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upon anorexia, for he says a common peculiarity of almost all cases is that the patients are never good eaters. This author actually puts this statement in italics. “Patient war nie ein starker Esser!"
Pfeiffer states a well-known fact when he says that children of tuberculous parents are often sickly from birth. Affections of the mucous membrane are unusually virulent and obstinate, and complications are more wont to develop. For instance, in such children there is with every simple catarrh of the throat an inflammation of the ear, “not only once, but every time, and not only in one child of the family, but often in every one.” Sometimes it seems that this disposition may skip individual generations, since such diseases are observed in children whose parents have been sound, but whose grandparents or more remote ancestors suffered with tuberculosis. How much prejudice may influence an opinion is seen from the conclusion which this author draws that “the presence of predisposing circumstances must be accepted in spite of the fact that in an extraordinarily large number of autopsies we found the remains of a more or less extensive tuberculous disease in the form of caseous or calcified deposits in the lungs, in the lymph glands, in cicatricial atrophy of the apices, proving that tubercle bacilli were once present." The author seems to be unaware of the disclosures of Ziemmsen, who found living bacilli in apparently quiescent cervical glands, and of Loomis, who reported of 763 autopsies, 71 cases apparently cured, the patients having died of different diseases. The cure was effected by the usual marked increase of connective tissue, but that the cure was not always so perfect as appeared to the naked eye was demonstated by the discovery of tubercle bacilli in three of the twelve lungs examined.
Of the affections of the ear, which are so prone to occur, tubercle bacilli have been already actually demonstrated in half the cases. Here, too, the sickliness of the child is the effect and not the cause of the tuberculosis.
Independent of inheritance altogether, the tendency is said at times to be acquired, and the same factors have been invoked, to wit, the paralytic thorax, the phthisical habitus, the frequent occurrence of catarrh, defective ciliary action, hypoplasia of the heart, etc. The statement resis upon
the same evidence as in the case of the inherited tendency, but more may be claimed perhaps for a chemical alteration of the juices or organs of the body, which may fertilize the soil for the growth of the tubercle bacillus, or what is more likely true, lessen resistance to its invasion. Such a change certainly takes place in diabetes. It is a notorious fact that onehalf of the cases of diabetes succumb to tuberculosis. Seegen found the lungs sound in diabetes in only a few cases. Leyden found a latent development of phthisis under insidi-' ous general symptoms especially remarkable in cases of diabetes, and usually under the entire absence of hemoptysis. In what this alteration consists we do not know, but studies in culture soil may throw some light upon this obscure subject. Sander found that a somewhat acid culture soil is the most favorable to the growth of the tubercle bacillus. This author observed also that growth occurred in neutral soils with the addition of glycerine. Here may be mentioned for what they are worth the experiments of Fermi and Salsano, who found that the long continued injection of dextrose and lactic acid into the bodies of guinea-pigs and mice increased the disposition to tuberculosis. All these conditions are found in diabetes, but that the predisposition is not peculiar to phthisis is shown from the fact that the diabetic patient is also especially liable to invasion by other micro-organisms, especially those of pus, as furunculosis is almost as common as tuberculosis.
I would like to begin the next section of this subject with the statement, which may not now be gainsaid, that tuberculosis depends solely and exclusively upon the tubercle bacillus. The tubercle bacillus is the one over-shawdowing fact in the whole history of this disease. It is the nucleus
about which everything else must crystallize. As the true believer would say, when everything else is in doubt this is the rock to which we cling.
Everything must conform to the tubercle bacillus. Whatever fails to fall in with this view is relegated as useless lumber to the ancient history of the disease. It illuminates a whole field of obscure diseases. It reconciles discordant facts. It establishes unity. For instance, it is a far cry from a basilar meningitis to a hip disease, from an otitis to an orchitis, from a miliary affection to an Addison's disease, from a lupus vulgaris to a fistula in ano. Tuberculosis is conveyed by infection, because it is conveyed by a living thing which grows only from itself. It belongs to the older civilizations, and is unheard of and unknown among newer peoples, as among the Australians, or our own Indians, until it was brought to them by Europeans. Tuberculosis is therefore most frequent in those organs which are most exposed to the outside air. Louis, long before the cause was known, declared it to be a law that if tuberculosis is found elsewhere in the body, it will always be found in the lungs. In fact, tuberculosis is found first in the lungs, next in the intestines, and in the lymph glands, as it is absorbed from these organs, and then and thence in other organs and tissues of the body. To this point we return again.
Tuberculosis is most frequent and intense in the most closed and crowded spaces. A sentence of imprisonment for any number of years is a condemnation to death by tuberculosis. Cornet has shown that sixty per cent. of nurses succumb to tuberculosis. It is useless here to dwell upon this fact.
No one now refuses to believe that tuberculosis of the lungs is acquired by inhalation of the tubercle bacillus. Even the exceptional case of inheritance is by infection of the ovum and in this case it is impossible to conceive that the mothers too came from an infected ovum. The problem is to solve the individual case of exemption with the same environment. It is alleged against infection
that many individuals exposed all their lives long fail to contract the disease. But the same thing has been said repeatedly of diseases infectious by universal acceptance-typhoid fever, for instance. Watson said long ago of variola, “There is no contagion so strong and sure as that of smallpox, and none that operates at so great a distance." But three of the great masters of medicine in the olden time, Morgagni, Diemerbroeck and Boerhaave, who walked among epidemics unscathed, believed that the disease was little or not at all contagious.
Then it is urged that cases have not multiplied in places to which tuberculous patients have been sent in numbers. Attention is often called to the fact that the disease has not diminished in Naples, where failure of registration of cases was punished with a fine of 300 ducats, and, on repetition, with banishment for ten years. For fifty-six years this decree was rigorously enforced with indescribable damage to the community, according to de Renzi, and according to Brehmer, entirely without influence upon the frequency of the disease.
Rompler reports of his fifteen years observations in Gorbersdorf, that the emigration of patients had not increased the number of cases among the indigenous in that village. In the last hundred years only 72 persons died of tuberculosis among a thousand from all causes, and the disease successively diminished in the last four decades notwithstanding the increased overflow of the place with lung disease.
The observations to the same effect made at the Brompton Hospital, which seemed to show that the disease was never contracted in these institutions, have been invalidated, partly by the subsequent discovery of cases-the mere remaining alive or even in apparent health is not evidence of exemption—and partly by the studies of Cornet, who showed the cleanliness of institutions, i. e., freedom from infectious dusts as compared with private houses.
Tuberculosis deposited in the recesses of the body is preceded by deposits in the course of the main avenues. Mention has been made already of deposits in the bronchial and
in the mesenteric glands. The disease irradiates from these centers. Sometimes the primary deposit is more concealed and the disease is disseminated from some cryptogenetic
Plain cases and curious cases of all kinds abound in literature. Thus Spengler found tubercle bacilli in the bronchial lymphatics of six children who had died of diphtheria, sepsis, etc., but who had shown no symptoms of tuberculosis. With one exception this was the only place where tuberculosis was present. The bacilli had clearly penetrated from the respiratory mucous membrane. Neumann, from his studies, concludes, as stated already, that the bronchial glands are the first depots of deposit in children. The inhaled bacilli are carried to the nearest gland and may here either be destroyed, or after a variable time, owing perhaps to some intercurrent affection, "measles, pertussis, bronchitis, inflammation of the lungs," may be carried to any part of the body to produce the various tubercular affections. Babes found affection of the bronchial glands in the children's hospital at Buda Pesth in more than half his sections. Muller, of Munich, found the same condition 103 times in 500 sections. Northrup, of New York, found caseation limited to the bronchial glands forty-two times in one hundred and twenty-five cases. In three cases only was the primary infection in the mesenteric glands. Engelnah made a bacteriological examination of the lungs, bronchial and mesenteric glands in one hundred and twenty infants, which died at a St. Petersburg hospital during six weeks of the fall of 1891. Tubercle bacilli were found in fourteen cases (11.7 per cent.) at ages varying from two months and four days, the youngest, to seven months and seven days. They were present in both the lungs and bronchial glands in 93 per cent. of cases.
Neumann goes so far as to say that children who have died of tuberculosis of any organ always show affection of the bronchial glands, and that affection of the bronchial glands depends always on infection with tubercle bacilli.