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But in the few established cases of fetal tuberculosis, the bronchial glands were not all or only very insignificantly affected.
Again, the anatomical situation of the glands indicates infection by inhalation. Buchner and Wyssokowytsch showed in their experiments that the inhaled spores of various bacteria could penetrate to these glands without lodging in the lungs. From these glands the bacilli irradiate.
According to Weigert, miliary tuberculosis of the lungs is a consequence of invasion of the pulmonary veins from the intra-pulmonary glands. In nearly all these cases, the exemption of the mesenteric and cervical glands is proof of the fact that the avenue was through the lungs.
The exceptional cases are sometimes very curious. Thus Jaccoud and Schurhoff each furnished interesting contributions to the origin of acute miliary tuberculosis. In the case of Jaccoud, the miliary tuberculosis occurred in the course of a hemiplegia, and its origin was from an old tuberculous deposit in the brain without meningitis. In the case of Schurhoff, the miliary tuberculosis arose from a tuberculous nodule in the mitral valve, which in turn had developed from an old pericarditis. In a case reported by Kobner, there developed, besides a laryngeal phthisis, an extensive tuberculous destruction of the skin of the chin. This patient had been shaved for many years in different barbershops, all the time carrying about a suppurating wound. In the case of Rethi, there developed, after the extraction of a tooth, a tuberculous ulcer of the mouth, which led to extensive destruction with further communication with the cavities of the mouth, nose and jaw. Hilbert reported a case from Konigsberg in which the tuberculous meningitis developed immediately after a violent concussion of the head, as tuberculous disease often does in other places. I know myself of two cases of basilar meningitis after trivial trauma. Mordhorst long ago called attention to the opportunity offered for the colonization of bacilli in the quiet regions of extravasated blood after trauma. Heiberg reported 84 cases
of uro-genital tuberculosis most frequently as a sequence to bone and joint disease. Dittrich reported 16 cases of tuberculous perichondritis of the cartilages of the ribs. The majority of the cases suffered from easily demonstrable tuberculous affection elsewhere. A case reported by Frankenburger of Nuremberg died of acute miliary tuberculosis, and the only lesion found post mortem was an old tuberculous disease of the uterus and tubes. Radcliffe mentions cases in which tuberculosis of the lungs ran a favorable course. The patient seemed perfectly well for years, and then began to show the insidious signs of a chronic nephritis, due to the direct penetration of the kidneys by tubercle bacilli.
It is not necessary to appeal to ancestral history in explanation of these cases. The ancestry of the disease is found in the individual himself.
There is no real immunity. Cornet has shown that when a number of animals are subjected to inhalations of atomized sputum, some are affected and others escape. If the inhalation is more prolonged they are all affected with one or two exceptions, and if then it is still more prolonged, the exceptions are also affected. Why is this difference in time? This much only may be said, that if these animals are reduced by different diseases, the differences are still more marked, and this is the truth about the predisposition in man, that is, there is no disposition peculiar to phthisis and there is no immunity to phthisis. Pathetic proof of this fact is often enough furnished by careless individuals. During the inhalation experiments of Tappeiner, his assistant, a remarkably robust and vigorous man of forty years, free from all hereditary taint, and previously in perfect health, could not be restrained from entering the apartments, boasting of his ability to show his strength and the lack of danger of this procedure. He continued to enter the rooms in defiance of entreaty and command. He fell a victim in the course of fourteen weeks to phthisis florida, and autopsy revealed exactly the conditions that were found in dogs killed in the
same way. Cornet tells the story of a clerk who asked his employer to supply the office with cuspidors. “If you have hectic, we don't want you,” he said, “if not, you don't need them." This brutality met its reward. In six months the employer had hectic himself.
The attempt to deduce conclusions from the laboratory is often greeted with contumely. It is a common saying, especially among clinicians of the old school, that a man is not a test tube. The fact is he is a test tube, enclosed in skin instead of glass, but containing a much more complex culture soil. If we do not understand the changes which take place in the culture soil in the interior of his body, it is not the fault of the comparison or the fact. Like the test tube he stands about with open mouth and receives what falls into it from the air, and they who believe in predisposition leave him standing helpless without the power of removing the contaminations in the air.
Do you recall the famous test tubes of Tyndall ?
Tyndall exposed one hundred test tubes, ten deep each way, filled with the same solution, fresh urine, to the action of the atmosphere. For fifteen hours the contents remained perfectly clear. This period of clearness he called the "period of latency." We call it the period of incubation. Toward the end of this period the tubes begin to show the effects of disease. The solution passes from clearness to cloudiness in the course of a few hours, but there is a great difference in the tubes. Some are spotted with mould, some are cloudy throughout, some are absolutely opaque. A number of tubes remain apparently unsmitten. Would it be fair to say that the tubes most affected were most predisposed, and that the unsmitten tubes had immunity to attack? By evening of the next day, under the same exposure, every tube of the hundred was attacked. “The whole process bore a striking resemblance to a plague among a population. The attack being successive and of different degrees of virulence.” Test tubes filled with the same fluid
sterilized by boiling and exposed to fresh air in a box remained clear for weeks. Was it because these tubes were not predisposed to attack by the bacteria of decomposition ?
One of the great arguments adduced against infection is the fact that individuals are said to be inost affected in early life, and that age secures exemption. Wurzberg showed the fallacy of this view in observations based on studies in Prussia where, of 10,000 persons, the percentage increased from the first decade, which included 10 per cent. regularly to the seventh decade, which included 71. The regiments which made the most campaigns suffered the most, and the few individuals who survived at the end are regarded as invulnerable only by the superstitious.
When it was objected to these conclusions that the statistics were based upon tuberculosis of the lungs alone, which is the most frequent occurrence in adult life, whereas gland and joint affection is more frequent in child life, the objection was met by Zwickh, who showed from the mortality statistics of Bavaria that the general view that tuberculosis is especially a disease of youth is wrong. There is, on the contrary, continual increase of the deaths up to old age. Of 100,000 of the same age, there died of tuberculosis, that is of tuberculous diseases of all organs, in the male sex alone, at the Age.
690 When we consider the universality of the disease, we may be led to ask the question, whether the subject of predisposition is not one rather of dissemination in the body of the individual, than acquisition in the first place. This subject
opens up the field of invasion by other, especially the pyogenic, micro-organisms, which are chiefly responsible for the spread of the disease in the body. Whatever degrades the body in any way favors the development and dissemination of a disease, or any disease, including tuberculosis. In this sense and this only may be admitted a predisposition to phthisis. We may recall in this connection the history of the celebrated rabbits of Trudeau. A number of animals were inoculated with like quantities of the disease. Half of them were allowed to run free in the open
air. The other half were supplied with food and drink and immured in a dark hole under ground. The animals were all killed at the same time. Those which had run free had either recovered entirely, or showed only localized lesions. The immured animals showed wide dissemination of the disease. Would any one say that these immured animals were more predisposed to the disease? The weak and feeble from whatever cause are the victims of all disease. Birch-Hirschfeld long ago showed that the mortality at the end of the year is not increased by the prevalence in its course of any epidemic. The epidemic numbers its victims among those who would have died of other cause.
It has been shown, I think, that the theory of a predisposition is dangerous, in that it removes attention from the avoidable sources of the disease. It is also undemonstrable, and experiments made to prove it are all open to objection. Finally, it is superfluous. A predisposition is a return to the assumption of a diathesis which excites a horripilation in a man of modern education. Like the doctrine of predestination to its opponents it takes away the chance of
Do you believe that a man is predisposed to syphilis? These diseases were for a long time studied together. Tuberculosis is aquired by infection. Ignorance of this fact favors the spread of the disease. I have more than once made this experience. I have been called to see a case sometimes in a tenement house, sometimes in an under-ground room, found the patient lying in bed in the last stages of phthisis, unable to lift his head to expectorate,