the history of the prison pneumonia prevailed 288 
CROUPOUS PNEUMONIA. 
to a fearfully fatal extent, and in both instances coincided with marked 
increase in the number of the prisoners. 
Dr. L. Dahl (Dublin Journal, I., 1875, p. 405) describes an outbreak 
of pneumonia in the Akerhus prison, Christiania, which commenced in 
Dec., 1866, and terminated in May, 1867. Among an average of 360 
prisoners in that period, 62 cases occurred with 15 deaths. The weather 
was very cold at the height of the epidemic, but the prisoners who worked 
in-doors were about equally attacked with those who worked in the open 
air. Prof. Boeck attributed the outbreak chiefly to overcrowding, and 
Dr. Dahl calls attention to the improved state of affairs coincident with 
a diminution in the number of the prisoners from 387, Jan. 1st, to 278, 
Dec. 31st, 1867. A former similar outbreak occurred in the prison in 
1847, and coincided with a prevalence of scurvy. 
Kuhn (Deutsch. Arch. f. klin. Med., 1878, p. 348, and Berliner klin. 
Wochenschrift, Sept. 15th, 1879) contributes reports of outbreaks in the 
House of Correction at Moringen, Hanover, in the years 1875 to 1878, 
which differ in some respects from that of Rodman. In the year 1874, 
it was noticed that there was an unusual amount of sickness among the 
prisoners, and that this increase was chiefly in diseases of the respiratory 
organs. Pneumonia ran a peculiar course, much more like that of an 
infectious disease than of the ordinary type. There were also a consid- 
erable number of cases of an ill-defined febrile affection, the onset of 
which was preceded by pain in the head and back, and malaise, which 
ran a mild course with sudden defervescence about the tenth day, 
and was followed by tedious convalescence. The most prominent symp- 
toms were either those of gastric catarrh or of bronchitis and lobular pneu- 
monia. Enlargement of the spleen was nearly constant. In 1875, cases of 
illness were still more numerous, the maximum being reached in Febru- 
ary, when ten and a half per cent was the daily proportion of the sick. 
During the year there were only eleven cases of pneumonia of the ordi- 
nary type, but during the first nine months there were eighty cases of 
general febrile disturbance, more sdvere and, at the same time, less vague 
in character than those of the year before. After prodromata lasting 
from five to eight days, rigors and a rapid rise of the temperature to 103 
-104.5° came on; during the next few days simple sore throat, enlarge- 
ment of the spleen, and, in the severer cases, albumen in the urine 
appeared; but the belly presented neither spots, distention, nor tender- 
ness. Not till the third or fourth day could consolidation of the lung be 
detected; this consolidation was generally lobar, very often of the upper 
or middle lobe, and sometimes disappeared without ever becoming com- 
plete, to reappear in another portion of the lung, thus resembling the 
so-called " wandering or migratory pneumonia." Foci of lobular pneu- 
monia were very common in the upper lobes, both with and without a 
lobar process in the lower lobes. Severe pleuritic symptoms were con- 
stant; meningitis was noted in five cases, and the cerebral symptoms in 
general were second in prominence only to the pulmonary. Pericarditis 
occurred in twenty-five per cent of all the cases, and the albuminuria CROUPOUS PNEUMONIA. 
289 
generally continued as long as the pyrexia. It was present in every case 
in which the temperature surpassed 104°. In two-thirds of the cases 
which proved fatal from the direct effects of the disease, the solitary fol- 
licles and Peyer's patches were swollen, but not ulcerated. In fact, the 
symptoms were those of severe general blood poisoning, but the course 
was decidedly shorter than that of typhoid fever, and the temperature 
curves were more like that of pneumonia. Sixteen cases were fatal, and 
in fourteen of these the pneumonia was exclusively of the lobar variety. 
That the affection was contagious to a degree is shown by its appearance 
in nursesand chronic patients in the hospital; and above all, by the fact 
that one of the overseers took it home to his family who lived at some 
distance and never came into direct communication with the prison. 
Kilim himself was laid up several days with malaise, and about the 
same time his coachman, whose duty it was to brush his clothes, fell ill. 
Then the housemaid who undertook this duty was taken sick, and finally 
his daughter, a child of four years; the two latter cases being quite severe, 
and followed by tedious convalescence and loss of the hair. As soon as 
the housemaid was sufficiently well she went to her friends, who lived 
some miles distant, taking with her articles of clothing which had been 
used and kept in her room during her illness. . She occupied the same 
bed with her sister, who, just eight days after the arrival of the sister at 
home, was also taken ill in precisely the same way. 
The above facts taken together lead Kuhn to formulate the following 
conclusion: " There is then a contagious affection, the course of which is 
the same as that of primary asthenic pneumonia, but which is entirely 
distinct from ordinary pneumonia, and differs no less from it than does 
typhoid from typhus fever." 
In this epidemic again we find that overcrowding seems to be the- 
exciting cause. The prisoners were chiefly incorrigible tramps and beg- 
gars, and averaged about one hundred and eighty in number previous to 
1874. In that year the influence of hard times began to be felt and the 
number of prisoners was about one-third larger than could be properly 
accommodated. New buildings were undertaken, and by the end of 1876 
there was room for six hundred prisoners, but commitments increased in 
still larger proportion, and overcrowding was constant, continuing at 
least into 1878, though in a less degree. It is stated that the sanitary 
arrangements were excellent, but on these points the account is not as 
full and clear as could be desired, and we are told that wooden buckets 
were used in many of the dormitories for the reception of the renal and 
alvine discharges. Great pains seem to have been taken to keep these 
buckets clean, and it is certain that the hygiene of the place was vastly 
superior to that of the Frankfort Prison. It will also be noted that the 
German mortality was less. In the town of Moringen itself, there was 
during the year 1875 decidedly less typhoid fever than in previous years; 
but diseases of the respiratory organs were rife, as well among adults as 
children, and partook in their course and complications somewhat of the 
nature of the prison disease. 290 
During 1876, 1877, and 1878, this form of pneumonia continued to be 
the prevailing disease in the institution. According to Jurgensen, pneu- 
monia constitutes 3% of all diseases, and 6.4$ of all diseases of the inter- 
nal organs; but in 1878 the proportions in the Moringen workhouse were 
8.81% and 17% respectively; catarrhal, cheesy, and secondary pneumonia 
being carefully excluded from the statistics. The number of cases was 
fifty-eight, seventy per cent of which occurred during the two months of 
March and April. A few of these cases differed in no respect from or- 
dinary pneumonia, but the great majority were of the previously de- 
scribed type. Eight were fatal, a proportion of 13.80%. The post-mor- 
tem appearances were much the same as in 1875, except that the swelling 
of the intestinal glands was decidedly less marked. The less intensity 
of the epidemic of 1878 is also shown by the fact that though a nurse in 
charge of a ward containing several pneumonia patients was taken down 
with the disease, there is no evidence that it was communicated to any 
person outside of the institution. In 1877, 71.82%, and in 1878, 77.58% 
of the cases were in those who had been less than six months inmates of 
the prison, while only 31.99$ of the whole number of prisoners had been 
there six months or more. 
Grimshaw and Moore {Dublin Journal, I., 1875, p. 399), call atten- 
tion to a type of pneumonia which was common in Dublin during the 
warm months of 1874, and which they characterize as "pythogenic." 
The distinctive symptoms were sudden invasion, the frequency with 
which the disease was arrested in the early stage, and a less liability 
constantly to attack the lower lobe of the right lung. It is stated that 
the disease is not usually very fatal, but that an accurate percentage of 
mortality cannot be given because of the difficulty in distinguishing some 
«of the cases from enteric fever on the one hand, and true pneumonia on 
the other. All of these patients came from houses the sanitary condition 
. of which was far from satisfactory. They refer to an epidemic of pleuro- 
pneumonia in some ships of the British Mediterranean fleet in 1860; the 
• disease was of an asthenic type accompanied with great congestion of the 
.lungs, and, in many cases in the ship chiefly affected, with scorbutic 
symptoms. Overcrowding and defective ventilation were the most 
tangible causes, and there were good grounds for supposing that the 
: affection was communicated by the sick landed from the vessels to the 
patients in the Maltese hospitals. 
Some of the conclusions drawn by the authors in their paper are as 
follows: 
1. That the bibliography of pneumonia indicates the existence of a 
form of the disease which arises under miasmatic influences and is con- 
tagious. 
2. That its etiology justifies us in regarding it as a zymotic affection 
. and in terming it "pythogenic " pneumonia. 
3. That pythogenic pneumonia presents peculiar clinical features 
'which enable.us to distinguish it from ordinary pneumonia. 
4. That whereas ordinary pneumonia is specially prevalent during a 
CROUPOUS PNEUMONIA. CROUPOUS PNEUMONIA. 
291 
continuance of cold, dry weather with high winds, and extreme variations 
in temperature, pythogenic pneumonia reaches its maximum during 
tolerably warm weather, accompanied with a dry air, deficient rainfall, 
hot sun, and rapid evaporation. 
Barella {Bull. de I'Acad, de Med. de Belg., No. 2, 1877) supports 
the views of Grimshaw and Moore, and adds that the disease has often 
at the beginning abdominal symptoms which make it look much like 
typhoid fever. In this connection it may be well to refer to Murchison's 
teaching, that in cases where the diagnosis is doubtful between pneu- 
monia and typhoid fever, the appearance of consolidation before the 
tenth day of the disease points to the former affection. < 
Hardwiche {Gaz. Med. de Paris, 1876, p. 515) reports some cases in 
which the disease seemed to be contagious, but they are so lacking in 
details as to be of little value. 
Kelemen {Pester Med. Chi. Presse, XII., 1776, 45-46) alludes to 
four cases of ''migratory pneumonia," and adds one of his own. . Wal- 
denburg compares the disease to erysipelas migrans, and Friedreich be- 
lieves that they are practically the same thing, as he has seen many cases 
of migratory pneumonia during the prevalence of erysipelas. In ordinary 
pneumonia one, two, or (very rarely) three foci are co-existent and dis- 
appear together, even if they do not begin at the same time; but in the 
migratory variety one focus makes its appearance and is followed by 
another, and another, the new one not appearing until its predecessor 
has vanished. The foci may run through all three stages, or never go 
beyond the stage of engorgement. In these five cases the maximum 
number of foci was ten, the minimum four. 
The limits and purposes of this report do not permit of anything 
more than a passing allusion to the typhoid pneumonia of which so 
much was heard during the late civil war, and to the possibility of some 
connection between the pleuro-pneumonia of cattle and certain epidemics 
in man. 
At what conclusions as to the etiology and pathology of pneumonia 
do the above facts, in connection with other knowledge and experience, 
enable us to arrive ? 
A good deal can be said in favor of each of the four following state- 
ments, and the profession doubtless comprises adherents of each: 
1. True pneumonia is simply a local inflammatory disease, but many 
general constitutional affections are at times accompanied by a pulmonary 
lesion which bears a close resemblance to simple pneumonia, though it is 
in reality a part of the constitutional process; the results of this pro- 
cess happening, for some cause unknown, to be localized largely in the 
lungs. 
2. Pneumonia is often simply an inflammatory disease, but may de- 
pend on various miasmatic influences and then present decided variations 
in its course and symptoms. 
3. Pneumonia is never a simple inflammation, but always an infec- 
tious disease arising from a single specific cause as yet unknown, and 292 
varying in its effects according to the intensity of the poison, the 
power of resistance and the surroundings of the patient. 
4. Pneumonia is always an infectious disease arising from dual, possi- 
bly plural, specific causes. Of these causes one produces sthenic fever, 
of more or less definite type, and with localized lesions, while the other 
or others produce an asthenic fever far less definite in type and with 
more or less extensive lesions of other important organs and parts as well 
as of the lungs. 
Of these statements the second is that which to me individually seems 
most in accordance with the facts at our disposal to-day, though any 
statement as to a matter of this nature is merely a halting-place, as it 
were, on our journey, from which we cast our eyes over that part 
which lies behind, and mentally remeasure and consider the length and 
obstacles of the path before us. 
Other aspects of the disease require but brief mention. Marshall 
{Medical Record, N. Y., Vol. 17, 1880, p. 185) reports a case of pneu- 
monia with recovery after a temperature of 110°. It is interesting to 
note that, while Jurgensen ansi Sturges agree in the main as to the infec- 
tious nature of pneumonia, they differ as to treatment. The latter advo- 
cates moderate bleeding as a means of relief to the dyspnoea, even after a 
considerable extent of the lung has become solid-so late as the third or 
fourth day, but says that the cold bath is less applicable to pneumonia 
than to other febrile conditions where the functional defect is less omin- 
ous, because he regards exceptionally high temperature in pneumonia as 
simply an indication of a necessarily fatal condition of the lung, and sees 
no reason to employ cold bathing as long as the pyrexia is moderate. As 
to the utility of stimulants to tide over a period of depression, he agrees 
with Jilrgensen. 
Hamburger reports that in the winter of 1877-78 seventy-seven cases 
of croupous pneumonia were treated at the Strassburg hospital. Of these, 
seven died, and the heart was healthy in every case-in other words, death 
was not due to cardiac failure. 
HYPOSTATIC PROCESSES IN THE LUNGS. 
HYPOSTATIC PROCESSES IN THE 
LUNGS. 
BIBLIOGRAPHY. 
Christensen, Ludwig: Einiges uber Lungenentzundungen beim acuten 
Gelenkrheumatismus, 1868.-Ramm, Heinrich: Ueber die Retraction der Lungen- 
rander, 1869.-Paulsen, Eduard: Ueber die Verschiedenheiten des raumlichen 
Inhalts des Thorax im Stehen und Liegen, 1874.-Erhardt, Wilhelm: Ueber 
den nachtheiligen Einfluss einer anhaltenden Riickenlage auf die Mechanik der 
Athmung und deren Bedeutung fur die Enstehung des Lungencollapses, 1875. HYPOSTATIC PROCESSES IN THE LUNGS. 
293 
(The following is translated from the second edition v. Ziemssen's 
Encyclopaedia.) 
In diagnosis there are two great sources of error. 
A croupous pneumonia, which supervenes on a long-standing mal- 
ady attended with considerable fever, may give rise to such slight symp- 
toms as to escape notice, unless examinations are often and carefully 
made. The same remark is true of croupous pneumonia in feeble and 
aged persons, especially when emphysema and chronic bronchitis are also 
present. If, under these circumstances, 'bilateral consolidation is found 
over the Lower lobes, the chances are very strong that the condition is one 
of hypostasis. We must not, however, entirely lose sight of the facts that 
unilateral hypostasis and bilateral croupouspneumonia are sometimes met 
with. A diagnosis which is based merely on the ground that one only, 
or that both sides are involved, is not much better than a guess. In many, 
yes, in most cases, the history or other points which one will have noted 
if the cases have been some time under observation, will throw all neces- 
sary light upon them. 
It is well known that collapse in a greater or less degree always occurs 
at the anterior borders, and the lower and posterior portions of the lungs 
of patients with feeble respiration, who are compelled to lie on their backs 
for long periods. A good deal of attention has been devoted to this point 
now for a series of years at the Kiel clinic, and Bartels has inspired a 
number of dissertations on the subject containing the results of his expe- 
rience (see bibliography). Collapse of the lower and posterior portions of 
the lungs occurs in connection with various apparently quite distinct dis- 
eases, provided that they,have the common factors of superficial respira- 
tion and the constant maintenance of the same bodily position; and this 
collapse may be sufficiently marked to give rise to physical signs if the dis- 
ease be of long duration. Portions of pulmonary tissue thus collapsed 
may become the seat of hypostasis and catarrhal pneumonia, the latter 
either in isolated patches or involving the whole area. Both conditions 
may be associated, or either may exist independently of the other. 
Bartels has shown that when the body is horizontal, the muscles which 
serve to dilate the thorax work at a disadvantage as compared with either 
the erect or the sitting posture. In the prone position the contents of the 
abdominal cavity gravitate upwards and press against the diaphragm; in 
standing or sitting, on the other hand, the exact reverse is the case, and all 
the abdominal viscera gravitate downwards toward the pelvis. The anterior 
wall of the belly serves as a support, but when the body is horizontal on 
the back, the weight comes entirely on the spinal column, the lateral sur- 
face of the abdomen, and the diaphragm. Of all these surfaces the dia- 
phragm is that which offers least resistance to the pressure, is consequently 
the first to give way to it, and thus encroaches on the pulmonary space. In 
the prone position again, the distance between the crest of the ilium and 
the lower ribs is increased, and the diaphragm is put at a greater disad- 
vantage by this increased tension of the abdominal wall. The observa- 
tion that the vital capacity of the lungs is less in the recumbent than in 294 
EMBOLIC PNEUMONIA. 
the erect position {Hutchinson, Wintrich, Panum, Pfahi-Quincke) is 
entirely in accordance with these facts. In very muscular persons, the 
difference is not indeed very great, certainly during the short time 
required to respire a few times while an observation is taken with the 
spirometer, but in rather feeble persons it is as great as 400-600 c. 
cm., even when the full inspiratory force has been called into play only 
a few times and no real fatigue has been incurred. 
A plain statement of the matter may be made as follows: A change from 
the erect to the recumbent position increases the forces which oppose respi- 
ration to such a degree that a decidedly greater demand is made upon the 
muscular power to counteract these forces in a measure, even for a brief 
period; to counteract these entirely is impossible. If the dilatation of 
the thorax incident to inspiration is lessened, or, in other words, if the 
difference in the atmospheric pressure within and without the thorax is 
diminished, the lungs tend to approximate to the position at which their 
elasticity is exhausted, and this the more in proportion as the respiration is 
feeble. The conditions which experience has taught us favor collapse are 
pain on inspiration from peritonitis, double pleurisy, or acute rheumatism, 
feebleness of the respiration from long-continued fever, and loss of mus- 
cular power from tonic spasm, such as that of tetanus. If something be 
superadded to these conditions which favors nutritive changes in the 
walls of the vessels-hypostasis, the escape of the constituents of the blood, 
both formed and amorphous-is the result. That this whole process may go 
through its several stages in a short period of time is proved by the exist- 
ence of well-marked collapse and hypostasis in a patient who died from 
tetanus on the fourth day after seizure {Erhardt'). When favorable con- 
ditions for the development of cartarrhal pneumonia are present, this 
process is also set up, either in isolated patches, or uniformly distributed 
over the whole collapsed portion of lung. 
Theoretically, doubtless, collapse, hypostasis, and catarrhal pneumonia 
are quite distinct processes, but their underlying causes are so often asso- 
ciated during life and their physical signs are so similar that it is often 
practically impossible to differentiate them at the bedside. 
EMBOLIG PNEUMONIA. 
Cohnheim and Litten : Ueber die Folgen der Embolie der Lungenarterie. 
Virchow's Archiv, Bd. 65.-Penzoldt : Ueber den hamorrhagischen Infarkt der 
Lunge bei Herzkranken. Deutsch. Archiv fiir klin. Med., Bd. XII., 1874.-Ger- 
hardt: Der hamorrhagische Infarkt. Volkmann's Sammlung der klinischen Vor- 
trage, Nr. 91.-Kossuchin: Zur Lehre von dem embolischen Infarkte. Virchow's 
Archiv, Bd. 67, p. 449.-Kuttner: Beitrag zur Kenntniss der Kreislaufsverha.lt- 
nisse der Saugethierlunge. Virchow's Archiv, Bd. 73, p. 476.-Lichtheim; 
BIBLIOGRAPHY. EMBOLIC PNEUMONIA. 
295 
Versuche uber Lungenatelektase. Archiv fur experimentelle Pathologie, Bd. 
X., 1878.-Litten: Untersuchungen uber den hamorrhagischen Infarkt and fiber 
die Wirkung arterieller Anamie auf das lebende Gewebe. Deutsch. Zeitschrift 
der klin. Med., No. 2, p. 131, 1879. 
PATHOGENESIS AND ETIOLOGY. 
As to the question, whether haemorrhagic infarction is invariably due 
to embolism, both Jurgensen and Gerhardt call attention to the fact 
that sometimes no embolus is to be found. That state of things is more 
common during the course of some infectious diseases, and thus natu- 
rally suggests the possibility that nutritive disturbance has so altered the 
walls of the vessels within a limited area of the lung as to allow the 
escape, not only of the coagulable plasma, but also of the red blood-cor- 
puscles. This explanation must, of course, remain purely hypothetical 
until the existence of such nutritive disturbances is proved. 
Our authors are also agreed as to the statement that those valvular 
lesions are most apt to lead to thrombosis in the systemic veins which 
bring about accumulation of blood in the same: similar results are liable 
to follow degeneration of the cardiac walls, especially when, as Jurgensen 
has found to be the case in Tubingen, such degeneration is predomi- 
nant in the right heart. The size of an embolus does not alone deter- 
mine the extent of the resulting infarction, for the greater or less supply 
of blood from other sources to the occluded vascular territory must also 
be taken into account; and in the case of metastatic abscess, there is 
still another factor to be considered : septic action, namely, may extend 
by contiguity into tissue supplied by arteries, other than that which is 
occluded. 
As to the method of development of haemorrrhagic infarction, our 
knowledge has been materially increased these last years. Jurgensen 
states that he regards the views of Gohnheim as unassailable, and these 
views assigned a very important part in the production of infarction to 
accumulation and stasis of blood in the pulmonary veins, due, simply, to 
complete loss of arterial pressure in the territory of the occluded artery. 
Litten's latest experiments (1879) agree entirely with those of IGuttner 
and Lichtheim, and essentially modify the results of his and Gohnheim's 
experiments expounded in the second German edition of v. Ziemssen's 
Cyclopaedia. He finds, namely, that in rabbits and dogs, though the 
hilus of one lung be ligatured en masse, infarction takes place, and a 
certain circulation is carried on through the arteries which supply the 
pleura, mediastinum, and pericardium. Venous accumulation cannot, 
therefore, be the cause of infarction, inasmuch as it may occur when the 
pulmonary veins are tied. Kilttner also slfowed that there is pretty free 
communication in the capillaries between the branches of the pulmonary 
and bronchial arteries. He tied the pulmonary artery and veins of one 
lung, and then introduced considerable quantities of fluid, with cinnabar 
in suspension, gradually into the circulation. The pigment was found 
in the branches and trunk of the ligated artery, in the capillaries of the 296 
EMBOLIC PNEUMONIA. 
alveolar walls, and in the pulmonary veins, and the bronchial arteries 
were dilated. The whole tract of the pulmonary artery and veins were 
filled with plugs containing the pigment. Cohnheim and Litten used an 
aqueous solution of aniline-blue in their experiments of 1875, a pigment 
which we now know is thrown down in the smaller arteries and veins, and 
plugs them. They were thus led to the erroneous conclusion that the 
branches of the pulmonary artery are practically terminal arteries, and 
have no communication with the bronchial artery. 
As proof that backward circulation does not take place in the pul- 
monary veins, Litten adduces the fact that when the pulmonary and 
bronchial arteries, as well as those external arteries which communicate 
with the lung, are all tied, that is when all arterial supply is cut off 
from the lung, while the pulmonary veins are left open, engorgement and 
infarction do not take place. But if the pulmonary artery alone, or the 
pulmonary and bronchial, or the whole hilus be tied, these results are 
constant. Physiologically, i. e., with free circulation, the blood-pressure 
in the pulmonary artery is all sufficient to overcome the resistance to the 
onward flow in the capillaries, which, in the lungs, are unusually large, 
and offer less resistance than capillaries in general. But when the pres- 
sure in the pulmonary artery ceases from occlusion of that vessel, the 
collateral circulation through the bronchial and external arteries is suffi- 
cient, indeed, to prevent a backward current in the veins, though not 
sufficient to force the blood onward to the right ventricle rapidly enough 
to prevent hypersemia and diapedcsis. The capillaries and smaller veins 
are in precisely the same condition of distension and dilatation as when 
the vein into which they empty is narrowed in calibre. Litten found the 
same results in experiments on the kidney and spleen. Infarction does 
not take place, in short, unless arterial blood from some source is still 
sent into the part after its main supply is cut off. 
In illustration of the great powers of resistance of the pulmonary 
artery to disturbances of nutrition, and of the different results of 'sudden 
and gradual occlusion of that vessel, Jurgensen reports the following case: 
A woman of 54 died with general dropsy dependent on degeneration 
of the walls of the heart. On autopsy, the main trunk of the right 
pulmonary artery and its larger branches were found completely filled 
with a coagulum as thick as the finger, partially adherent to the wall 
of the vessel, laminated, externally grayish, internally reddish-black in 
color. The main coagulum was about 4 cm. long, and sent off numer- 
ous fresh offshoots into the lateral branches of the vessel. The intima 
was very atheromatous, thickened, and fatty in spots. The right lung 
was simply ansemic and oedematous, and entirely free from infarction. 
The condition of the thrombus clearly indicated that occlusion must have 
been gradual. The accumulation of blood in the systemic veins was so 
great that, when the large trunks at the root of the neck were incised, 
the blood spurted out in a stream three inches in height. Toward the 
last the circulation in the lung must have been excessively slight, and 
yet no marked tissue lesions were found. EMBOLIC PNEUMONIA. 
297 
The writer of this article has reported a somewhat similar case (Bos- 
ton Medical'and Surgical Journal, 1880, I., p. 242). The patient, 
becoming insane, was sent to an asylum, and was there so uncontrollable 
that it was necessary to put him into a padded room; and yet there was 
at the time almost complete occlusion of the right pulmonary artery, 
beside chronic disease of both lungs. 
In the above case there, was an hereditary tendency to insanity; but it 
is interesting to note that Gerhardt seems frequently to have seen cerebral 
symptoms supervene on embolism of the pulmonary artery in patients 
with weak hearts. According to his experience, loss of consciousness is 
very apt to be the first symptom of extensive embolism, whether death 
occurs soon after, or not. He finds that there is great variation in the 
degree of the cerebral symptoms : there may be a fainting fit, or merely 
transitory disturbance of some of the special senses. In one case the 
sense of hearing remained intact, while that of sight was lost. More or 
less well-marked signs of cardiac weakness follow the lodgment of the 
embolus, and it is said that an increase in the area of cardiac dulness is 
demonstrable. The brain symptoms are attributed to cerebral arterial 
anaemia. \ 
If the embolus be very large, death may be almost instantaneous, oi' 
may be preceded by collapse, intense dyspnoea, oi* even convulsions. 
Such deaths are not very uncommon after confinement, and have been 
reported in increased numbers of late years. Though it is the rule that 
the temperature does not generally rise for several days after the occur- 
rence of embolism, Jurgensen states it cannot be denied that fever 
attributable to this cause sometimes appears very soon. He agrees with 
Gerhardt that the character of the sputum is not absolutely pathogno- 
monic of infarction. If the expectoration is moderately copious, careful 
examination will always enable us to distinguish it from that of croupous 
pneumonia; but that we may be deceived in other ways is shown by the 
following case : 
A woman of 34 came under treatment with right hemiplegia, loss of 
the power of articulation, and aphasia. She was first seen ten days 
before her death, and the leading points of the clinical diagnosis were 
confirmed at the autopsy: failure of the heart from mitral stenosis and 
insufficiency, and great dilatation of the right cavities. A pleuritic 
effusion reaching as high as the third rib on the right side was also 
detected, and part of the expectoration was precisely like that due to 
haemorrhagic infarction. This, and the presence of all the conditions of 
thrombosis led to the diagnosis of infarction in the right lung. The 
day before death a bloody sputum was thrown out, of the same character 
as before. Neither thrombus nor embolus was found in the lungs, but the 
bronchi contained a dark-colored secretion mixed with blood, and there 
was haemorrhagic pleurisy. In the Iqft auricle was a red, partially softened 
thrombus. 
SYMPTOMATOLOGY AND DIAGNOSIS. 298 
FAT EMBOLISM OF THE LUNGS. 
According to Gerhardt, the character of the sputum in cancer and 
echinococcus of the lung may also be similar to that after infarction. 
After the lapse of two or three weeks, haematoidin, both in the form of 
granules and crystals, takes the place of the blood-corpuscles. Bloody 
expectoration may be entirely lacking in haemorrhagic infarction : its 
absence was noted by Gerhardt in two cases out of fifteen. 
The authorities are not unanimous as to the size which must be 
attained by an infarction before it will give rise to physical signs. Ger- 
hardt expects to find decided dulness on percussion as a rule over an 
infarction which is seated at the periphery of the lung, and involves an 
area of from one to four cubic inches. Jurgensen does not doubt that 
this may be the case with so experienced and conscientious an observer 
as Gerhardt, but questions whether others will succeed so well, even 
when the dull area is increased by a zone of oedematous tissue around 
the infarction. If emphysema is present to any marked degree, it may 
be difficult to determine positively the existence of even pretty extensive 
consolidation. Laennec, Skoda, and Hopf are all very guarded in their 
statements on this point. 
TREATMENT. 
Prophylaxis deserves passing mention in cases of peripheral thrombo- 
sis. Patients should be kept as quiet as possible until the thrombus has 
disappeared, for bodily movements tend to detach it and allow its being 
swept into the circulation. Gerhardt recommends large doses of morphia 
subcutaneously to relieve the attacks of dyspnoea, and musk and alcoholic 
stimulants may be used to excite the heart. 
FAT EMBOLISM OF THE LUNGS. 
BIBLIOGRAPHY. 
Zenker: Beitrage zur norm, und path. Anat. der Lunge. Dresden, 1862.- 
E. Wagner: Die Capillarembolie mit fliissigemFett. Arch. f. Heilkunde, III., p. 
241,1862. The same, IV., p. 146, 1865.-Busch, F.: Ueber Fettembolie. Virchow's 
Archiv, Bd. 35, p. 321, 1866.-Bergmann: Zur Lehre von der Fettembolie. 
Schmidt's Jahrbiicher, Bd. 131, p. 316.-Cohnheim: Untersuchungen uber Em- 
bolische Processe. Berlin, 1872, p. 69.-Czerny: Berliner Wochenschrift, Nos. 
44 and 45, 1875.-Riedel: Deutsch. Zeitschrift f. Chirurgie, VIII., p. 571.- 
Flournoy: Contribution a 1'etude de 1'embolie graisseuse. Strasbourg et Paris. 
Virchow u. Hirsch, 1878, I., 226.-Wiener: Wesen und Schicksal der Fett- 
Embolie. Archiv fiir experiment. Path, und Pharm., Bd. XI., p. 275.-Lucke: 
Allgemeine Wien. med. Zeitung, 1880, p. 105. 
Inasmuch as the occurrence of fatty embolism of the lungs is not even 
hinted at in v. Ziemssen's Cyclopaedia, it would seem not out of place to 
describe the condition briefly here. FAT EMBOLISM OF THE LUNGS. 
299 
Zenker and E. Wagner were the first to discover that the smaller ves- 
sels in the lungs may become plugged with fat. The former attached no 
practical importance to the condition; but the latter was led to connect 
it with the origin of metastatic abscesses, and in his second publication 
on the subject expressed his surmise that sudden fatty embolism might 
be fatal through pulmonary hyperaemia and oedema, though he could 
bring forward no proof of this. We now know that Wagner's surmise 
was quite correct, and that many deaths after injuries which were formerly 
supposed to be due to shock, as well as death for which we were at a loss 
to account in some other affections, are in truth due to fatty embolism 
of the lungs. 
There is reason to think that in almost every fracture of the long 
bones, at least, more or less of the medullary fat gets into the veins, and 
is carried into the circulation, but it is only very exceptionally that the 
quantity is sufficient to give rise to any symptoms or disturbance. Some 
of the fat may pass through the pulmonary circulation and be deposited 
in capillaries or small vessels elsewhere, especially if the action of the 
heart be feeble. 
As a typical case I will cite that reported by Bergmann (Berl. klin. 
Woclien., No. 23, 1873). A fall of thirty feet resulted in comminuted 
fracture of the thigh. After a short time complaint was made of pain in 
the chest, and later a frothy, bloody expectoration appeared, the respira- 
tion increased in frequency, the lips became livid, the temperature rose, 
and fine moist rales were heard throughout both chests. B. made the 
diagnosis of oedema of the lungs caused by fatty emboli, eliminating 
traumatic pneumonia, and pulmonary hemorrhage. Death occurred 
forty-nine hours after the accident. At the autopsy both lungs were 
hypersemic, cedematous, dotted with small dark spots, and contained 
hemorrhagic infarctions the size of a pin's head. 
EgU (Jahresbericht der gesammt. Med., 1873, p. 214) reports two 
cases of fat embolism in which the source of the fat was supposed to be 
thrombi in the right heart which had undergone puriform softening. 
The degenerated blood-clots were found to contain large and small fat- 
drops. 
Riedel reports two cases of injury to the soft parts, in one of which 
fatty embolism occurred to a great, in the other to a slight degree. He 
also found it in three cases of inflammation of the bones, with and with- 
out subsequent operation on the same. In two cases of inflammation of 
the soft parts he found no trace of it. 
Out of 250 bodies examined by Flournoy in the Pathological Institute 
at Strassburg, fatty emboli were found in 26 cases-about 10 per cent- 
but he throws out three of these as they were imperfectly reported. The 
remaining 23 cases he divides into two groups with reference to etiology; 
the first group containing 13 cases, the second 10. Of the first group 
there was injury to the bones in five cases, osteo-myelitis in one, acute 
suppuration in fatty tissue in two, suppuration in both bone and soft parts 
in five. Of the second group there was contusion of the soft parts in one 300 
HYPEK2EMIA AND (EDEMA OF THE LUNGS. 
case, but in the other nine there was no injury whatever, either to the bone 
or soft parts. Six of these, however, presented peculiar changes in the 
bone-marrow which F. considers the source of the emboli. The marrow, 
namely, was very soft, fluid, and dark in color; and microscopic examina- 
tion showed that these changes were due to intense hyperaemia and 
marked atrophy. He does not attempt to decide whether the condition 
arose from haemorrhage or from simple hyperaemia with laceration of the 
fat-cells and thus absorption. In support of his view that the hyperaemia 
of the marrow is the cause of the embolism he cites the case of an old 
person whose bone-marrow was atrophic, but pale in color, and in whom 
no embolism could be found. In three of his cases the condition was 
the sole apparent cause for death, and in many of the others no doubt 
contributed materially toward the fatal result. He has collected and 
analyzed 140 cases, including his own, and finds that in 18 of these-■ 
12.86 per cent-death was due to fatty embolism alone. Injury to the 
bones was responsible for 72 per cent of the cases, and one case was due 
to fatty softening of the brain. 
Sanders and Hamilton {Edinburgh Med. Journ., July, 1879) reporta 
case of diabetes mellitus with death from fatty embolism. One morning 
dyspnoea came on, followed in the evening by unconsciousness, twitch- 
ings of the extremities, and death at four the next morning. Lipaemia 
was very marked and the embolism seemed to be largely confined to the 
lungs and kidneys, which were in other respects sufficiently healthy. No 
fat was found in the uriniferous tubes. It is probable that we have 
here the true cause of the sudden dyspnoea, coma, and death, which is 
not infrequent in diabetes, and which has been attributed to acetonaemia 
by Kussmaul and Balthazar Foster among others. 
Fatty emboli in the lungs and other tissues may be detected by 
treating sections with perosmic acid, which turns the fat-drops a deep and 
uniform black without attacking the other structures. 
Wiener has shown experimentally that the fat is absorbed into the 
circulation and eliminated with the urine by the kidneys. 
HYPER2EMIA AND (EDEMA OF THE 
LUNGS. 
BIBLIOGRAPHY. 
Koster: Virchow's Archiv, Bd. 55, p. 455.-Orth: Virchow's Archiv, Bd. 58, 
p. 126.-Strumpell: Acute Primary Fatal CEdema. Archiv der Heilkunde, 1877, 
p. 193.-Welch: Zur Pathologie des Lungen-CEdems. Virchow's Archiv, Bd. 72, 
p. 375.-Mayer: Bemerkungen zur experimentellen Pathologie des Lungen- 
CEdems. Prager Vierteljahrschrift, 1879,1., p. 141.-Lund: Acute Fatal Pulmo- IIYPEIUEMIA AND' (EDEMA OE THE LUNGS. 
301 
nary (Edema. Schmidt's Jahrbucher, 1879, IV., p. 29.-Borden: (Edema of the 
Lungs. With cases. Boston Med. and Surg. Jour, 1880, II., p. 9. 
PATHOLOGY AND ETIOLOGY. 
Welch and Mayer are led to conclude from experiments on dogs and 
rabbits that none of the explanations which have been current up to the 
present time as to the mode of production of acute general pulmonary 
oedema are really satisfactory. 
The former author criticises the use which has been made hitherto of 
the term "collateral" hypersemia and oedema, and remarks that two very 
different conditions have been included under it: A sharp distinction 
should be drawn between local serous transudation in the vicinity of in- 
flammatory foci and new formations, and acute general oedema. He 
agrees with Cohriheim that the former depends on inflammatory changes 
in the walls of the vessels primarily; and only secondarily, and in small 
measure, on compensatory increase in the blood-pressure within the ves- 
sels of the part. General oedema, on the other hand, generally comes on 
suddenly and may as suddenly disappear; it affects both lungs, occurs in 
connection with a great variety of diseases, but is a constant accompani- 
ment of none, and very often appears during the agony, an attendant 
rather than the cause of death. 
Welch then ably discusses the causes of pulmonary oedema as laid down 
by Niemeyer in his Handbook of Medicine and Hertz in the Cyclopaedia, 
showing that some of them are unsound and that neither individually nor 
collectively do they serve to explain the facts. His experiments were 
chiefly directed to the attempt to produce oedema from passive congestion 
in the lung, which latter may be brought about by obstruction to the cir- 
culation in the aorta, the pulmonary veins, or the left heart. He found 
that it was necessary to tie the aorta itself between the innominate and 
left subclavian, and all its branches except one-either one of the carotids 
or the right subclavian-before he could induce pulmonary oedema as a 
constant result; or, in other words, that obstruction to the systemic cir- 
culation can give rise to pulmonary oedema only when such obstruction 
attains a degree scarcely Conceivable in the human subject. He then ex- 
perimented on the pulmonary veins and found that oedema did not result, 
nor was the pressure in the pulmonary artery materially increased, until 
the circulation was nearly completely shut off through all of them. Occlu- 
sion of all the pulmonary veins of one lung was followed by infarction, 
never by oedema. He then turned to the left ventricle and found that 
he could often succeed in paralyzing it in the rabbit by pinching the wall 
between the fingers, while the right ventricle retained its activity for 
a time; and general pulmonary oedema was the invariable result. The 
right ventricle is more easily paralyzed than the left, owing to the thin- 
ness of its walls, but paralysis of this was never followed by oedema. 
From these considerations he forms the hypothesis that general pul- 
monary oedema is due to predominant weakness of the left ventricle, and 
then goes on to show that this hypothesis will explain the facts and ac- 302 
ATELECTASIS. 
count for the great rapidity with which oedema may appear and disappear 
and its remarkable inconstancy. 
Mayer's experiments bear out those of Welch, but also throw some 
new light on the subject. He found that if the arteries ascending to the 
brain (innominate and left subclavian) are laid bare according to Kuss- 
maul's method and occluded, non-curarized animals get severe convul- 
sions and, in the great majority of cases, extensive pulmonary oedema. 
In curarized animals, treated in the same way in other respects, oedema 
does not occur. Aftei' closure of the above-named arteries, the oedema 
was so marked as not to require a post-mortem to prove its existence. 
The tracheal canula was filled with a reddish frothy fluid within one or 
two minutes, and this fluid was so abundant as to render prompt artifi- 
cial respiration fruitless. Arterial tension is greatly increased by the 
anaemia of the brain, while the forcible respiration and muscular spasms 
certainly contribute materially to forcing the blood upwards to the right 
ventricle. In the curarized animal the muscular fibre is paralyzed, and 
consequently forcible respiration, spasms, and oedema are absent. In 
short, the conclusion is that those conditions which materially hinder the 
discharge of the blood from the left ventricle or the lungs bring about 
at the same time indirectly through the cerebral centres other condi- 
tions which increase the accessory onward pressure of the blood, and 
keep the right ventricle so fully supplied that stasis in and oedema of the 
lungs result. 
ATELECTASIS. 
BIBLIOGRAPHY. 
Smith: Med. Times and Gazette, 1873, March 22d.-Kjelberg: Behandlung 
der angeborenen Atelektase durch warme Wasserdampfe. Jahrb. fiir Kinderheil- 
kunde, N. F., VI., 61-65.-Hauke: Wien. med. Presse, 1774, XV., 34-36.-Rosen- 
bach : Berliner klin. Wochenschrift, 1878, No. 12.-Lichtheim: Versuche uber 
Lungenatelektase. Archiv fiir experiment. Path, und Pharmak., Bd. 10, p. 54. 
Lichtheim produced atelectasis experimentally on rabbits by closure 
of a main bronchus with laminaria tents, by ligation, and by opening the 
pleural cavity. His results confirm the idea of Virchow that the air 
which is shut in by the closure of the bronchus is absorbed by the blood- 
vessels, and go to show that the elastic contractility of the pulmonary 
tissue continues to act until the air is completely absorbed. 
He thinks his experiments show that atelectasis in connection with 
fluid in the pleural cavity is not always due to compression, as has been 
almost universally held. Very large effusions do, it is true, compress 
the lung and squeeze the air out of it; but a different explanation must be 
ETIOLOGY. ATELECTASIS. 
303 
given in some cases of moderate serous effusion in which the pressure 
exerted on the lung by the fluid must be decidedly less than the ordi- 
nary atmospheric pressure, and yet that portion of lung immersed in the 
fluid is leathery and completely devoid of air, though not also of blood. 
In these cases, that part of the lung which lies below the level of the 
fluid cannot follow the inspiratory enlargement of the thorax, and the 
air which it contains, not being renewed, must necessarily be absorbed. 
If this view be correct, the number of cases of atelectasis by com- 
pression is much smaller than has been supposed. 
TREATMENT. 
Kjelberg, ot Stockholm, recommends a new method which he has 
employed in three cases of congenital atelectasis. A wooden frame 
was placed over the bed and covered with blankets so as to form a sort 
of tent, and this was converted into a steam bath by keeping a vessel of 
hot water in it constantly, the water being renewed every half-hour. The 
temperature was thus kept at 26°-30° C. and the treatment continued 
during eight to fourteen days. As the respiration and general condition 
improved, the temperature was gradually lowered and the coverings re- 
moved, but the air of the room was still kept moist for some time. 
Hertz tried this method in one case, but had no great success with it, and 
truly remarks that the difficulties in the way of carrying it out thoroughly 
are not inconsiderable. 
The last-named author reports favorably on the use of compressed air, 
especially during the stage of absorption of pleuritic effusion (second 
edition of v. Ziemssen's Encyclopaedia). "I have repeatedly seen this 
method exert a favorable influence, not only in aiding the re-expansion of 
the lung and thus diminishing the risk of permanent deformity of the 
chest, but also in promoting rapid absorption of the fluid. It has been 
attended with specially happy results after thoracentesis. Expiration 
into rarefied air, should, however, be combined with the inspiration of 
compressed air to a certain extent, in order to avoid undue dilatation of the 
sound tissue. For 'when a considerable portion of lung is compressed the 
healthy portions are liable to be the seat of collateral hypersemia, with 
oedema and consequent loss in elasticity; and these parts will offer less 
resistance to the increase in pressure of the inspired air and be in danger 
of becoming permanently emphysematous." This method is to be pre- 
ferred to Hauke's pneumatic cuirass, which is said to exert eccentric 
force on the parietes and lungs when it is applied to the chest, and the 
air between the body and the cuirass is rarefied. It is true that Hauke 
recommends his procedure especially for asphyxia in new-born infants 
and collapse of the lung in children, cases in which co-operation on the 
part of the patient is, of course, out of the question. 304 
EMPHYSEMA-HAY ASTHMA. 
EMPHYSEMA. 
J. Lange: Heber das substantive Lungenemphysem und dessen Beliand- 
lung mit comprimiter Luft, 1870.-Waldenburg: Die lokale Behandlung der 
Krankheiten der Athmungsorgane, 1872.-Thierfelder: Pathol. Histologie der 
Luftwege, 1872.-Immermann: Correspondenzblatt der Schweizer Aerzte, 1873, 
No. 1.-Lange: Die pneumatischen Cabinette und die transportablen pneumat. 
Apparate. Med. Central-Zeitung, 1874, Nos. 28-30.-Hanish: Deutsch. Archiv 
f. klinische Med., 1874, Bd. XIV., p. 445.-Geyer: Diss. Jena, 1874.-Schnitz- 
ler: Wien. med. Presse, 1874, Nos. 14, 15, 17, 18, 22, 23. Wiener Klinik, 
Jahrg. I., 1875, Heft 6.-Stork: Mittheilungen uber Asthma bronchiale und die 
mechanische Lungenbehandlung. Stuttgart, 1875.-Ganghofner: Prager Vier- 
teljahrschr. f. pract. Heilkunde, Bd. IV., p. 79.-Waldenburg: Diepneumatische 
Behandlung der Respirations- und Circulationskrankheiten, Berlin, 1875.-• 
Biedert: Deutsch. Archiv f. klin. Med., 1876, Bd. XVII., p. 165, Bd. XVIII., p. 
115.-Cohen, J. S.: Therapeutic Uses of Compressed and Rarefied Air. Transact. 
Coll. Physicians of Philadelphia, 1876, p. 165.-Powell: On Some Effects of Lung 
Elasticity in Health and Disease. Medico-Chirurgical Transact., 1876, vol. LIX., 
p. 165. Eppinger: Das Emphysem der Lungen. Prager Vierteljahrschrift, 1876. 
Knauthe: Handbuch der pneumatischen Therapie. Leipzig, 1876; Bericht 
fiber pneumatische Therapie. Schmidt's Jahrbiicher, 1878, I., p. 135.-Berkart: 
On Asthma.. London, 1878.-Schnitzler: Asthma. Wiener med. Presse, 1880. 
BIBLIOGRAPHY. 
HAY ASTHMA. 
BIBLIOGRAPHY. 
Bt.acikt.ev: Cause and Nature of Hay Fever. London, 1874; New Observa- 
tions on Hay Fever. London, 1877.-Morrill Wyman: Autumnal Catarrh. 
Boston, 1876.-Beard: Hay Fever. New York, 1876. 
THEORY OF THE DEVELOPMENT OF EMPHYSEMA. 
That forcible inspiration may be a cause of emphysema is shown by 
Waldenburg's pneumatometric investigations. He found that in bron- 
chitis and asthma inspiration is normal, while expiration is deficient; 
the air is thus expelled through the narrowed bronchial tubes only im- 
perfectly, and carbonic acid accumulates sufficiently to increase the de- 
mands of the system for oxygen. This demand is partially satisfied 
through forcible inspiration, but at the same time more air enters the 
alveoli than can be expelled, and thus dilatation of the alveoli, loss of 
elasticity, and emphysema are induced. EMPHYSEMA. 
305 
Hertz thinks it very doubtful whether increase in the inspiratory force 
alone can produce emphysema in healthy lungs with unimpaired expira- 
tion; for it is reasonable to suppose that the increased pressure is, under 
these circumstances, so uniformly distributed throughout the lungs as 
to be incapable of doing mischief. According to Waldenburg, unwonted 
calls upon the respiratory organs, as in much mountain or stair climbing, 
may cause emphysema, and the author cites the case of a medical student 
in support of this view. The young man came from a small place where 
the houses were low to Berlin, and there took a lodging in the fifth story; 
he became emphysematous, apparently from mounting the four flights 
rapidly several times every day. Pepper (Phila. Med. and Surg. Repor- 
ter, April, '74, p. 373) thinks that prolonged and severe exercise of the 
muscles of the arms and shoulders, such as that to which some classes of 
laborers are subjected, produces emphysema through increase in the ex- 
piratory pressure; but Hertz regards this explanation as incorrect, and 
remarks that in cases of this kind there are probably primary nutritive 
changes in the lung tissue which act as predisposing causes, though their 
existence has not as yet been proved. 
Hertz expresses the opinion, furthermore, in the second edition v. 
Ziemssen's Encyclopaedia, p. 456, that the inspiratory as well as the ex- 
piratory act plays a part in the production of emphysema; the former in 
the diffuse form of the disease, the latter in those cases in which it is 
localized chiefly in the upper portions of the lungs. In the diffuse 
form, both acts may, indeed, contribute to the result; in chronic bron- 
chitis, for instance, increase in the force of inspiration tends to produce 
general dilatation of the alveoli, while the upper lobes bear the 
brunt of the heightened expiratory pressure incident to the attacks of 
cough. 
Whether asthma plays the part of cause or of effect may, in individual 
cases, be very difficult to determine. There is no doubt that asthmatic 
attacks intensify pre-existent emphysema, and that, vice versa, emphysema 
and the circulatory disturbance which it involves, favor the occurrence of 
asthma, the two having a very close relation to one another. The pneu- 
matometer shows deficient expiratory power in cases of asthma, without 
previous emphysema, precisely as in emphysema itself. 
This latter fact speaks in favor of the views of Berkart, who most 
vigorously and ably maintains that asthma is not a disease at all, but 
"only one link in a chain of quasi-independent affections, which com- 
mences with changes of the pulmonary tissue, and terminates with emphy- 
sema or bronchiectasis"-in fact, a symptom, indicating always structu- 
ral modifications of the lung tissue (see a review of Berkart, Boston Med., 
and Surg. Journ., Feb. 12th, 1880). 
PROGNOSIS. 
The experience of the last few years in the treatment of emphysema; 
shows that some cases may be even cured which were formerly supposed 
to be incapable of improvement, though this remark holds true only of 306 
EMPHYSEMA. 
cases in which there is some impairment of the elasticity, but no exten- 
sive rarefaction of the lung. 
It has been shown of late that the pneumatometer is of great service in 
prognosis, affording us information, not only as to the degree of existent 
deficient ins- or expiratory power, but also as to the value and effect of 
our therapeutic measures. Increase in the pneumatometric measure- 
ments and simultaneous improvement in the condition and symptoms of 
the patient are of favorable prognostic import, while non-increase or 
diminution are correspondingly unfavorable. The spirometer is also 
used by Waldenburg for purposes of prognosis; he finds that it is a rather 
unfavorable sign when the capacity of the lungs is diminished as much as 
fifty per cent-in men to 1,500-2,000 cc., in women to 1,000-1,500; but 
absolutely unfavorable if it be as low as 1,000-1,400 in men, and 700-1,000 
in women. It is, however, to be borne in mind that patients differ 
greatly in the skill with which they use the spirometer, and we should 
never, therefore, be content with the results of one trial, but repeat it sev- 
eral times on different days before drawing our conclusions. 
Assistance in prognosis may also be derived from the use of the pneu- 
matic apparatus with a view to the treatment of emphysema. It is of 
good import, showing that the thorax is distensible, and the lung still 
retractile, if an amount of air can be drawn out of the lung equal to the 
normal vital capacity; whereas with less amounts the contrary is true. We 
•can always, hence, be sure that there are textural changes in and atro- 
phy of the pulmonary tissue, for the repair of which there are, at present, 
no means in our power, when the spirometer shows small vital capacity, 
the pneumatometer low measurements, and at the same time the amount 
of air extracted by the pneumatic apparatus is relatively deficient. The 
worst cases are in persons advanced in years with ossified and fixed 
.thorax. 
DIAGNOSIS. 
These same instruments are also of service in diagnosis. 
The spirometer indicates, as in various other affections of the respi- 
ratory organs, the degree of diminution in the vital capacity; but does 
not enable us to distinguish between these affections. The pneumatome- 
ter, on the other hand, shows that in emphysema and bronchiolitis the 
■ expiratory force is diminished, while in phthisis the loss is in inspira- 
tion, and we are enabled to detect commencing emphysema with the aid 
of this instrument in people who appear quite well, complain of nothing, 
and are only slightly short of breath on exertion. Waldenburg's careful 
investigations show also that we can determine the degree of the affec- 
tion. In slight cases, in which dyspnoea is present only after unusual ef- 
fort, and there is no modification of the percussion note, it is found that 
the expiratory pressure is somewhat less than the inspiratory, instead of 
being decidedly greater, as it is under normal conditions. In a later stage 
of the disease, when slight exertion suffices to induce dyspnoea and per- 
, cussion reveals unquestionable pulmonary dilatation, it is found that the 
. expiratory is one-third or one-half less than the inspiratory pressure; the EMPHYSEMA. 
307 
latter remaining usually normal in amount, though it may be increased 
in order to compensate for the deficiency of the former. In the worst 
cases, finally, with bronchitis of years' standing, severe dyspnoea and 
asthma, cyanosis, oedema, and rigid thorax, the inspiratory pressure is 
found to be diminished also, though it still remains greater than the ex- 
piratory. 
The stethograph also affords valuable information, Riegel's observa- 
tions showing that expiratory insufficiency is indicated by very character- 
istic curves which deviate from the normal standard in proportion with 
the emphysematous changes in the lungs. The normal curve is repre- 
sented during inspiration by a gentle wavy rise with gradually increasing 
rapidity, and then gradual descent; during the transition from in- to ex- 
piration, by a line curved in the form of a bow which then descends with 
uniform rapidity until the respiratory pause. The curve of emphy- 
sema, however, has a much less gradual and an unduly rapid ascent dur- 
ing inspiration, and falls away at an acute angle during expiration, which 
latter is further characterized by increased duration and a rapidity which 
is at first normal, gradually decreases, and in the last third becomes very 
much less than it should be. 
The strikingly short in- and prolonged expiration, as contrasted with 
the nearly equal duration of the two acts in a healthy person, is very 
characteristic of emphysema, and Riegel holds that the change in their 
relations is exactly proportional to the loss of pulmonary elasticity. The 
lung which is already distended cannot take in much more air, but does 
its best with the aid of the accessory muscles of respiration. The enlarge- 
ment of the chest is not gradual as in healthy persons, but inspiration is 
rapid and brief, as is indicated by the steep rise in the curve, and the 
first portion of expiration is rendered relatively rapid by what elasticity 
is still retained by the lung, the pressure of the abdominal organs, and 
the tendency of the ribs to return to a position of rest. The second por- 
tion of expiration is more slow; and the last portion the slowest of all, 
for the reason that all save the accessory forces of the act have been ex- 
hausted during the first period, and these latter work feebly and at a dis- 
advantage against the resistance of the chest-walls. 
TKEATMENT. 
According to Berlcart, the nutritive changes in the pulmonary tissue 
which are in the course of time followed by emphysema and asthma, are 
in the great majority of cases traceable to chronic bronchitis, and catar- 
rhal pneumonia complicating whooping cough, measles, and typhoid fe- 
ver; it may hence be in our power by careful treatment of these affections 
to save persons from much future misery. Whether this view be correct 
or not time will show; but, if we err at all, we shall certainly err on the 
safe side in attempting to keep under and cut short; as far as possible those 
affections in which inflammation of the bronchi has a tendency to spread 
to the parenchyma of the lung. Nor is this all; careful attention to hy- 
gienic measures should also be enforced after the symptoms of these af- 308 
EMPHYSEMA. 
fections have subsided, that the general nutrition may be raised to the 
highest possible point, and the lung tissue thus restored to a perfectly 
healthy condition. Cases in which an hereditary tendency to emphysema 
and asthma is discovered should, of course, engage our most earnest at- 
tention. Asthma having been generally considered hitherto as depend- 
ent on derangement of the central nervous system, treatment has been 
directed almost exclusively to the palliation of the dyspnoeal paroxysm, 
and the underlying condition has been greatly neglected. It should be 
our object to arrest the progress of existing pathological lesions and to 
maintain the healthy portion of the lung in a state of greatest efficiency; 
the proper way to attain this object being to improve the nutrition of the 
body in general, and indirectly that of the lungs, and to restore the nor- 
mal function of the bronchial surface. 
Fresh air, sunlight, warm clothing, cleanliness, suitable exercise, and 
careful attention to the gastric and intestinal digestion, are the most im- 
portant points. Proper ventilation of the sleeping room is of prime mo- 
ment. 
There are certain patients who are so afraid of fresh air that its 
effect on them is almost like that of alcohol. The chemical changes 
of the body which have been hitherto at the lowest ebb are roused by a 
free supply of oxygen to an energy previously unknown, at times even so 
great as to produce an almost febrile condition. Moreover, by prolonged 
confinement in impure air, the bronchial mucous membrane is apt to be 
anaesthetized by the narcotic influence of the carbonic acid; then, on ex- 
posure to a pure atmosphere, the membrane recovers part of its sensibil- 
ity, and cough is readily induced. But this return of bronchial sensibil- 
ity is not regarded by these patients as a favorable sign, rather as a " fresh 
cold " and they refuse to continue the treatment, returning to narcotics 
in order to suppress the cough. Hence, the longer they have breathed 
in a vitiated atmosphere, the more gradually are their habits to be changed; 
otherwise the neglect of this precaution would deprive the sufferers of 
the benefit of the treatment, and cause the practitioner the annoyance 
of seeing his best efforts frustrated (Berkart). Sufferers from hay asth- 
ma or autumnal catarrh cannot, of course, afford to fight out their an- 
nual attack, but must, if it be possible, take refuge in some spot which 
gives them immunity from their enemy. [Reference is made in the 
bibliography at the beginning of this article to the most important re- 
cent monographs on this subject. ] 
The medical literature of the pneumatic treatment since the publication 
of the first edition of v. Ziemssen's Cyclopaedia is enormously copious, but 
there is not much which is really new. Waldenburg's apparatus has 
been modified by Schnitzler and others, but the underlying principles re- 
main the same. Schnitzler has, for instance, constructed an apparatus- 
it is called of twin cylinders; one of these contains 
compressed, the other rarefied, air; and the patient can thus change 
readily from one to the other, economizing his own time as well as that 
of the physician. EMPHYSEMA. 
309 
In the second edition of v. Ziemssen's Encyclopaedia, Hertz has greatly 
modified and enlarged his remarks on the pneumatic treatment as con- 
tained in the first edition; and as it is not likely that any further change 
of consequence would be made if a third edition were to appear now, I 
shall simply translate a short portion of his exposition. 
The favorable results which have been obtained by the use of the 
pneumatic apparatus these last five years ('72-'77) show that in it we 
have a valuable means of alleviating and curing emphysema. According 
to Waldenburg, expiration into rarefied and inspiration of compressed 
air are indicated in all cases of obstinate bronchitis, in which the pneu- 
matometer indicates expiratory insufficiency, whether there be any other 
sign of emphysema or no. In case the pneumatometric measurements 
do not increase at all after several weeks' use of the apparatus, or if 
the thorax be rigid and we are satisfied that there is already extensive 
atrophy of the parenchyma of the lung, the treatment is to be discon- 
tinued, as it only serves unnecessarily to fatigue the patient. The pneu- 
matic treatment is, moreover, contra-indicated if there be secondary de- 
generation of the heart. 
The effects of the pneumatic apparatus in emphysema are then briefly 
as follows: 
By expiration into rarefied air: 1. An increased amount of residual 
air and carbonic acid are sucked out of the lung, and consequently more 
oxygen can be absorbed and pulmonary ventilation is furthered. 2. The 
lung is diminished in size more than after an ordinary expiration. 3. 
This diminution becomes gradually permanent, as is evidenced by per- 
cussion and direct measurement; and 4. Simultaneously with the gain in 
elasticity of the lung and the diminution in the residual air, the vital 
capacity is increased. 
Inspiration of compressed air undoubtedly leads in time to dilatation 
of the lungs, and thus acts directly contrary to the above treatment 
unless it be practised with the greatest caution; with this proviso, how- 
ever, it is unquestionably of service in emphysema, inasmuch as it tends 
to counteract hyperaemia of the bronchial mucous membrane, whether 
this hypersemia be already present and intensified, or called forth by the 
use of the rarefied air. Compressed air also increases the force of the 
cardiac contraction and heightens the pressure in the systemic circula- 
tion, as is shown by the pulse becoming harder, and thus relieves the 
pulmonary circulation ; it may, furthermore, act as an expectorant in 
bronchitis, the aerial current dislodging mucus impacted in the finer 
tubes. In the treatment of emphysema, consequently, a subordinate and 
symptomatic position alone can be accorded to the inspiration of the 
compressed air, whereas expiration into rarefied air is to be regarded as 
directly curative. 
As for medicinal treatment, Germain See {Gazette Med. de Paris, 
1878, p. 69) uses iodide of ethyl and iodide of potassium in asthma. 
The former is given by inhalation during the paroxysm, in a dose of five 
to ten drops and, it is said, with very satisfactory results. The potash is 310 
EMPHYSEMA. 
given in the intervals between the attacks to ward off their occurrence. 
He gives twenty to forty-five grains per diem and is not afraid of iodism 
which he combats by increasing the dose of the drug. In twenty-four 
cases treated in this way, which have been under observation for several 
years, the results are very satisfactory. 
Dr. J. P. Oliver, of Boston, has also used large doses of iodide of 
potash in asthma of late with surprising success {Boston Med. and Surg. 
Jour., Feb. 19th and March 4th, 1880). He increases the dose gradually 
up to fifty or sixty grains per diem and continues it for a long time, 
warning the patient not to expect relief too soon and that six weeks may 
elapse before any change can be noticed. Some of his patients were 
unable to take the iodide, even in small doses, and he then substitutes 
hydriodic acid. The syrup of hydriodic acid prepared by Robert Gardner, 
of New York, he considers the best form of administration, it being 
agreeable to the taste and not very likely to be affected by exposure to air 
and light. He begins with small doses, twenty or thirty drops well 
diluted with water, and taken half an hour to an hour before meals; if 
taken after meals it may disturb the stomach. The dose is gradually 
increased, but should not exceed a tablespoonful. In cases of chronic 
bronchial catarrh, and in fact in all cases where iodine is indicated, he 
has found this syrup of great value. The above is taken from a mere 
preliminary notice of the method of treatment, a more detailed account 
of which, with a large number of cases, is to appear in the Boston Medi- 
cal and Surgical Journal shortly. 
Westbrook {Proceedings Med. Soc. Kings Co., N. Y., 1879, IV., p. 7) 
reports ten cases of asthma with bronchitis and emphysema, all of 
which were greatly relieved by iodide of potash which he usually gives in 
seven and a half grain doses four times a day. 
It should be mentioned that iodide of potassium is contra-indicated 
when the bronchial mucous membrane is acutely inflamed; the iodine in 
contact with the atmosphere being disengaged from its combination 
with the albumen of the blood, and when thus set free being apt to irri- 
tate the surface of the air passages. 
Penzoldt {Berlin klin. Wochenschrift, No. 19, 1879) first called at- 
tention to the value of quebracho bark-from a Brazilian tree-as a 
remedy for dyspnoea, whatever its cause apparently. It is said that 
South American physicians attribute antifebrile qualities to the remedy, 
similar to those of quinine. Penzoldt could see no effects from the drug 
when used as an antipyretic, but found that the alcoholic extract of the 
bark dissolved in water had a marked effect on dyspnoea, decreasing the 
frequency of and greatly facilitating respiration. He gave the drug to 
hospital patients with emphysema (both simple and complicated by bron- 
chitis), phthisis, chronic pneumonic processes associated with periodic 
attacks of an asthmatic nature, pleurisy, etc., and concludes that "we 
possess in quebracho bark a remedy which affords more or less complete 
relief for hours from the various forms of dyspnoea incident to diseases of 
the organs of respiration and circulation; without, at the same time, EMPHYSEMA. 
311 
producing any sort of disturbance. Its action is manifested by decrease in 
the frequency, and often in the depth, of respiration, diminution of the 
cyanosis, and, above all, improvement in the subjective condition of the 
patient." 
Berthold and Picot (Berl. Idin. Wochenschrift, No. 52, 1879) also 
report on the drug. The former found relief from it in only two out of 
six cases of phthisis. The latter administered it in dyspnoea from catarrhal 
pneumonia, asthma, and valvular disease of the heart-of each one case 
-with decidedly beneficial effect. He then took it himself while on a va- 
cation tour in the mountains and was satisfied that the drug enabled him 
to walk up hill with much less fatigue and shortness of breath. 
This is, of course, far too slender a basis of facts to enable us to decide 
on the merits of the remedy, and it is more than possible that further 
investigation will consign quebracho to the place occupied by so many of 
the drugs of the pharmacopoeia, but no harm can apparently come from 
giving it a fair trial. The writer is informed by a competent authority 
that the bark is not at present to be had in this country, but that it will 
be on hand before this volume appears in print. 
Since the above was written, a new report has come in from 
Laquer {Wiener med. Presse, Jan. 25th, 1880). He administered the 
remedy according to the following formula: 
Ext. corticis quebracho, 
12. 
Mucilag. gum. acac., 
. 40. 
Aquae, . 
. 200. M. 
to twelve patients with emphysema and. severe bronchits. In some cases 
decided relief followed a dose of one to two teaspoonfuls, but in others no 
effect was observed. He tried it also in one case of valvular disease of 
the heart, but it seemed to aggravate the sufferings of the patient, and he 
did not feel encouraged to give it to other cases of the kind. 
With a view of ascertaining whether the remedy produced permanent 
or only temporary relief, it was then administered in doses of one to 
two teaspoonfuls thrice daily in nine cases of emphysema, one of chronic 
bronchitis, and one of right pleurisy. The results were not unsatisfac- 
tory, though not as good as had been hoped for. In some of the cases 
the drug caused, after a few days, headache with a sensation of heat and 
confusion in the head and giddiness, these symptoms increasing so that 
the patients begged to be let off. 
Conclusions.-1. The drug appears to be a useful palliative in many 
cases of dyspnoea in emphysema and chronic bronchitis; but in other 
cases, especially in old people, is of no service. 
2. After prolonged administration, various disagreeable effects may 
appear, rendering it necessary to omit the medicine. 
3. The frequency of respiration is diminished with a certainty pro-* 
portional to its previous increase above the normal standard. The 
remedy has no constant effect on the pulse. 312 
GANGRENE OF THE LUNG. 
GANGRENE OF THE LUNG. 
BIBLIOGRAPHY. 
Traube: Berliner klin. Wochenschrift, 1871, No. 25.-Louisa Atkins: Ueber 
GangranaPulmonumder Kinder. Dissert., Zurich, 1872.-Lancereaux: Archives 
Generates de Med. Mars, 1873.-Foot: Dublin Jour. Med. Sciences, Jan., 1873. 
-Zuchner : Ueber Lungenbrand. Dissert., Berlin, 1874.-Bucquoy: L'Union 
med., 1875, Nos. 84-95. Bull. gen. de therapeutique, 15 Aout, 1875. Gazette des 
Hopitaux, 1879, p. 738.-Hanot: Progres med., 1876, No. 4.-Refer: Med. Cen- 
tralzeitung, Mai, 1876.-Huntington : Boston Med. and Surg. Journ., 1876, II., 
p. 485. Remarks on Thirty-two Cases of Pulmonary Gangrene.-Filehne: Ueber 
die Vorgange bei dem Lungenbrande, etc., etc. Schmidt's Jahrbiicher, 1877, Bd. 
185, p. 33.-Kersten : Ueber Lungenbrand, Berlin, 1878.-Curschmann: Zur 
Lokalbehandlung der putriden Bronchial- und Lungenaffectionen. Berliner klin. 
Wochenschrift, 1879, Nos. 29 and 30. 
In the second edition of v. Ziemsseri's Encyclopaedia, Hertz adds that 
diseases or conditions which involve very great prostration with degene- 
ration of the heart and sluggish circulation may result in thrombosis 
in the systemic veins, infarction, and gangrene of the lungs. Steffen 
suggests the possibility of thrombosis of the vessels of the lung in conse- 
quence of feeble and superficial respiration. Some English writers have 
supposed the existence of what they call " gangraemia "-a special condi- 
tion of the blood favorable to the occurrence of gangrene-but Hertz 
knows of no case which does not admit of some more satisfactory explana- 
tion. He cites five cases in which blows and falls on the chest or shoulders 
have been followed by gangrene-traumatic-and a case is reported 
by IFhAZ {Schmidt's Jahrb., 1878, Bd. 178, p. 32) of a man who re- 
ceived a violent blow on the head, laying bare, though apparently not 
fracturing the skull. The patient kept his bed for five days without an 
unfavorable symptom, but then, his wound being healed, he rose contrary 
to advice and began to work. Almost immediately he had a chill 
followed by pain in the region of the right nipple, gangrene of the lung, 
and death. 
Magrath {Lancet, 1880, I., p. 89) reports a case of the passage of a 
head of grass into a bronchus with death after twelve weeks. The grass 
was found in the lower right lobe, about one-third of which was gan- 
grenous. The diaphragm was perforated, the upper surface of the liver 
showed commencing softening, and the right side of the bodies of two 
dorsal vertebrae were excavated and carious. There are a number of simi- 
lar cases on record, but it is on the whole surprising how large a propor- 
tion of the foreign bodies which get into the lungs are sooner or later 
expelled with final recovery on the part of the patient. 
ETIOLOGY. GANGRENE OF THE LUNG. 
313 
Hertz states, but without quoting his authority, that gangrene of the 
lung has been noted with special frequency during epidemics of diph- 
theria. Nothing is definitely known as to the relations of the two diseases, 
but the idea is suggested that, in those cases especially in which they are 
co-existent, the gangrene is really to be regarded as pulmonary diph- 
theria caused by low organisms. 
Lancereaux has found bacteria in the gangrenous fluid and in the blood 
after death; he inoculated a rabbit with a very small quantity of the lat- 
ter, causing death in twenty-four hours, and found precisely similar 
organisms in the animal's blood. 
DIAGNOSIS AND PROGNOSIS. 
Traube and Leyden consider the absence of elastic fibres in the spu- 
tum as very characteristic of grangrene as contrasted with other affections 
which involve destruction of the pulmonary tissue. 
Fileline thinks that the statements of the above-named authors are 
too strong, though he allows that the elastic fibres are often absent, or 
present in far less numbers than one would naturally expect. He was 
led to experiment with a view to explaining this fact, and his results seem 
to show that gangrenous sputum or pulmonary fluid contains some fer- 
ment which has the property of dissolving albumen and elastic tissue, 
while it does not attack fibrous tissue. 
Bucquoy thinks that by observance of the following points a diagno- 
sis may be often made before the sputum becomes offensive. As was 
first remarked by Stokes, the pain in the side is far more obstinate and 
severe than in any pleurisy or pneumonia; the temperature and pulse rate 
are not increased in proportion to the general phenomena of the disease, 
while dyspnoea and prostration of the system are very extreme. It is 
conceivable, of course, that the diagnosis should be reached from these 
symptoms alone, especially if the gangrene be diffuse, but we know that 
when it is circumscribed the disease may be far removed from the sur- 
face of the lung, and that the symptoms may not be very marked at first. 
On the other hand, the fever may be very intense in either form. 
Huntington has collected thirty-two cases from the records of the 
Massachusetts General Hospital, being all the cases of the kind admitted 
from 1857 to 1875 inclusive. The results being brief and decidedly more 
favorable than leading authorities would allow us to expect, they are given 
in full. Seven cases were discharged well; six much relieved (these with 
proper care and favorable circumstances doubtless proceeded to ultimate 
recovery); three cases were temporarily relieved; five were not relieved, 
two of which were in the hospital but a brief period and were not treated; 
eleven cases terminated fatally. 
COMPLICATIONS. 
Cases with complication, .... 
a • 
10 
Cases without complication, . . ■ . 
22 
Phthisis as a complication occurred in . 
• • 
8 314 
GANGRENE OF THE LUNG. 
Emphysema as a complication occurred in ... . 
1 
Cancer of the oesophagus as a complication occurred in 
1 
In seven of the cases without complication gangrene followed pneu- 
monia, and was diffuse. Leaving them out of the discussion, the follow- 
ing statement can be made. Of the fifteen cases without complication, 
five were well, six much relieved, one was relieved temporarily, three not 
relieved, none died. In other words, among the cases of circumscribed 
gangrene there were eleven favorable and four unfavorable terminations. 
On the other hand, of the complicated cases, four died, two were not 
relieved, two were temporarily relieved, and two were cured of gangrene. 
That is, two terminated favorably as far as the disease under considera- 
tion is concerned, and eight terminated unfavorably. 
Summary of results and complications. 
CASES WITHOUT COMPLICATION'S. 
Terminated favorably, 
" unfavorably, • 
73.3 + per cent. 
■ 26.6 + " " 
CASES WITH COMPLICATIONS. 
Terminated favorably, 
20 per cent. 
" unfavorably, 
80 " " 
Bucquoy recommends highly the tincture of Eucalyptus globulus in 
two-gramme doses, finding that the drug has a very marked effect on the 
fetor of the breath and sputum, and also alleviates the cough. 
Draper (Boston Med. and Surg. Journ., 1876, II., p. 595) reports 
the successful use of salicylic acid in ten-grain doses, thrice daily. 
Wys has used creasote by inhalation with benefit, a few drops being 
poured on flannel, and prefers it to turpentine, as being less disagreeable 
and irritating. 
Curschmann has employed since 1871, in private and hospital prac- 
tice, a mask which covers the mouth and nose and resembles in appear- 
ance the mouth-piece of Waldenburg's pneumatic apparatus. A compart- 
ment in the mask or respirator is filled with sponge to receive the remedy-• 
turpentine, carbolic acid, thymol, creasote-and the apparatus is recom- 
mended in all pulmonary affections characterized by fetid breath and 
expectoration. His experience with gangrene seems to be very slight, 
the cases being chiefly of putrid bronchitis and bronchiectasis. Car- 
bolic acid was used in very strong alcoholic solution and also pure after 
having been liquefied by heat, giving rise to no unpleasant symptoms 
even when the respirator was worn for days; thymol was always used in 
alcoholic solution. The solution of either remedy has the advantage that 
the drug is thus more volatile, but the disadvantage, on the other hand, 
of being more irritating, and hence more likely to excite cough. The 
fetor was sometimes greatly diminished within twenty-four hours, 
though usually a somewhat longer period was required, and in many 
TREATMENT. GANGRENE OF THE LUNG. 
315 
instances was entirely relieved; fever dependent on. decomposition in 
the secretion ceased, and the bodily weight came up. Turpentine and 
creasote were used in the pure state, and the latter is preferred in cases 
with a tendency to haemoptysis. It would seem worth while to try this 
method of treatment in some cases of circumscribed gangrene. 
Two cases have been reported recently in England in which gan- 
grene of the lung was treated by incision. Both were very severe and 
terminated fatally, though the operation afforded marked relief. The 
first of these cases is reported by Cayley {Lancet, 1879, I., p. 440). 
A man of forty entered the Middlesex Hospital, having been ill five 
weeks, and had fetid cough and expectoration two weeks. Prostration 
and emaciation were extreme, and small quantities of brownish, hor- 
ribly offensive mucus were raised with great difficulty. The signs pointed 
to consolidation at the right base, but it was inferred that there was a 
full cavity at the spot, and an exploratory puncture was made with an 
aspirator needle. A few drops of fetid pus coming out, an incision three 
inches long was made in the ninth interspace, on a line with the lower 
angle of the scapula. About five ounces of frightfully offensive pus and 
several bits of gangrenous lung-tissue escaped; a drainage tube was 
inserted, and the cavity was washed out twice daily. The patient experi- 
enced great relief, ceased to cough and raise fetid mucus, the bad smell 
disappeared, and the temperature, which had been very high, fell to the 
normal point. He died of prostration five days after the operation. At 
the autopsy it was found that the right lower lobe was consolidated by 
pneumonia and firmly adherent to the chest-wall. The point where the 
cavity was most superficial was more than an inch from the surface of 
the lung. 
In the second case, Smith {Lancet, 1880, I., p. 86), gangrene super- 
vened on right pneumonia in a man of over sixty years of age. His con- 
dition became most critical and a cavity was detected in the right middle 
lobe. On consultation, it was decided that the only chance for life lay in 
opening the cavity and evacuating the contents, especially as the dis- 
charge was not free through the bronchial tubes. An aspirator needle 
was introduced to the depth of three or four inches near the angle of the 
scapula; no fluid escaped, but there was a gush of very foul air, and, on 
holding a candle near the open canula, the flame was blown to and fro 
Avith respiration. The canula was then used as a director; a knife was 
passed in between the ribs, and by its side a pair of dressing forceps, by 
opening which the wound was dilated sufficiently to allow of the intro- 
duction of a drainage-tube. Through this a little carbolic lotion was 
injected, which seemed to excite a coughing-fit and the forcible expul- 
sion of half a pint of fetid pus. For the first week after the operation 
the improvement was very decided, but a change for the worse then set in 
and the patient gradully sank. There was no autopsy. Mr. Smith's ' 
conclusions are: "(1) When the opening through the bronchi seems 
to be insufficient as an exit for the fluid, or the passage of the gangren- 
ous ichor seems to be setting up irritation in the bronchial mucous 316 
NEW GROWTHS IN THE LUNGS. 
membrane; (2) the patient appears to be sinking rather than rallying; 
and (3) auscultation shows the presence of a cavity, an incision with a 
view to drainage is justifiable." 
NEW GROWTHS IN THE LUNGS. 
BIBLIOGRAPHY. 
Harting and Hesse: Der Lungenkrebs-die Bergkrankheit in den Schneeberger 
Gruben. Vierteljahrschrift fur Gerichtliche Medicin, 1879, Apr., July, Oct.- 
Schmidt's Jahrbucher: 1879, II., p. 81 et seq.-Finlayson: Primary Epitheli- 
oma of the Lung. Medico-Chirurg. Trans., Vol. LX., p. 313. 
Finlayson adds three cases-one of his own-to the short list of obser- 
vations of primary epithelioma of the lung, and many cases of the more 
common varieties of new growths in the lungs have been reported since 
1874. The only article which requires especial reference is, however, 
that the title of which heads the above bibliography. 
At Schneeberg, in south-western Saxony, there is a large cobalt mine, 
affording employment in 1877 to five hundred and eighty-four persons 
in all, and it has been known for some time that the workmen at this 
mine were especially liable to a peculiar thoracic affection, the nature of 
which the painstaking investigations of our authors go far to explain. 
Until seventeen years ago, the disease was regarded simply as consumption. 
The arrangement of the article is so involved and lacking in clearness 
that it is a difficult matter to extract from it a clear statement of the 
disease. I will, therefore, begin by stating they- conclusions, and then 
enlarge upon them somewhat. 
1. The disease endemic in the Schneeberg mines is pulmonary cancer 
and is the cause of about seventy-five per cent of all the deaths among 
the employees. 
2. The disease assumes the form of lymphosarcoma, though in rare 
cases of endothelial carcinoma; both forms are, however, intimately con- 
nected, and originate invariably in the bronchial glands. 
3. All of the miners who do not die from some accident incident to 
calling or from some intercurrent affection, as it were, finally fall vic- 
tims to cancer of the lung. 
4. The disease never appears earlier than twenty and rarely later than 
fifty years after the occupation was embraced. The miners, especially 
those who are continuously employed in the drifts, are affected sooner than 
the masons and timber cutters, who do not pass their whole time under 
ground, and are occasionally furloughed. 
5. A low condition of the general nutrition and previous affections of 
the lung or pleura, and emphysema, are all predisposing causes. NEW GROWTHS IN THE LUNGS. 
317 
6. The immediate cause of the disease is arsenic, which in this mine 
is found unconibined with sulphur in the regulus of cobalt; is inspired; 
passes into the lymphatic current; is arrested in the bronchial glands, 
and there sets up an irritation which eventuates in sarcoma. 
In most arsenic-bearing mines that metal is combined with sulphur, 
and the sulphide, being insoluble, is vastly less poisonous. The work- 
men in the mines of Sweden, Hungary, and Tyrol are said to be free 
from any disease of this nature, and there is little doubt that the depth 
of the mine and the difficulties in the way of ventilating it are not with- 
out a certain influence. 
The anatomical • appearances are shown by twenty autopsies to be 
briefly as follows: 
The cutaneous veins of the neck, chest, and arms, especially on 
the affected side, are generally unduly prominent. The mucous mem- 
branes are pale, -often livid, and the nails are almost always incurved. 
The intercostal spaces are broad, but the affected side of the thorax is 
rarely notably enlarged. The pleura of the side which contains the 
tumor is distended by a moderate effusion, which is sometimes blood- 
stained, and adhesions are always found at the root of the lung. 
The affected lung is diminished in size, sometimes very markedly, and 
the tumor is generally unilateral, yellowish-white in color, in some 
cases confined to the root of the lung, in others involving one or even 
both lungs, the pleura, mediastinum, pericardium, etc., and of large size. 
The disease may extend to the ribs or sternum, and secondary nodules 
of larger or smaller size are often found in the liver. No constant 
changes are found in any of the other organs which can be connected with 
the affection under consideration. The nodules are found only in the 
lungs in some cases, and when present in other organs are always more 
recent; tubercles have never been observed. The disease starting as a 
growing tumoi' at the root of the lung, the symptoms are usually very 
ill-defined at the commencement, and in some cases never assume any 
prominence. Later they vary of course according to the direction taken 
by the growth and the parts compressed by it, though a general cachexia 
is well marked. The duration of the disease, dating from the time when 
medical aid is first invoked, varies usually between six and eighteen 
months, though in one case three years elapsed; and at the autopsy a 
fattily degenerated tumor the size of a hen's egg was found at the root of 
the lung. 
Treatment has hitherto proved practically of no avail. 
Out of an average total of 650 employees, the disease has proved fatal 
as follows: 
1869-1871, 
• . . . 63 cases. 
1872-1874, . . . . 
47 " 
1875-1877, 
. 40 " 
The authors claim only approximate accuracy for these figures and 
attribute the diminution in the number of cases of late to the adoption 
of hygienic measures, especially to improved ventilation of the mine. 318 
PULMONARY CONSUMPTION. 
PULMONARY CONSUMPTION. 
BIBLIOGRAPHY. 
PlDOUX: Etudes generates et pratiques sur la phthisie, 1873.-MASSINI: Ueber 
die Heilbarkeit der Lungenschwindsucht. Deutsch. Archiv fur klin. Med., 1873, 
Bd. XI., p. 446.-Sommerbrodt: Ueber die Abhangigkeit phthisischer Lungener- 
krankungenvon primaren Kehlkopfaffectionen. Arch, fur experimentelle Patho- 
logie, Bd. I., 1873.-Mosler: Ueber Zokale Behandlung von Lungencavernen. 
Berliner klin. Wochenschrift, 1873, No. 43.-Bennet: Recherch.es sur le traite- 
ment de la phthisie pulmonaire. Paris, 1874.-Metzquer: Etude clinique de la 
phthisie galopante. Paris, 1874.-Frantzel: Ueber den inneren Gebrauch von 
Atropinum Sulph. bei profusen Schweissen, etc. Virchow's Archiv, Bd. 58.- 
Weber: The Communicability of Phthisis from Husband to Wife. Trans. London 
Clinical Soc., 1874.-Flint: On Phthisis. Lea, Philadelphia, 1875.-Duhrssen: 
Ueber die Behandlung der Haemoptoe. Deutsches Archiv fur klin. Med., 1875, 
Bd. 16, p. 93.-Friedlander: • Experimenteluntersuchungen uber Lungen- 
schwindsucht and chronische Pneumonie. Virchow's Archiv, 1876, Bd. 67, p. 
234.-Muller: Statistische Beitrage zur Beleuchtung der Hereditatsverhalt- 
nisse bei der Lungenschwindsucht. Inaugural Diss., Berne, 1876. Deutsch. 
Archiv fur klin. Med., Bd. 18, p. 521.-Williams: Lettsomian Lectures on the 
Influence of Climate in the Treatment of Pulmonary Consumption. Brit. Med. 
Journ., 1876, Vol. I.-Hayden: Abstract of 330 Cases of Phthisis. Dublin Jour. 
Med. Sciences, 1877, II., p. 493.-Geddings: Aiken as a Health Station. Charles- 
ton Med. and Surg. Journal, 1877.-Gleitsmann: Western North Carolina as a 
Health Resort. Phila. Med. and Surg. Reporter, Feb., 1876. Contribution to the 
Treatment of Pulmonary Phthisis. New Orleans Med. and Surg. Journal, July, 
1877.-McCall Anderson: Lectures on Clinical Medicine. London, 1877.- 
Loomis: Climatic Treatment of Phthisis. Trans. Am. Med. Assoc., 1878, p. 124. 
-Green: The Pathology of Pulmonary Consumption. London, 1878.-Fother- 
gill: The Early Treatment of Phthisis. Practitioner, 1878.-Holden: Is Phthisis 
Contagious? Am. Jour. Med. Sci., July, 1878.-Webb: Is Phthisis Contagi- 
ous? Am. Jour. Med. Sci., April, 1878.-Thompson: The Pathological Traces of 
Pulmonary Hemorrhage. Medico-Chirurgical Trans., LXL, p. 253.-Powell: 
Consumption and Certain Diseases of the Lung and Pleura. London, 1878.- 
Blau: Die kasige Pneumonie und Diabetes. Schmidt's Jahrbiicher, 1878, II., p. 
76.-Lente: The Constituents of Climate with Special Reference to Florida. 
Richmond and Louisville Med. Jour., August, 1878.-Chaille: The American 
Mountain Sanitarium for Consumption, at Asheville, N. C. New Orleans Med. 
and Surg. Jour., April, 1878.-Loomis: The Adirondack Region in the Treatment 
of Phthisis. Trans. N. Y. Med. Society, 1879, p. 403.-Flint: Self-limitation in 
Cases of Phthisis. Archives of Med. (N. Y.), June and Oct., 1879.-Leaming: A 
New Classification of Phthisis. Archives of Med., June, 1879.-Wernich: Die 
Lungenphthise. Wann steckt es an? Berliner Wochenschrift, 1879, pp. 354 and 
370.-Charcot: The Pathological Anatomy of Phthisis. Lancet, 1879, II., 963 
and 1880, I., 182.-Brunton: Pathology of Night-sweats and Mode of Action of 
Strychnia, etc. St. Bartholomew's Hospital Reports, 1879.-Peter: Des tempera- 
tures locales dans la phthisie pulmonaire. Bull, de 1'Acad. de med., 2me Serie, 
VII., No. 37. Revue des Sciences Medicales, 1879, XIV., 151.-Lebert: Traite 319 
PULMONARY CONSUMPTION. 
clinique et pratique de la phthisie pulmonaire et des maladies tuberculeuses des 
divers organes (posthumous work), Paris 1879.-Dobell: Loss of Weight, Blood- 
spitting, and Lung Disease. Philadelphia, 1879.-Fonssagrives: Therapeutique 
de la phthisie pulmonaire basee sur les indications, II. ed., Paris, 1880.-Deni- 
son : Rocky Mountain Health Resorts (with Copious References to Climatic Liter- 
ature), Boston, 1880.-McCall Anderson: Further Remarks on the Curability of 
Galloping Consumption. Glasgow Journal, 1880.-Hamilton: On Catarrhal 
Pneumonia and Tubercle in the Human Lung. Practitioner, 1880.-Thomson: 
On Phthisis and the Supposed Influence of Climate. Melbourne, 1879. Review 
in Dublin Journal, May, 1880.-Peter: Legons de clinique medicale. Tome II., 
Paris, 1879. Rev. in Edinburgh Jour., April, 1880. See also Schmidt's Jahr- 
biicher, the Jahresberichte von Virchow and Hirsch, the Index Medicus, Reports 
of Colorado State Board of Health, etc., etc., for articles of minor importance not 
included in the above Bibliography. 
For the sake of clearness and convenience, it is proposed to treat 
under this head of phthisis from a clinical point of view chiefly, but little 
attempt being made to distinguish the tubercular from the inflammatory 
form. For references and remarks as to the artifical production of 
phthisis and allied diseases, the reader is referred to the article on tuber- 
culosis. 
The question as to the communicability and the means of communi- 
cation of phthisis from one individual to another has been brought into 
renewed prominence recently. In evidence of the view that the disease is 
not so communicated, Cobrings forward the fact that out of the large 
number of clinical assistants and attendants connected with the Brompton 
Consumptive Hospital between the years 1846 and 1867, very few indeed 
have ever contracted the malady. The chaplain has been at the institution 
seventeen, the matron sixteen years. This fact speaks well for the hygienic 
arrangement of the hospital, and the care with which the nurses are 
selected, but nothing more. As Webb nqtj justly observes, there is a 
great difference between the nursing of the phthisical in hospitals and in 
private practice. In the former, there is one skilled nurse to a dozen 
patients or so, and the nurse occupies her own apartments after being on 
duty for a portion of the twenty-four hours, more or less careful precau- 
tions being observed as to ventilation and the like. In the latter, the 
nurse is generally some member of the family or a friend, unskilled, and 
the circumstances under which the office of nursing is performed are apt 
to be such as to increase the risk of contagion. 
Walshe in 1860 was not prepared to admit that the evidence of con- 
tagion was by any means conclusive, but said in 1871, " My belief in the 
reality of such transmissibility has of late years strengthened. I have 
now met with so many examples of the kind that coincidence becomes it- 
self an explanation difficult of acceptance." The evidence adduced by 
Weber, Webb, Holden, Wernich, and others is overwhelming. Weber has 
collected the histories of twenty-nine marriages of phthisical women to 
healthy men, and fifty-one marriages of healthy women to phthisical men. 
But one of the healthy men contracted the disease, while eighteen of 
the healthy women fell victims. Weber thinks that these facts indicate 320 
PULMONARY CONSUMPTION. 
transmission through the semen, but this explanation seems rather far- 
fetched. It is very rarely that the male is so constantly exposed to the 
emanations from a consumptive partner as is the female when the con- 
ditions are reversed; and the reasons are obvious. One of Weber's 
phthisical males sacrificed four wives, another three, and four two each. 
Holden thinks that the Brompton experience negatives the possibility of 
infection through the atmosphere where ventilation is observed, and be- 
lieves " that consumption is communicable in its later stages by means of 
soluble excrcmentitious mattei* thrown off by the skin and deposited on 
the bedding or underclothing, or in any other manner brought into con- 
tact with the naked surface of a healthy body; and that, although in 
some instances this may be thrown off without development into new 
disease, it is yet very liable to be so developed, and more liable when the 
healthy person is by heredity or depression in a favorable state for its 
reception." The proviso, where ventilation is observed, is a very import- 
ant one, especially in connection with the experiments of Tappeiner, 
Schweninger, and Lippi, and the clinical observations of Reich (see Tuber- 
culosis). 
According to the most trustworthy authorities, hereditary predisposi- 
tion to phthisis can be traced only in twenty-five to thirty-five per cent 
of all cases of the disease, and it would seem not improbable that conta- 
gion is responsible for a share in the large proportion which remains. 
MacCormac is a strong opponent of the influence of contagion, asserting 
that the disease is no more communicated thus than is a fractured limb. 
But he holds that propagation takes place through pre-breathed air, and 
thus, as Webb shrewdly observes, inadvertently becomes one of the strong- 
est advocates of contagion. If the exhalations from healthy lungs can 
produce consumption, is it not rational to suppose that such exhalations 
plus gases and floating particles from disintegrating lungs will have 
that effect in a still higher degree ? 
In this connection the articles of Muller and Thomson are of great 
interest. The former analyzes with minute care 988 cases of phthisis 
which came under his observation at Weissenburg, a Swiss sanitary resort. 
He found that heredity was traceable in thirty-five per cent of the cases 
from the country, while in those from cities it was so traceable in only 
nineteen per cent. In other words, more cases are acquired in cities, 
where large numbers of human beings are congregated. 
The latter shows that the mortality from phthisis in Australasia has 
been and is steadily increasing with the increase in population, and that it 
is now nearly as great as in England. In fact we are learning the true 
relation between climate and phthisis, a disease which is eminently social. 
The climatic conditions are more favorable in some places than in others 
for the development of the disease, as will be touched on more at length 
under the head of treatment, but no climate can claim complete immu- 
nity from consumption. 
As for contagion, the practical deductions to be drawn from a con- 
sideration of the question are plain. A physician should nevei' sanction 321 
the sharing of the bed of a consumptive by any other person, and should 
enjoin upon those who must necessarily bo much with such patients care- 
ful attention to ventilation, and an interval of daily exercise in the fresh 
air. 
A recent paper of Senator {Berliner Wochenschrift, 1879, Nos. 4, 5, 
and 6) calls attention to the connection between phthisis and brain dis- 
ease, and shows that Ruehle's statement (Cyclopaedia, Vol. V., p. 561) of 
the safety with which we can infer cerebral tuberculosis whenever phthisi- 
cal patients present decided brain symptoms must be somewhat modi- 
fied. Senator reports a case admitted to hospital with phthisis of the 
upper portion of the right lung, the patient being up and in pretty fail' 
general condition. Five days after entrance weakness of the right hand 
was noticed; this was soon followed by complete motor paralysis of the 
right forearm, right unilateral epileptiform convulsions, paralysis of 
motion in the face and right leg, high fever, aphasia, coma, and death 
on the twentieth day after entrance. A large abscess was found at the 
autopsy in the left hemisphere. The possible dependence of cerebral 
abscess on lung disease was first pointed out by Sir IF. Gull, in 1858, 
and has since been insisted on by Biermer, Huguenin, and R. Meyer. 
The latter collected and published, in 1867, eighty-nine cases of abscess 
of the brain, eleven of which were complicated by suppuration in the 
lungs. The pulmonary affection has often been mentioned casually, as 
if it could have no bearing on the abscesses, and it is to be hoped that in 
the future this point will be carefully investigated. Senator reports a 
second case of phthisis, in which the invasion and localization of the 
paralysis was very similar to that in the first, but without convulsions,, 
aphasia, or coma; at the autopsy no localized disease could be found in 
the brain. In both cases the general sensibility and control of the rectal 
and vesical sphincters were unimpaired. 
PULMONARY CONSUMPTION. 
DIAGNOSIS. 
Peter has made a careful study of local temperatures in phthisis and 
other diseases. He uses the ordinary clinical thermometer, placing the 
bulb on the surface of corresponding intercostal spaces on the two sides 
of the chest, and finds that the temperature of the affected side is always 
TV~1° C. higher than that on the other. The application of this sign in 
doubtful cases with obscure signs is obvious. Peter's results are substan- 
tiated by Vidal {Bulletin de I'Acad, de Med., VII., No. 38). 
Charteris {Lancet, 1876, May 13th) and McAldowie {Times and 
Gazette, 1878, II., 269) report on axillary temperatures in phthisis. 
The former found that the temperature on the affected, or more-affected, 
side was always higher; whereas the latter, basing his conclusions on 
880 observations on 42 patients, finds that there is no law of the kind 
regulating the temperature. Of 359 observations in cases of unilateral 
and well-marked lesion, higher registrations were obtained on the healthy 
side 162 times, on the affected side 162 times, and 35 times the registra- 
tions were equal. Everything depends in such observations as these on 322 
PULMONARY CONSUMPTION. 
minute pains and precautions, but the probability is that Peter is correct. 
Broca's experiments on localized cerebral temperatures are well known, 
and Peter has found local elevation in various inflammatory conditions. 
The same author reports (La France Medicale, '78, Oct. 12th and IGth) 
four cases of phthisis in which venous pulsation synchronous with the 
systole of the heart was noted on the back of the hand. The phenomenon 
is attributed to paralysis of the muscular walls of the arterioles from 
asphyxia, and indicates that death is near at hand. 
Heitler (Wiener Wochenschrift, 1877, Nos. 49 and 50) reports on the 
diagnostic value of epithelium in sputa, and denies that there are any 
cells the presence of which is characteristic of phthisis. All the epithe- 
lial forms which are found in this disease occur also in other pulmonary 
affections which do not lead to destruction of tissue. 
PROGNOSIS. 
Dr. Flint maintains the view that phthisis is, in some cases at least, 
a self-limited disease. He has preserved notes of and analyzed G70 cases 
from among those which have come under his observation in thirty-four 
years, the list embracing a few cases of acute tuberculosis and interstitial 
pneumonia, and of these 44 ended in recovery, 31 ceased to progress. 
Of those which recovered there was no medicinal treatment to which the 
arrest of the disease could be attributed in 23; and of those which ceased 
to progress in 15. With respect to hygienic treatment, in some cases of 
both groups there was no change whatever in habits of life. In other cases 
there were changes involving more favorable circumstances pertaining to 
hygiene; but a considerable portion of these changes were not of such a 
-character that a potential influence could be attributed thereto. It is 
probably correct to say that the changes may have favored recovery or non- 
progression, but were inadequate to cause an arrest of the disease. With- 
out wishing in any way to decry medicinal and climatic treatment, Flint 
expresses his conviction that some of the cases, the cure of which has 
been attributed to these measures, really got well by self-limitation. He 
briefly relates an instance from his own practice of recovery in New York 
City, without any important medication, the cavity gradually disappear- 
ing and leaving a permanent, circumscribed depression of the chest wall 
.to mark its site. 
The writer has a patient whose case is interesting in two respects. A 
young man, of vigorous New England stock, married soon after twenty 
a lady with commencing phthisis, took her to Europe and up the Nile, 
and was most assiduous in his devotions to her till she died of consump- 
tion, about a year after her marriage. Very soon after he began to cough, 
hemoptysis appeared and recurred frequently, cough and expectoration 
persisted. He did not care much whether he recovered or not, was reck- 
less at times, but made several changes of climate, passing a large part of 
• one winter in North Germany, and after various ups and downs during 
a period of six or seven years, finally recovered completely and is now a 
very hard-working professional man. A sufficiently long period has now PULMONARY CONSUMPTION. 
323 
elapsed-at least five years-since the cessation of all symptoms to justify 
the use of the term recovery. He undoubtedly contracted the disease 
from his devotion to his wife, but digestion remained good throughout, 
loss of weight, though decided, was never excessive, and I am satisfied that 
self-limitation played a larger part in the production of the favorable 
result than whiskey with cod-liver oil and change of climate. 
It is, of course, an excessively difficult matter to estimate in any 
given case beforehand how far we can rely on this element of self-limita- 
tion, but we are not entirely without a basis for drawing conclusions as 
to this point. Toleration of the disease affords grounds for encourage- 
ment; the chief indication of toleration being the maintenance of the nor- 
mal, or nearly the normal, pulse rate and temperature, and the retention 
of the power of digestion and assimilation. Again, other things being 
equal, the smaller the amount and extent of the lesions the better the 
chance of recovery through self-limitation. Flint states that he has 
been led to believe that phthisis not very infrequently ends by self-limita- 
tion before it has made sufficient progress to develop well-marked physical 
signs; in other words, that there are abortive cases of this as well as of 
other diseases, and remarks on the frequency with which the traces of 
small, old phthisical affection are found in bodies of those dead with 
various diseases. 
When there are cavities resulting from the involvement of a consider- 
able portion of pulmonary tissue, the absence of signs denoting progres- 
sive extension or general diffusion is the most reliable of the points on 
which to found a relatively hopeful prognosis. But Dr. Flint's whole 
article is deserving of thoughtful perusal. 
Prof. McCall Anderson, of Glasgow, reports three cases of entire 
recovery from galloping consumption or acute tuberculosis, according 
to his diagnosis. The treatment was antipyretic and highly supporting, 
and the cases are very interesting and suggestive, even if one is not fully 
prepared to accept the diagnosis without question. No attempt is made 
in the published report to eliminate typhqid fever, whatever may have 
been done at the bed-side, and Anderson is led to found his belief in the 
curability of tuberculosis in general largely on a case of Spencer Wells 
(Diseases of the Ovaries, London, 1872, p. 13&). A lady of twenty-two 
had abdominal enlargement which it was supposed might be due to a thin, 
non-adherent, unilocular ovarian cyst, and a small incision was made below 
the umbiliicus. " A large quantity of opalescent fluid escaped, and then 
the whole peritoneum was seen to be studded with myriads of tubercles. 
Some coils of small intestine were floating, but the great mass was 
bound down with the colon and omentum, all nodulated by tubercle, 
towards the free and upper part of the abdomen. The uterus and ova- 
ries were felt to be of normal size, but their peritoneal coat was very 
rough." The patient made a good recovery and has since married. 
Now the writer inclines strongly to the belief that limited tubercle cer- 
tainly, and extensive perhaps, is not so necessarily fatal as has been gen- 
erally supposed, but Mr. Wells is not a pathologist, and every pathologist 324 
PULMONARY CONSUMPTION. 
knows that small bodies are occasionally found in great numbers in the 
peritoneum and elsewhere which are not tubercles, but can be distin- 
guished from them only by very careful examination-much more careful 
than is possible after a small opening has been made in the abdomen of a 
living human being, and it has been ascertained that the condition pres- 
ent is not that which was sought for. 
TREATMENT. 
It is proposed to refer first to the chief recent contributions to our 
knowledge as to the alleviation of the prominent symptoms of the disease 
and then to the treatment in general. 
Haemoptysis.-The subcutaneous injection of ergotine suspended in 
water with or without glycerine has come more into vogue, and certainly 
seems to have a marked influence in some cases. It may be given in 
doses of five to ten grains, and repeated as often as seems necessary. 
Pain at the point of injection is often sufficiently prominent, but abscess 
is not apt to occur, and both pain and reaction are said by ILobert 
{Schmidt's Jahrb., 1879, III., 241) to be much less than when, sclerotinic 
acid is thus injected. He has also found the latter decidedly less effica- 
cious in checking the bleeding, though Nikitin {Schmidt, 1879, I., 19) 
seems to have obtained more favorable results. 
Pasley {Brit. Med. Journ., 1880, I., 53) reports that in Trinidad at 
least eighty per cent of hospital cases of phthisis originate in catarrhal 
pneumonia and prove fatal in six to twelve weeks. At the lowest esti- 
mate, ten per cent of the cases which die in hospital terminate in profuse 
hsemoptysis, the patient expiring in the very act of bringing up blood. 
Williamson {Lancet, Sept. 2d, '76) publishes his observations of one 
hundred and twenty cases of hsemoptysis with reference to barometric pres- 
sure and the theory that active hemorrhage takes place with increased, 
passive with diminished pressure. He does not find the theory borne 
out. 
Diarrhcea.-Frohnmuller {Schmidt, 1879, IL, 230), among others, 
reports on the use of coto bark and its derivatives-cotoin and paraco- 
toin-in diarrhoea from various causes, including that incident to phthisis. 
During the last six yearshe has administered the drug in ninety-two 
cases of diarrhoea, mostly of a colliquative character, in the course of 
typhoid fever and phthisis, other remedies having generally been tried 
without success. The preparation most commonly used was the tincture 
of the bark. In fifty cases the diarrhoea was checked, in twenty-six it was 
diminished, and in nine the drug failed altogether. Asa rule, the looseness 
reappeared after several days and again yielded to the remedy, but in some 
cases no repetition was required. The drug is well borne and the appetite 
usually improves under its use. The writer has ordered the fluid extract 
prepared by Metcalf, of Boston, in some half a dozen cases without 
obtaining any apparent effect on the condition. 
Night-sweats.-Lauder Brunton {Bartholomew's Hosp. Reports, 
1879) contributed an interesting paper on the pathology and treatment PULMONARY CONSUMPTION. 
325 
of this symptom. He thinks that sweating in phthisis is due to exhaus- 
tion of the respiratory centre by the reflex irritation from the lung, 
constant cough, and consequent accumulation of carbonic acid in the 
blood, which stimulates the sweating centres. The venosity of the blood 
and imperfect tissue change, not, as was formerly supposed, the mere loss 
of fluid, are the causes of prostration observed after night-sweats. It 
thus occurred to him that simply by stimulating the respiratory centre 
the symptom might be prevented from appearing, and putting his theory 
into practice he administered strychnia and nux vomica to a number of 
patients. The night-sweats were checked, though the drug seemed to 
lose its effect after a time, and, in one case, a very troublesome cough 
appeared to be aggravated. In cases where cough is prominent, atropia 
is better, this drug acting not only on the peripheral terminations of the 
sweat nerves, but also lessening the irritability of the sensory nerves in 
the lung and stimulating the respiratory centre. 
Dover's powder, by diminishing the irritation from cough, tends to 
prevent the exhaustion of the respiratory centre, which is also powerfully 
stimulated by the ipecac. The favorable action of picrotoxiney reported 
on by Murrell (Brit. Med. Jowrn., Jan. 17th, 1880), is also probably due 
to its stimulating qualities. Picrotoxine is the active principle of Coccu- 
lus indicus, a plant first known in Europe as a poison for taking fish, 
which it first throws into violent, irregular motion, and then stupefies. 
It had fallen into disuse as a medicinal agent till very recently. Murrell 
employs a solution in water, 1 part to 210, giving one to four minims thrice 
daily, the last dose at bed-time or just before the time at which the perspi- 
ration usually commences. The drug failed in only one case in which 
it was tried, is best given alone, and does not parch the skin, as atropia is 
liable to do. 
There is no doubt that night-sweats are sometimes due in part to 
the stimulus of increased temperature on the sweat nerves, and in such 
cases quinine is indicated. Oxide of zinc and sulphate of copper act as 
astringents. 
Fothergill attaches a far more direct weakening effect to night-sweats 
than does Brunton and employs largely a pill containing one-fourth of 
a grain of the hydrochlorate of morphia, a fortieth of a grain of atropia, 
with a grain of capsicum and three of aloes and myrrh. He has never 
seen this combination followed by any toxic effects of atropia, which is 
sometimes given in doses as high as a twenty-fifth of a grain. The prac- 
titioner must not go away with the impression that atropia has failed in 
any case until he has pushed the dose to a decided dryness of the throat 
and impairment of vision, flinging aside any effect upon the pupil as a fal- 
lacious test not to be trusted. Dr. Sayre, of New York, reports that an 
irregular practitioner gained a great reputation in that city many years 
ago in the treatment of phthisis by sponging the patient with hot vinge- 
gar containing a considerable quantity of powdered capsicum. He was 
very successful in arresting night-sweats, and when these are checked 326 
PULMONARY CONSUMPTION. 
the appetite returns, and food is relished and digested. Fothergill has 
found these spongings useful in obstinate cases. 
Cough.-The last-named author is no friend of sedative cough mix- 
tures or of chloral, and recommends as a pleasant and effective remedy 
for cough, which is at once harassing and useless, hydrobromic acid with 
spirits of chloroform three or four times a day. His article is a very 
valuable one; and it may be observed in general that German literature is 
not the place to which one turns for useful hints in therapeutics. 
Daremberg {Lyon Medicale, Nov. 12th, '76) advocates the administra- 
tion of creasote from beech-tar for the purpose of diminishing the expec- 
toration, which is sometimes a serious drain on the patient. The purity 
of the remedy is of the utmost importance, and creasote from beech-tar 
may be distinguishod from that derived from coal-tar by its behavior with 
collodion. Fifteen parts of coal-tar creasote and ten of collodion give a 
gelatinous mass when mixed, while beech-tar creasote gives a clear solu- 
tion. The remedy may be administered in doses of one to three grains. 
Dyspnoea.-For remarks on the use of quebracho as a remedy for 
dyspnoea the reader is referred to the article on emphysema. 
Tapping a Cavity.- Williams {Brit. Med. Journ., 1878, I., 101) 
reports the case of a man of twenty-eight with a phthisical cavity in the 
right lung, which was tapped with a moderately large trocar, about two 
litres of offensive pus being evacuated; the expectoration immediately 
diminished in quantity and lost its fetid character, the pulse and tem- 
perature fell, and the general condition of the patient was greatly 
improved. The cavity was washed out several times with disinfectants. 
GENERAL TREATMENT. 
I. Medicinal.-Dr. Andrew H. Smith, chairman of the Committee 
on Restoratives of the New York Therapeutical Society, reports {New 
York Med. Journ., April 20th, 1879) on the use of ether with cod-liver oil 
in ninety-four cases, as suggested by Dr. Foster, of London. The conclu- 
sions of the committee are as follows: 
1. The addition of ether to cod-liver oil in about the proportion 
of fifteen minims to each half-ounce (or an equivalent amount of the 
compound spirit of ether) will succeed, in the vast majority of cases, in 
enabling the patient to take the oil, even though it previously disagreed. 
2. In some cases in which the oil still disagrees after the addition of 
the ether, the difficulty may be overcome by giving the ether separately, 
from fifteen minutes to half an hour after the oil is taken. 
No facts have been laid before the Committee having a bearing on the 
question as to whether the etherized oil is superior to the plain oil in its 
ultimate effect on nutrition, supposing them to be equally well tolerated 
by the stomach. 
The same Committee reported on defibrinated blood for rectal alimen- 
tation, and, though this treatment can scarcely be classed as " medici- 
nal," a brief notice comes in here better than elsewhere. Thirty-eight out 
of the sixty-three cases were of phthisis in every stage, some with large PULMONARY CONSUMPTION. 
327 
cavities, and several within a few days of death. Eight could not tole- 
rate the injections, either because of irritability of the rectum or on 
account of severe and persistent colic, even when the dose was reduced 
to two ounces and laudanum was added. This leaves thirty cases in which 
the treatment had a more or less thorough trial, and of these ten showed 
no effect which could fairly be attributed to the injections. Some were 
improving before the treatment was begun, and continued improving at 
about the same rate during its continuance. Others were losing ground, 
and their downward tendency seemed not to be checked in any appreci- 
able degree. These cases were, therefore, regarded as not affected either 
way by the treatment. In the other twenty cases, positive benefit 
seemed to have attended the use of the blood; the improvement being 
in some cases slight, in others very decided. 
The conclusions of the committee are as follows: 
1. That defibrinated blood is admirably adapted for use for rectal 
alimentation. 
2. That in doses of two to six ounces it is usually retained without 
any inconvenience, and is frequently so completely absorbed that very little 
trace of it can be discovered in the dejections. 
3. That, administered in this way once or twice a day, it produces in 
about one-third of the cases for the first few days more or less constipation. 
4. That in a small proportion of cases the constipation persists, and 
even becomes more decided the longer the enemata are continued. 
5. That in a very small proportion of cases irritability of the bowels 
attends its protracted use. 
6. That it is a valuable aid to the stomach whenever the latter is in- 
adequate to a complete nutrition of the system. 
7. That its use is indicated in all cases not involving the large intes- 
tine, and requiring a tonic influence which cannot be readily attained by 
remedies employed in the usual way. 
8. That in favorable cases it is capable of giving an impulse to nutri- 
tion which is rarely, if ever, obtained from the employment of other 
remedies. 
9. That its use is wholly unattended with danger. 
Schnitzler (Wiener Presse, 1876, No. 32) has employed subcutaneous 
injections of carbolic acid in phthisis, being encouraged to do so by suc- 
cess in a severe case of diphtheria which had resisted other remedies. 
During June and July, he treated more than one hundred cases, injecting 
one or two syringefuls of a one to two per cent solution once daily-though 
in a few cases twice-into the back or front of the chest. The result, in a 
large majority of cases, was diminution of the fever, marked improvement 
in the general condition, and in a few cases alleviation of the cough 
and expectoration. The injections were kept up for several weeks, and 
no injurious effect was observed. The patients experienced no more 
pain than from morphia injections, though the local burning sometimes 
continued a little longer. Slight, but never serious, inflammation was 
occasionally observed. 328 
PULMONARY CONSUMPTION. 
Experiment having indicated that phthisis may be an infectious 
disease, the idea was naturally suggested that an antiseptic treatment 
might produce favorable results-hence the employment of carbolic acid 
subcutaneously and by inhalation. The latest development of this idea 
has excited such interest in Germany that it is worthy of notice, although 
the brilliant success with which benzoate of soda inhalations were heralded 
to the profession does not stand the test of extended experience. In June, 
1877, Prof. Klebs communicated to a scientific meeting in Munich the 
opinion, founded on experimental and microscopical observations, that 
tuberculosis is an infectious disease of parasitic nature; that it is induced 
by certain micro-organisms which invade the body and multiply in it, 
and that the expectation might be entertained of curing it by the 
employment of means which annihilate these organisms. One of these 
means is the inhalation of benzoate of soda solutions. Rokitansky, of 
Innsbruck, then took up the idea and employed a five-per-cent watery 
solution of the substance which was pulverized and inhaled, and his 
assistant, Kroczak, communicated to the IFtener medicinische Presse for 
Sept. 14th, 1879, " results exceeding all expectations," in fifteen cases so 
treated. Persons, so to speak, moribund upon entrance to the hospital 
were sent out cured apparently, after about three weeks of the treatment. 
The matter was taken up by the lay press, great excitement was caused, 
and the drug was forthwith tested in many of the German hospitals. 
Sufficient reports are now in to show that the inhalations are not only 
useless, but indeed harmful in some cases; causing nausea and vomiting 
and irritation of the air passages. Those who are curious on the sub- 
ject are referred for details to articles in the British Medical Journal for 
Jan. 3d, 1880, and Wiener Presse, 1879, No. 51, and 1880, No. 1. 
Among the observers who report on the uselessness of the drug are 
Guttmann, Senator, Frankel, and Wolff. 
Klebs (Allgemeine Wiener Centralzeitung, 1880, Nos. 1, 9, lOetseq.), 
however, does not give up the ship; but maintains now that the formation 
of miliary tubercles can be stopped, and those already formed made to 
vanish, by the internal administration of the benzoates, especially mag- 
nesium benzoate. And in infiltration of the apex of moderate standing, 
attended with high septic fever and preceded by haemoptysis, under the 
inhalation or insufflation of about ten grammes of sodium benzoate, 
two or three times daily, and the injection of twenty to thirty grammes 
of magnesium benzoate daily, permanent defervescence, disappearance of 
catarrhal symptoms, and notable increase in weight have been observed. 
II. Climatic Treatment.-It will clear the way if we here make a 
brief classification of phthisis, a term which represents a group of patholog- 
ical conditions. This group consists, according to modern pathology, of 
three members, tubercle, pneumonic infiltration or exudation, and inter- 
stitial growth. It is true that in the majority of cases we find two or all 
three of the members of the group co-existent and intimately associated 
with each other; but we do, on the other hand, meet with cases in which 
some one of the members is alone, or almost alone represented, as in PULMONARY CONSUMPTION. 
329 
acute miliary tuberculosis, acute inflammatory phthisis, and cirrhosis 
of the lung-fibrous or fibroid phthisis. We are not infrequently able 
to determine clinically which member of the group is present or predomi- 
nant in a given case, and the attempt should always be made, inasmuch 
as the decision has a most important bearing on the advisability of 
change of climate. 
" Within the past few years, in this country and in foreign lands, mono- 
graphs have been published with carefully prepared tables in regard to the 
temperature range of different health-resorts, the amount of rainfall, the 
degree of atmospheric pressure, the prevailing winds, the altitude, etc. 
Some localities are mentioned as especially desirable for phthisical 
invalids on account of their equability of temperature, other places are 
recommended on account of their luxuriant vegetation or the peculiarity 
of their soil. Some are thought desirable on account of their dryness of 
atmosphere, others on account of the humidity of their atmosphere." 
" Vague and uncertain are the statements in the literature of the sub- 
ject, and widely different conclusions have been arrived at by various 
observers. Places which at one time were the favorite resorts of con- 
sumptives have been abandoned as unhealthful and dangerous. Directly 
opposite views are held in regard to the therapeutic value of the same 
resort. An educated physician, who was in the last stage of the disease, 
and who had vainly tried all climates, expressed what I mean when he said 
to me: ' In attempting to follow the instructions of my New York medical 
adviser, and also those of my Philadelphia medical adviser, the one re- 
commending a cold, the other a warm climate, I have made the result a 
failure.' " 
" Fifteen years ago, the belief prevailed that the essential climatic ele- 
ment for the arrest or cure of phthisis was a warm, dry atmosphere. 
More recent observations and investigations have settled the fact that 
phthisis is not necessarily hastened in its development by a low tempera- 
ture, and is not prevented or cured by a high temperature. Again, it 
has been claimed that the higher the altitude, the fewer were the cases of 
phthisis, until at a certain elevation it entirely disappeared, and that 
this diminution in the number of cases was due to diminished atmo- 
spheric pressure. More extended observation has demonstrated that the 
altitude at which this supposed immunity exists varies with the latitude; 
tliat the nearer the approach to the equator the higher must be the alti- 
tude to accomplish the desired result. This fact seems to prove that 
the development of phthisis does not depend upon atmospheric pressure, 
for the laws governing atmospheric pressure are ever the same at a given 
altitude." 
" Elevation was also regarded as the cause of this immunity from 
phthisis. This theory was disproved by the fact that, whenever the in- 
habitants of elevated regions engaged in manufacturing pursuits which 
confined them in unwholesome air, phthisis was very frequently developed. 
Nevertheless, this theory so rapidly grew in favor that a large number 
of phthisical patients were sent to the mountains; these more markedly 330 
PULMONARY CONSUMPTION. 
improved than those who were sent to the milder regions of the southern 
lowlands. A new series of investigations established the fact that this 
immunity from phthisis was not due to altitude, but to the absence of 
organic matter in these high elevations. In the presence or absence of 
these organic substances we have a very important element of difference 
between the air of the lowlands and the air of the mountains. That 
atmospheric germs are also more abundant in cities and towns has been 
plainly shown. Dr. Schreiber, in his lecture on Climatology, states that 
" ozone and rain have the power of purifying the atmosphere, that is, of 
freeing it from organic substances; that the purifying power of ozone de- 
pends on its oxidizing power; that while oxygen requires a considerable 
degree of heat before it will combine with other substances, ozone will 
do so at an ordinary temperature. Ozone destroys the products of de- 
composition by chemically combining with them. The air of a locality 
may not necessarily be unwholesome because no ozone is present, .as the 
ozone may already have been expended in oxidizing the organic substances 
in the surrounding atmosphere. Yet the presence of ozone in the atmo- 
sphere is presumptive evidence that it contains no organic substances." 
"The air of the ocean and high mountains is richer in ozone than that 
of the plains, and this substance promotes nutrition and blood changes 
by supplying to the respiratory organs a most active form of oxygen. 
Therefore, when choosing a health resort for phthisical invalids, we 
should give the preference to a locality in which there is constantly an 
excess of ozone in the air, for experience has established the fact that 
there the climate is especially salubrious. Experience has also shown 
that the direct inhalation of ozone has little if any power in preventing 
or arresting phthisical development, and we must, therefore, conclude that 
it acts simply as a purifier." (The above is quoted precisely from 
Loomis: further points will be borrowed from his paper without the use 
of quotation marks.) Damp warm as well as damp cold climates are un- 
favorable for phthisis, but the worst form of dampness is that dependent 
on a clayey, ill-drained soil; and this mattei' of soil-moisture is of the 
utmost importance. 
Temperature has always been regarded as of very great importance in 
the treatment of phthisis, and a warm, sedative climate was long regarded 
as best for the purpose ; more recently it has been claimed that a cold 
climate is the favorable one, and that phthisical mortality decreases as 
we go northward. Both views are correct to some extent. It is not the 
warm temperature of a locality which is so important as the absence of 
sudden and frequent changes, such as those to which the eastern sea- 
board of the greater part of this country is subject. Whether a cold or 
warm climate is indicated in any given case, can be determined only by 
the experience of the individual prior to the phthisical development. 
Some are greatly depressed by a cold and exhilarated by a warm climate; 
with others the contrary holds true. There is no evidence that tempe- 
rature is directly curative. 
As proof that altitude alone is too highly regarded by some, Loomis PULMONARY CONSUMPTION. 
331 
states that there is no place where patients do worse in all stages of the 
disease than among the Catskill Mountains, as he has found by experi- 
ence, and he finds similar testimony given by others in regard to other 
mountain regions. 
Sea and mountain air do not differ as widely as has been supposed by 
many. The latter is less dense, of lower temperature, and less humid; 
but they are alike in containing an excess of ozone, in freedom from or- 
ganic substances and impurities, and in being cooler, and less subject to 
frequent variations in temperature than is the air of inland plains. 
I. Individuals in whom the processes of tissue change do not require 
hastening are better in the mountains than on or by the sea. 
II. Persons past middle life in whom phthisis has been developed do 
better in sea than in inountain air. 
III. Phthisical invalids should not go to the mountains unless they 
are capable of considerable muscular activity. 
IV. As a rule, phthisical subjects with an exhausted nervous system, 
with an overtaxed brain from excessive mental labor, or an all-absorbing 
occupation, yet who still retain considerable latent muscular power, 
will improve in the mountains, while those whose processes of tissue 
change require hastening or stimulating, they being in too feeble a con- 
dition to take active muscular exercise, should go to the sea. 
The above conclusions are drawn under the provisional acceptance of 
the correctness of Beneke's experiments, which go to show that tissue 
changes take place more rapidly on or by the sea than in the mountains. 
Loomis'1 conclusions from his own experience are as follows: 
1. We can expect permanent improvement in cases of developed 
phthisis only after prolonged residence in the locality which experience 
has proved best suited to each individual case. Permanent favorable 
results cannot be obtained from an annual change of climate. 
2. Cases of tubercular phthisis, in any stage of the disease, grow 
steadily and rapidly worse in all localities. Such cases do best in the 
quiet, well ventilated apartments of their own homes, where they can be 
surrounded by all those influences and circumstances which tend to make 
a feeble invalid comfortable. 
3. Cases of fibrous phthisis in every stage, whether the fibrous process 
commenced in the pleura or bronchial tubes, even after retraction of the 
chest-walls, especially in the infra-clavicular region, is well marked, and 
the bronchial dilatations which accompany it give the physical signs of 
extensive cavities, improve and often reach a condition of comparative 
health when they take up their residence in regions having very high 
altitude, such as are found in Colorado and the Rocky Mountain ranges, 
where patients with asthma and emphysema derive very marked benefit. 
4. Experience has led me to be very cautious in recommending these 
regions of high altitude to invalids with catarrhal phthisis. In the ad- 
vanced stage of this form, I have never seen good results from a residence 
in such regions, and it is quite doubtful whether any one in the first 
stage has received benefit. 332 
PULMONARY CONSUMPTION. 
C. Theodore Williams (Lancet, Aug. IGth, 1879) says that the in- 
fluence of high altitudes is intensely stimulating to respiration, circula- 
tion, and digestion; the cases in which it is indicated being those with- 
out pyrexia and with limited consolidation at one apex, limited cavity, 
and hemorrhagic phthisis. He is speaking largely with reference to 
Davos am Platz in the Swiss Alps, 5,200 feet above the sea, and so situ- 
ated in a valley that the sunshine is unobstructed, while there is great 
protection from cold winds. The season at Davos extends from Novem- 
ber to March, and during that time the average temperature is 23.5° F. 
above zero. The air is, however, so dry that patients can pass much 
time out of doors, and they are encouraged to sit in the fresh air and ex- 
ercise as much as possible. Four hundred invalids are said to have 
sought this resort in 1874, from all parts of Europe, and its reputation 
has increased steadily since then. Clifford Albutt gives very favorable 
reports of the influence of the place on suitable cases in the Lancet (1877, 
II., Oct. 20th and 27th, 1878, I., 824). 
Loomis has seen only a very limited number of cases of catarrhal (this 
class is apparently the same as that called by other authorities ' pneu- 
monic ') phthisis improved permanently by long sea voyages or residence 
in a warm climate. A large number in the early stage of the disease, 
going from a northern to a southern winter, are temporarily improved; 
after the first apparently beneficial effects are passed, the degenerative 
inflammatory processes go on more rapidly than before. The invalids 
whom he has found most markedly benefited by a sojourn during the 
winter months in a southern climate are those convalescing from some 
acute pulmonary affection, in whom the delayed convalescence raises the 
fear of possible phthisical development, and those in whom acquired or 
hereditary phthisical tendencies exist, yet in whom there may be no posi- 
tive physical signs of disease of the lungs. For such cases, Aiken, S. 
C., Palatka, Enterprise, and Gainesville, in Florida, and Thomasville, 
in Georgia, are of great service. 
In cases of consolidation, his best results have been obtained in those 
who have made a prolonged stay-one to three years-in regions of a 
medium elevation, 1,500 to 2,000 feet, such as Asheville, North Carolina, 
and the Adirondack region; a number of cases are cited by the author 
in illustration of the benefits derived from the latter region, and he 
strongly urges the further establishment of sanitariums under the charge 
of well educated, careful, and intelligent physicians. 
Now for a few words as to some of the leading American resorts for 
consumptives. The climate of Florida is moist and warm, the changes 
in temperature between day and night being often marked, and fires 
being frequently needed in the evening. At Jacksonville, Palatka, 
Magnolia, and some other places, many comforts are attainable, and an 
improvement is taking place in this respect every year. With the 
development of railroads and the growing use of Pullman cars, the region 
is becoming easier of access for those who wish to avoid a sea voyage. 
Patients can also work gradually northward in the spring, when the PULMONARY CONSUMPTION. 
333 
heat in Florida begins to be excessive and debilitating. Thomasville is 
in southwestern Georgia, not elevated, but with a porous sandy soil, and 
large pine forests in the vicinity. It was, I believe, discovered, so to 
speak, by Prof. Metcalfe, of New York, and has one or more good 
hotels. Aiken, South Carolina, is also low, with a dry, bracing atmo- 
sphere and sandy soil; it is the winter home of Dr. Geddings. At Ashe- 
ville, North Carolina, Dr. Gleitsmann has established a home for con- 
sumptives, at an elevation of 2,250 feet, the sunny hills of this region 
offering facilities for outdoor life and active exercise. In East Tennessee 
is Walden's Ridge (" A people without consumption," Dr. Wight, Chatta- 
nooga), part of the Cumberland table-land, at an elevation of 2,000 feet, 
but there is no provision for feeble invalids as yet in the region. The 
Adirondacks are too well known in this part of the country to require 
further mention here. In parts of Minnesota we have a dry, cold climate 
with medium elevation, while in San Diego and Santa Barbara, Califor- 
nia, and Nassau, in the Bahamas, a moist sea atmosphere and very great 
equability of temperature are combined. Within a few years, Colorado 
and the foot-hills of the Rocky Mountains have attracted great attention, 
though they will doubtless attract still more as the life becomes less 
rough, and the region better supplied with those luxuries which to many 
of the inhabitants of the older States have become necessities. Dr. 
Denison, of Denver, gives full details as to the benefits of this region in 
his recent book. 
In recommending any particular health resort, careful attention should 
always be given to the personal peculiarities and preferences of the patient. 
It is not only important that the atmosphere should be pure and the 
climatic conditions such that the utmost possible amount of time should 
be passed in the fresh air, but due regard must also be had to the oppor- 
tunities offered by the resort under consideration toward the mental 
occupation and amusement of each patient. There is, as a rule, but 
little use in sending the patient who abhors the simplicity of country 
life to a quiet village, and for this reason, during many years to come, 
we shall continue to send certain patients to Europe; the greater luxury 
of a certain kind, novelty, and distractions of which certainly more than 
counterbalance its inferiority from a strictly climatic point of view. In 
short, the mind of the patient as well as his lungs must receive our 
earnest consideration, and a step which often involves uprooting a 
whole family is not one to be entered on lightly. 
Dr. Harry Leach {Practitioner, 1878) writes of his personal experi- 
ence of South Africa, and the reckless way in which English practitioners 
have sent patients thither without knowing anything about the special 
localities recommended, the means of reaching them, with the necessary 
expense involved, and their accommodations and special resources. South 
Africa is not the only resort to which his remarks are applicable, nor are 
English physicians the only ones who have sinned in the way he describes. 
The congregation of large numbers of invalids at health resorts also 
exercises a most depressing influence on some people, and it would not 334 
TUBERCULOSIS. 
be a bad thing if it were part of the education of physicians to spend 
three months in one of these places, as it was the fortune of the writer 
to do in Nassau, a number of years ago. The less many patients think 
about their own symptoms and cases the better. There is in this country 
opportunity for the fulfilment of every climatic indication, and we have 
entered on a great era of progress in the "home treatment" of con- 
sumption. 
TUBERCULOSIS. 
BIBLIOGRAPHY. 
Friedlander: Ueber lokale Tuberculose. Volkmann's Sammlung der klini- 
schen Vortrage, No. 64, 1873.-Wolff: Entziindliche Veranderungen, etc. Vir- 
chow's Archiv, Bd. 67, 1876, 234.-Metzquer: Archives generales, XXX., 1877, 
239.-Malmberg: Zur Geschichte der Inokulationstuberculose, etc. Hygiea, 
August, 1877.-Foot: Two Lectures on Tuberculosis. Dublin Journal, II., 1877, 
pp. 1 and 101.-Reich: Die Tuberculose, eine Infektionskrankheit. Berliner Woch- 
enschrift, 1878, p. 551.-Tappeiner: Eine neue Methode die Tuberculose zu erzeu- 
gen. Virchow's Archiv, 1878, Bd. 74, 393.-Schottelius: Experimentelle Unter- 
suchungen tiber die Wirkung inhalirter Substanzen. Archiv f. path. Anat. und 
Phys., LXXIII., p. 524.-Lippl: Allgemeine med. Central-Zeitung, 1878, XXXVIII., 
461.-Ziegler: Tuberculose. Volkmann'sSammlung, 1878, No. 151.-Spillmann: 
De la tuberculisation du tube digestif, Paris, 1878 (with full bibliography of the 
subject).-Schuller: Therapeutische Versuche bei tuberculosen Thieren, etc. 
Arch, fiir exp. Pathologie, Bd. XI., p. 84.-Epstein: Tuberculose im Sauglings- 
alter. Prager Vierteljahrschrift, 1879, 103.-Orth: Experimentelle Untersuchun- 
gentiber Fiitterungstuberculose. Virchow's Archiv, 1879, Bd. 76, p. 217.-Weigert: 
Zur Lehre von der Tuberculose und den verwandten Erkrankungen. Virchow's 
Archiv, 1879, Bd. 77, 269.-Bollinger: Kiinstliche Tuberculose erzeugt durch 
den Genuss der Milch tuberculoser Kiihe. Aerztliches Intelligenzblatt, 47, 1879. 
Allg. med. Centralzeit., 96, 1879.-Aufrecht: Zur Kenntniss der Scrophulose und 
Tuberculose. Deutsch, med. Wochen., 1879, No. 50. Allg. med. Centralzeit., Dec., 
1879.-Virchow: Ueber die Perlsucht der Hausthiere und deren Uebertragung 
durch die Nahrung. Berliner Wochen., 1880, Nos. 14 and 15.-Cohnheim: Die 
Tuberculose vom Standpunkte der Infektionslehre. Leipzig, 1880. 
The nature of tuberculosis and its relations to scrofula and phthisis 
are still questions which engage some of the best minds in the profession, 
and towards the ultimate solution of which important contributions 
have been made during the last six years, though its solution may be, and 
probably is, still far off. At the time of the publication of the second 
edition of the Encyclopaedia, the giant cell was regarded by many as the 
characteristic anatomical element of tubercle and tubercular products, 
but it has more recently been shown that these cells are found in other 
and widely different formations. In fact, suffice it to say, we are 
acquainted to-day with no anatomical criterion of any kind which stamps TUBERCULOSIS. 
335 
a formation as indisputably tubercular. From a theoretical point of 
view, this admission is very discouraging and unsatisfactory, but the 
practical results are not so serious as might be supposed, inasmuch as 
any reasonable doubt can be removed, in the great majority of cases, by 
consideration of the circumstances and origin of the formation, its locali- 
zation, distribution, symptoms, and termination. 
Aufrecht says that miliary tubercle is not the anatomical basis of 
tuberculosis, a term which has merely an etiologico-clinical meaning, 
the granulation being the result of various causes, and never the primary 
change in that condition which has so long been known under the name 
tuberculosis. In perfect analogy with the term scrofulosis, the term 
tuberculosis means simply this-a tendency, generally hereditary, to 
weakness of certain organs, in consequence of which weakness they 
become readily the seat of inflammatory processes and resulting cheesy 
degeneration of the tissue. Pulmonary consumption is the most common 
localization and manifestation of tuberculosis. Scrofula and tuberculosis 
are brothers, as they generally appear in the same families. If some 
members of a large family have died of scrofulous affections, some of the 
survivors are pretty sure to have tuberculosis later in life. Moreover, 
individuals who in childhood suffered from the former, are more likely 
than other people to develop the latter as they grow older. Finally, 
tuberculosis m the parent is eminently a cause of scrofula, and eventually 
tuberculosis, in the children. This view is directly opposed to that of 
those who believe tuberculosis to be an infectious disease like syphilis, 
whether low organisms play a part in it or not. If it is an infectious 
disease, how can so many people recover from it, and how can we expect 
to combat a chronic, infectious disease by simple hygiene? This is not 
the way in which we cure syphilis. [It is not obvious why people should 
not recover from an infectious disease, and the best authorities are 
unanimous in insisting on the very great importance, and even curative 
influence, of hygiene in syphilis. ] 
In view of the fact that the theory of the infectious nature of tuber- 
culosis has necessarily been based on experiments on the lower animals, 
great interest is attached to the observations of Reich, which indicate 
the transmission of the disease from a phthisical midwife to a number 
of children. The village of Neuenburg is healthily situated on the Rhine, 
counts 1,300 inhabitants, and gave occupation to two midwives. One of 
these was healthy, the other began to suffer from a pulmonary affection 
in the winter of '74-'75, and when examined by Reich in July, 1875, had 
several cavities in the right lung, with profuse purulent expectoration. 
She nevertheless pursued her occupation almost uninterruptedly up to the 
time of her death, July, 1876. Of ninety-two children who died during 
their first year in Neuenburg, between 1866 and 1874, tubercular menin- 
gitis was the cause of death in but two cases ; of twelve who died in 
1877 in but one case, and in that there was hereditary predisposition. 
Now, between July 11th, 1875, and September 29th, 1876, tubercular 
meningitis caused the death of ten children who were born between April 336 
TUBERCULOSIS. 
4th, 1875, and May 10th, 1876, of healthy parentage. All of these ten 
cases occurred among the clients of the consumptive midwife, and not a 
single case of the kind among the clients of the healthy midwife. The 
disease began with bronchial catarrh, which was followed by well-marked 
symptoms of tubercular meningitis, though in no case does an autopsy 
seem to have been made, and it was found that the midwife was accus- 
tomed to suck the mucus out of the mouths of new-born children under 
her care, to blow into their mouths if there was any asphyxia, and to sub- 
ject them in general to an unusual degree of kissing and fondling. 
The important bearings of the above report are too obvious to require 
comment, and in this connection the experiments of Tappeiner are of 
great interest. He caused, namely, dogs to inhale the spray of human 
phthisical sputa rubbed up and diluted with water, dogs being chosen on 
account of their great relative immunity from tubercular disease. Eleven 
animals were subjected to the treatment, some for longer, others for 
shorter periods, during four to eight weeks, and though only two of these 
showed any signs of sickness, all were found to present marked evidences 
of disease when they were killed. In all but one miliary tubercles were 
found, especially in the lungs, but often also in other organs, and that 
one had extensive degenerative pneumonia. The amount of sputum 
used seems to have been very small, and the earliest period at which the 
nodules appeared was during the third week of the inhalation. In order 
to determine whether the transmission of the disease took place really 
through the air-passages, or through the digestive tract, the particles 
of sputum which lodged in the mouth and pharynx being swallowed, 
Tappeiner fed some dogs with portions of the same sputum which was 
used in the other experiments. He thus produced miliary tubercles, but 
not with the same constancy as under the other method. Schotlelius 
was led by these experiments to see what effect follows the inhalation 
of powdered cinnabar, brain, cheese, and bronchitic sputum, likewise 
rubbed up and diluted with water. Miliary nodules were found in the 
lungs in all cases, in equal quantity with both phthisical and bronchitic 
sputum. Cheese produced a smaller quantity, brain still less, and cinna- 
bar least of all, namely, a few whitish nodules with pigmented centres. 
He consequently concludes that powdered mineral substances give rise 
to little irritation, but that powdered organic matter, especially sputum, 
sets up broncho-pneumonia, which may appear in small foci, and beai' a 
great resemblance to miliary tubercles. Bronchitic sputum gives rise to 
precisely the same lesions, and the cause is not specific, but simply the 
irritation of an organic matter, which is in a state of fine subdivision, 
and prone to decay. This view is shared by Ziegler, who considers true 
miliary tubercle as the indication of a general infection. how- 
ever, considers the nodules produced by Tappeiner as genuine tubercles, 
while agreeing that those of Schottelius were simply inflammatory; and 
this for the reason that in the experiments by the former the nodules 
were found in other organs as well as the lungs, while in those of the 
latter they were not. TUBERCULOSIS. 
337 
Chauveau was the first to experiment on the transmission of tubercu- 
losis through the intestinal canal, and very recently the subject has been 
taken up by Bollinger, Orth, Virchow, and others. The two former 
hold that the pearl disease of cattle and human tuberculosis are one and 
the same disease, but the latter is more cautious, and his lecture is well 
worth a detailed abstract, showing as it does, not only the present state 
of oui' knowledge on the relation of these affections, but also the difficul- 
ties which are involved in investigations of the kind. 
Foi' four years Virchow has been experimentingin the Royal Veteri- 
nary School in Berlin, at the instance of the Minister for Agriculture, to 
ascertain how far the secretions and flesh of animals, especially cattle, 
with the pearl disease are prejudicial to man, what bad effects may be 
produced, and what sanitary measures should be adopted by law for their 
prevention. He is apparently led to make known his results thus far by 
the unduly positive statement of the first-named authors and Klebs, who 
thinks that he has discovered a special germ or parasite, the common 
cause and carrier of tubercle and the pearl disease. 
In the first place, confusion has been introduced into the cpiestion 
by those who fail to recognize due distinction between the characteristic 
products of the pearl disease and those of chronic peribronchitis and 
pneumonia. Both affections are common in cattle, and are sometimes 
co-existent but their products differ greatly as regards their life-history. 
The pearl disease is characterized, namely, by the presence of hard tumors 
which increase in size with age, scarcely ever become cheesy, and conse- 
quently do not lead to ulceration, but have a marked tendency to creti- 
fication. These are important points of distinction, and in the present 
state of our knowledge we shall do well not to interchange the terms 
pearl nodules, inflammatory products, and tubercles. 
It is a cause of difficulty that our common domestic animals are not 
well suited to experiment on the subject, all being subject to diseases 
which are more or less similar to the tubercular, or may induce tubercu- 
losis itself. Dogs are completely exempt from tuberculosis by ingestion 
-they can eat what they choose; and in rabbits, guinea-pigs, cats, pigs, 
goats, and sheep it is first necessary to study the exact pathology of the 
nodules and cheesy or calcified masses to which they are subject. Echino- 
coccous disease is very common in pigs' livers, but here we also fre- 
quently meet with nodules which, when they first appear, are no larger 
than miliary tubercles, but increase in size without ever becoming cheesy, 
and have a great resemblance to those of cancer. Time will enable us to 
distinguish between these various conditions and tuberculosis, but then a 
new difficulty arises: it is, namely, not to be directly concluded that the 
changes found are the result of our experiments. Suppose we take a 
young and apparently healthy pig, and feed him daily for five or six 
weeks with pearl-disease products, the question arises whether the vari- 
ous changes are due to the food. From extreme antiquity the pig has 
been notoriously subject to swellings of the lymphatic glands, especially 
the submaxillary and jugular; the very term scrofula has this origin,. 338 
TUBERCULOSIS. 
and signifies a condition in man similar to that which occurs in pigs. 
These glands are by no means easy to feel, far less the mesenteric and 
bronchial glands, and it may well happen that we pronounce a pig 
healthy when, in fact, his glands are more or less enlarged. 
Again, not a single experimenter in this field pretends that his results 
are constant and invariable. Analogous changes are found in animals 
which have not been fed with pearl-disease products; as to the fre- 
quency of these changes, we have no statistics at our disposal, but Vir- 
chow's experience satisfies him that they are certainly common in the 
pig and coincide in their course with what are called scrofulous glands 
in the human subject. The process begins with cellular hyperplasia, 
which then becomes cheesy and very often calcified, but is not followed 
by the development of nodules-tubercles. In the majority of cases, as 
in the human subject, the cervical glands are chiefly affected, but in 
some cases the mesenteric, in others the thoracic, present the most 
marked changes. It is not, however, unusual for one of these three 
groups to be alone affected, and genuine tubercular affections are very 
rare, provided that the name tubercle is not applied where it does not be- 
long/ Much more weight is to be attached to small nodules or tubercles 
within the different organs than to the glandular swellings: the more 
common the lesion the greater the allowance which must be made for 
accident. 
Pregnant sows have been bought and cared for until after the birth 
of their young; the litters have been preserved, and when they have 
reached a certain size, fed with meat or milk from cattle with the 
pearl disease, some animals from each litter being kept under natural 
•conditions for purposes of comparison. In some litters the submaxillary 
and cervical, in others the mesenteric glands were chiefly affected; but 
the latter not so frequently as we would naturally expect, the supposed 
poisonous material being introduced into the digestive tract; the intes- 
tine itself remained invariably free from changes. It is difficult to under- 
stand how the submaxillary glands should be the seat of changes under 
these circumstances, while the mesenteric are unaffected, and Bollinger's 
-explanation is more ingenious than satisfactory. He supposes that in 
these cases the virus is completely absorbed in the mouth, but this is 
utterly inconceivable. But there is still another difficulty. If a young 
pig eats daily a material which is always poisonous, one would naturally ex- 
pect the changes thus induced to present a constant and steadily progres- 
sive character: it is true that this does happen, but only very exception- 
ally. In the great majority of cases, the lesions which are found after 
four to six weeks' feeding are already relatively old, instead of being 
in various stages of development. One fact is, however, unquestionable, 
and all experimenters are agreed upon it. More animals, namely, be- 
come diseased among those thus fed than among those kept for com- 
parison and leading the ordinary life of domestication. 
During the series of experiments, a most instructive mistake was 
made. A cow was purchased, after being pronounced by the best veteri- TUBERCULOSIS. 
339 
nary authorities as the subject of the pearl disease, and a number of 
animals of various kinds were fed upon her milk. After a time the cow 
was killed, and no trace of the pearl disease was found, but the lung- 
tissue was almost entirely replaced by echinococci! The animals fed on 
her milk were killed before the cow; a calf which had been thus fed dur- 
ing a period of three months presented no recent lesions, but partially 
cheesy masses were found in the lungs and various glands, which latter 
looked exactly like those found in the subjects of the pearl disease. 
Others of the animals presented various changes, even some of those fed 
with the milk after it had been boiled, and others were unaffected. If 
the cow had not been killed, the results would have been considered bril- 
liant, though it must be confessed that a larger number of animals of this 
series escaped disease than of another, in which the milch cow proved 
really to have the pearl disease. 
Virchow does not feel warranted in going further at present than to 
suspect that pearl-disease products are injurious. The lesions of the dis- 
ease are never found in the muscular tissue which is used for human 
food, and we are scarcely warranted as yet in taking legal measures to 
prevent the consumption of those parts. No human being has ever yet got 
a pearl tumor from eating the flesh of an animal with that disease. Some 
experiments have also been made with the meat of horses and beef more 
or less in decay, but the results do not as yet show much, one way or the 
other. In regard to milk, it appears probable that a distinction must 
be drawn between the milk of cows with local manifestations of the 
pearl disease in the udders, and those free from this complication. In 
a case of the former kind, large numbers of micrococci were found in 
the milk, but whether they were the peculiar cocci of this disease is not 
known at present. 
Epstein's experience leads him to think that children at the breast 
acquire tuberculosis chiefly through the nurse's milk. He has seen large 
numbers of children of tubercular parentage, and observed that most of 
them did well when given to healthy nurses, and kept away from contact 
with tuberculous people; some died of chronic catarrhal processes in the 
lungs, but in no one of these instances were tubercles found at the 
autopsy. On the other hand, children suckled by tubercular mothers 
became tuberculous very soon after the appearance or the exacerbation 
of the pulmonary affection of the mother. In one of his cases, the 
tubercular changes were chiefly marked in the mesenteric glands and 
intestinal canal. In other words, nurslings generally ingest the disease, 
while older children inhale it. 
Metzquer holds that the ingestion of tuberculous food is never a means 
of the inoculation of phthisis. After a certain time, irritation and 
inflammation of those parts of the intestinal canal with which the mate- 
rial remains longest in contact ensues, giving rise to diarrhoea and loss 
of weight. Hyperaemia and interference with the circulation result in 
intestinal thrombosis, and the inflammation may result in ulceration; in 
the latter event, and in that event only, is the way opened for infection. 340 
TUBERCULOSIS. 
A remarkable pamphlet has come from the pen of Cohnheim within 
a very few months, bringing forward fresh evidence that tuberculosis may 
be propagated by a specific process of infection, and propounding an 
exact and complete theory of the origin of the disease in the human 
subject. The original paper has not as yet come to hand, and the fol- 
lowing summary is taken, with but few changes, from the British Med- 
ical Journal for May 8th, 1880, it being expressly stated that the exposi- 
tion is, as far as possible, almost literally in the words of Cohnheim him- 
self. 
In the theory which was originated by Virchow, long adopted in Ger- 
many, and now largely taught in this country, it is held that a funda- 
mental difference exists between miliary tubercle-tubercle properly so 
called-and the inflammatory products found in scrofulous diseases of the 
lymphatic glands, and in the form of phthisis called by the Germans cas- 
eous pneumonia. The latter processes are regarded by Virchow as purely 
inflammatory in their nature, and as differing from other such processes 
only in that there is neither absorption nor further development. This 
theory is based on certain anatomical facts, and may be conveniently termed 
the anatomical theory. One of Cohnheim's objects is to show that, since 
Villemin has proved that tubercle can be transmitted by inoculation, this 
anatomical theory has been completely shattered. The test for tubercle no 
longer consists in anatomical elements or arrangement of elements, but in 
the capacity of a morbid product, when introduced into the body of a rabbit 
or guinea-pig, to produce tuberculosis in the animal. What produces 
tuberculosis is tubercle; what fails to produce tuberculosis is not tubercle. 
Judged by this criterion, caseous pneumonia and miliary tubercle are 
manifestations of one virus, and the doctrine of Laennec, which for a 
time had been in the shade, has now received ample confirmation. Fur- 
ther, the scrofulous lymphatic gland is found to contain the same poison. 
Other simple tissues, such as that of lupus, are found not to be inoculable. 
For the application of this test all animals are not equally reliable. 
Dogs, for example, show little susceptibility, while rabbits and guinea- 
pigs have it in a remarkable degree. The way in which the tuberculous 
substance is introduced into the animal is almost a matter of indifference; 
the common and most convenient method of procedure is inoculation by 
a small incision, either into the subcutaneous tissue, the pleural and peri- 
toneal cavities, or the anterior chamber of the eye. Whether there is 
much or little tubercular substance employed, whethei' it is used alone or 
mixed with other tissues-as, for example, pieces of lung containing tuber- 
culous nodules-is of little importance; of far greater consequence, on 
the other hand, is it that the substance used should be fresh and free 
from decomposition. The fresher it is, the less likely is the experiment 
to be affected by septic and similar influences, and infection is the more 
certain. How the infection takes place is best seen in animals when the 
tubercular matter has been introduced into the anterior chamber of the 
eye. In this case, if the substance be absolutely fresh, the irritation pro- 
duced by the introduction soon passes away, the small portion introduced TUBERCULOSIS. 
341 
becomes gradually smaller and smaller, and may even completely disap- 
pear. Then, for a time, the eye is perfectly clear and intact, until sud- 
denly a larger or smaller number of minute gray nodules appear on the 
iris, grow to a certain size, and then caseate, exactly as happens with 
human tubercle. In the rabbit Salomonsen and Cohnheim observed 
the eruption usually about the twenty-first day after inoculation; in 
guinea-pigs, as a rule, a week earlier. In the rabbit, also, the period of 
incubation is sometimes shortened to fourteen days. 
It is this test that, applied to human tubercle on the one hand, or cas- 
eating scrofulous products on the other, shows that they are both caused 
by the same virus. All these morbid products are effective, and in the 
same degree. If a piece of tubercular peritoneum or cerebral membrane 
be introduced into the peritoneal cavity of a rabbit, typical tuberculosis, 
beginning in the abdominal organs, is the result. But inoculation with 
a piece of lung affected with caseating pneumonia, or of a caseating tes- 
ticle, produces exactly the same effect, and nothing succeeds better than 
a freshly excised scrofulous lymphatic gland from the neck. 
Those who are convinced that all contagious virus is due to a parasite, 
will, of course, not hesitate to believe that the tubercular poison is 
corpuscular, and that, in a not very distant future, this corpuscle will be 
demonstrated in tubercle and in scrofulous products. Until, however, 
this goal has been reached, there remains no other test for tubercle than 
that of infection. The leading principle here, as in all infecting maladies 
which produce local changes, is that a tubercular or scrofulous product is 
generated wherever the tubercular virus is present and remains for a certain 
time. The chief factor, therefore, in determining the localization of the 
disease, is the mode of introduction into the system. Once introduced, its 
further extension is influenced by the conditions of the structure of the 
part, and takes the direction of the natural roads of the part. Consequently, 
whilst, on the one hand, the course which the disease takes is very dif- 
ferent in different cases, the eventual entrance of the virus into the cir- 
culation affords the conditions for the development of tubercle in distant 
organs. The influence of the point of introduction is strikingly exem- 
plified by inoculation experiments. Where a small piece of tubercle is 
introduced into the peritoneal cavity, there constantly follows, in the first 
instance, tuberculosis of the peritoneum, liver, and spleen; after inocula- 
tion into the anterior chamber of the eye, the iris is first affected; after 
feeding with tubercular matter, the intestine and the mesenteric glands; 
after the inhalation of pulverized sputa, the lungs and bronchial glands; 
and, when the material has been introduced into the subcutaneous con- 
nective issue, it is the nearest lymphatic glands in which the disease first 
develops. 
That the lungs are affected with tubercular disease in a far larger ratio 
than other organs shows, in Professor Cohnheim''s opinion, that the poison 
is introduced into the human economy most frequently with the inspired 
air. This conception finds support, he believes, in the frequency with 
which the bronchial and tracheal lymphatic glands are affected in a very 342 
TUBERCULOSIS. 
early stage of the disease-so much so, that an extensive tubercular pleu- 
risy, and still more frequently advanced caseation of the glands, is found 
whilst in the lungs there are only a few nodules or a very scant amount 
of caseous infiltration. An analogous condition is found in the certainty 
and rapidity with which inhaled carbonaceous particles reach the pleura 
and bronchial glands. The conditions which determine whether the in- 
haled virus shall produce disseminated tubercles or caseous pneumonia 
are still unknown. 
Whilst the pleura and bronchial glands become diseased immediately 
after or simultaneously with the lungs, the anatomical relations of the 
air-passages with each other and the digestive canal, furnish the means 
for further development of the disease. So soon as the tubercular products 
break down and ulceration takes place, a certain amount of tubercular, 
that is to say, of infecting matter, must leave the lungs. This reaches 
the trachea and larynx, and, if it take root there, tubercle and tubercular 
ulceration are the consequence. Then come the pharynx, the soft pal- 
ate, the root of the tongue, and the tonsillar region, which are all exposed 
to the same influence. A certain proportion of the matter is swallowed, 
but the passage through the oesophagus is too rapid, and undoubtedly the 
acid reaction of the gastric juice too adverse to the local inoculation and 
further development of the organized tubercle poison, to favor the dis- 
ease in the stomach and gullet, where tuberculosis is exceedingly rare. 
When, in consequence of the swallowing of large quantities of tubercular 
matter, catarrh of the stomach has been produced, the chief obstacle to 
the transmission of the virus into the intestine is overcome. In the 
bowel, infection will most likely follow at points where the intestinal 
contents are longest detained; that is to say, in the neighborhood of the 
ileo-coecal valve, the lower portion of the ileum, the ccecum and ascend- 
ing colon. The upper and lower extremities of the tube are less exposed. 
It is easily ascertainable in what parts of the intestinal wall the tubercle 
is most likely to fix itself-on those points, namely, where all absorbed 
substances are first retained; that is to say, in the lymphatic structures, 
the isolated and grouped lymph-follicles. These are, in fact, as is well 
known, the seat of caseating and tubercular ulcers of the intestines. Sim- 
ultaneously with or immediately following the development of the virus 
in the follicles comes the development in the mesenteric glands; whilst, 
on the other hand, the tubercular ulcers admit the poison into the 
branches of the portal vein, and the liver is then endangered. How fre- 
quent tuberculosis of the liver is, every one knows who has taken the 
trouble to examine this organ with sufficient care in all cases of chronic 
tuberculosis. With this combination, consumptive disease of the lungs 
and intestines frequently ends, but further developments sometimes take 
place. The disease may enter the ductus choledochus and produce tuber- 
culosis of the bile ducts. More frequent and more important is trans- 
mission to the peritoneum from deep ulcers of the intestines. And the 
virus inhaled with the atmospheric air may take root directly in the larynx 
and trachea, producing the so-called primary tuberculosis of the larynx. TUBERCULOSIS. 
343 
Whilst the tubercular disease of the digestive tube which has been de- 
scribed. in the foregoing sketch is secondary to the affection of the lungs, 
there are cases in which the intestinal canal admits the virus into the sys- 
tem for the first time. Amongst this class of cases, Cohnheim reckons 
advanced tubercular disease of the mesenteric glands and peritoneum, 
without disease or with only very slight disease in the lungs-a form of the 
affection rare in adults, but unfortunately very common in young children. 
The reason why young children are specially exposed to this danger may, 
perhaps, be found in the experiments of Gerlach, Klebs, Orth, and others, 
who have shown how close is the connection between the virus of the con- 
sumptive disease of cattle and that of human tuberculosis, and have further 
proved that the virus from the diseased cows is contained in their milk. 
Whether the milk of tubercular women contains the virus does not seem 
yet to have been investigated [see the observations of Epstein referred to 
above]; but, with the well-known prevalence of tuberculosis among cattle 
on the one hand, and with the prevalence of the habit of bringing up 
children on cow's milk on the other, an explanation of the frequency 
of primary consumptive disease of the intestines is ready to our hand. 
Perhaps the influence of food in producing tubercular disease has even a 
wider extent. The question may at least be entertained whether all the 
so-called scrofulous inflammations of the lips, mouth, and pharynx, and 
especially the caseating swellings of the lymphatic glands of the neck, are 
not due to the direct inoculation of the tubercular virus contained in 
food, and more especially here, also, in infected milk. 
Cohnheim's remarks on uro-genital tuberculosis are very suggestive. 
Direct infection from one sex to the other, as by syphilis, although not 
impossible, is scarcely to be expected. If the virus from tuberculosis of 
the uterus ever is transmitted in coitu to the male urethra, or perhaps, 
what is not so unlikely, if a man with tuberculosis of the lung or other 
organ can transmit the virus to the genital mucous membrane of a woman, 
such cases must still be very exceptional. As a rule, uro-genital tubercu- 
losis is a disease of excretion. The virus, from whatever source it has 
entered the blood, is excreted by the kidneys, and doubtless, like cinnabar 
particles, oil-drops, milk-globules, and bacteria, through the glomeruli. 
It by this means gets access to the urinary passages, and, on whatever 
point it gets a hold, tuberculosis develops. Most frequently, this takes 
place in the open canaliculi of the pyramids; but the disease may develop 
also in the pelvis of the kidney, in the ureter, and the bladder, and even 
in the prostatic portion of the urethra tuberculosis may occur. It may 
cross in the bladder to the other ureter, and ascend to the other kidney; 
more frequently, however, it is the urethra that is attacked. In the male 
the virus attacks the prostate, thence passes by the ductus ejaculatorii to 
the seminal vesicles, and onwards to the vas deferens, the epididymis, and 
testicle, but it can also pass directly where the ureter and the vas deferens 
cross. In the female, the anatomical arrangement of parts renders the 
route by the urinary passages very improbable. In the great majority of 
cases, the parts affected are the Fallopian tubes and the uterine mucous 344 
TUBERCULOSIS. 
membrane, the virus entering the former from the peritoneum, which is 
scarcely ever found free in genital tuberculosis in the female. 
Although analysis shows that uro-genital tuberculosis is scarcely ever 
the primary outbreak, this cannot be said of all the parts where tubercle 
is localized. In meningeal tuberculosis, there are cases, especially in 
children, in which the usual deposits in the lungs and glands are not to 
be found. How, in such cases, and even in those in which the deposits 
in other organs are present, is the transmission of the virus to the mem- 
branes of the brain to be explained? Cohriheim is in such instances dis- 
posed to accept Weigerfs explanation, who has suggested that the poison 
gets access to the membranes of the brain from the nose, passing through 
the foramina of the ethmoid bone. 
Still more difficult of explanation are cases of vubercular disease of 
bone and fungating tubercular disease of joints, occurring in individu- 
als in whose other organs no tubercular deposit is to be discovered. 
Although in most such cases the development of the local disease is 
traced to an injury, yet it is not to be supposed that an injury can beget 
the tubercular' poison. Cohriheim conceives it to be possible that, in such 
persons, the virus is already circulating in the blood, and that, with 
the exudation which follows the injury, the poison leaves the blood and 
engrafts itself in the tissues. As a rule, tubercular poison is not spread 
through the medium of the circulation, though in favorable instances 
this occurs; and metastatic tubercle, comparable to the most developed 
forms of metastatic inflammations and tumors, is sometimes found. 
When we add to this mode of infection the direct transmission from 
the peritoneum to the spleen, through the lymphatics of the diaphragm to 
the pleura, from the pleura to the pericardium, etc., we need not wonder 
at the number of organs that are sometimes found affected with tubercu- 
losis. 
In explanation of the instances of acute miliary tuberculosis come the 
cases described by Ponfick, in which, as a cause of the contamination of 
the blood with large quantities of the poison, tuberculosis and infiltration 
of the thoracic duct were found. A more frequent cause, however, of 
this rapid form of the disease is tuberculosis of the blood-vessels of the 
lungs, instances of which are recorded by Weigert. A local tuberculosis 
of the pleura, bronchial glands, or mediastinum has extended into the 
wall of a pulmonary vein, and a large surface of caseating tubercular sub- 
stance has projected into the lumen of the vessel. In the light of these 
discoveries, acute miliary tuberculosis loses much of its mystery. 
When the chronic nature of scrofulous affection of the lymphatic 
glands, and the immunity to the general health that often follows it and 
scrofulous diseases of the joints, are compared with the rapid and deadly 
course of acute tuberculosis, it may seem extraordinary that they are 
all attributable to the same poison; but inoculation of rabbits shows that 
they all produce the same disease-a pure tuberculosis. In endeavoring 
to account for the comparative innocence of some classes of cases, it must 
not be forgotten that the human organism may entirely overcome the TUBERCULOSIS. 
345 
poison. Tuberculosis can heal. Pathological anatomy has long known 
cretification and cicatrization after tubercular deposit and ulceration. 
Cohnheim, assuming the error of the dualistic theory of syphilis, compares 
the localization of tubercular affections with cases of syphilitic infection 
in which there is no manifestation of the disease beyond the nearest 
lymphatic glands. Individual differences in the behavior of the organism 
which has been infected by tubercle are seen even in inoculated rabbits. 
When equally large pieces of the same caseating lymphatic gland are 
introduced into the peritoneal cavity and the anterior chamber of the eye 
of a number of guinea-pigs or rabbits, the first outbreak of tuberculosis 
takes place at about the same time and in the same manner in all of 
them, but the further progress shows the greatest imaginable diversities. 
One animal succumbs after and, on examining the body, nodules 
and caseation are found in almost every organ-the peritoneum, liver, 
spleen, lymphatic glands, the lungs, vascular walls, etc. A second lives 
over two months; a third, three months or more; in another, the respi- 
ratory organs are almost entirely free, while the abdominal organs are 
extensively affected; in another, the eye is completely destroyed by caseous 
panophthalmitis, whilst the animal is otherwise perfectly healthy, is not 
emaciated, eats well, and is strong and lively; and when, finally, after 
many months, it is killed, tubercle is found nowhere except in the eye. 
Colinheim, will not have it that the different powers possessed by indi- 
viduals of resisting the tubercular poison are due to the presence or 
absence of a phthisical or consumptive habit of body. The so-called con- 
sumptive habit has nothing to do, he believes, with a facility for receiv- 
ing the virus, but is a product of the disease. Individuals with this 
phthisical habit of body are not specially disposed to tubercle, they are 
already tubercular. In their case, the disease has been either acquired 
in early life or has been inherited. That tuberculosis is hereditary is 
too well known to require to be more than stated; but, translated into 
other language, that means nothing more or less than that the virus can 
be transmitted in the semen and in the ovum; whether it can, like the 
virus of small-pox, be transmitted to the fetus through the placental 
circulation remains yet to be learned. The only difference, in this 
respect, between it and the syphilitic poison is that, while the latter 
manifests itself in the offspring before or soon after birth, in the case of 
the tubercle poison, development takes place at a later period. 
Thus, in the whole history of tubercle, everything is due to the special 
nature of the poison and its effects. According to the present manner of 
looking at the subject, every man is tubercular in whose body the tuber- 
cular poison has taken root. There is, accordingly, no predisposition for 
tubercle any more than for syphilis, although some persons are more 
easily infected than others. Nor is there any constitutional predisposi- 
tion that causes hyperplastic or inflammatory products to caseate like 
tubercle instead of being absorbed or changed into connective tissue, 
but only those pathological products undergo the specific change which 
are already the product of the tubercular virus. Other than this, there is 346 
TUBERCULOSIS. 
nothing in the whole course of tuberculosis wherein there is a difference 
in principle between it and other diseases arising from local infection. 
Not even the fever is pathognomonic. 
This brilliant generalization is to be submitted to the test of time and 
criticism; but the source from which it emanates commands respectful 
attention, as does the vast practical and theoretical importance of the 
subject. 
The whole question of tuberculosis is in such an unsettled state that 
the purpose of this article has been merely to indicate the drift and 
results of recent investigation, without attempting criticism.