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was stung on the 23rd of May; on the 28th she said to a friend, who called to see her, " I have lost the use of my hands " she complained also of her feet, that she had lost the use of them. On the 30th was seen by another neighbour, dying: "her nails had turned purple, her eyes and mouth were open, and she was labouring very hard for breath [i. e., death from asphyxia, as in fatal cases of snakebite. J. W. v. T.l; she died in about half an hour. After her death I looked into her mouth and found the back part of her throat very much swollen. I think she was suffocated. I do not think she could swallow. A surgeon by order of the coroner examined her body, and found traces of several stings on the back of her neck. The veins of the neck and throat were very much swollen and discoloured. This is much more definite than anything given by C. Hering, valuable as his treatise on Apia is. The only pathogenetic symptom in the direction of paralysis which I can find is S. 877, "Eingenommenheit des linken Armes." It was developed in himself, on taking the poison of one bee, in fifteen minutes; he does not say how long it continued, but from the way in which it is recorded in the proving it was evidently only a vague and passing sensation.


(Continued from Vol. XXXI, p. 483.)

We have now to consider the proofs derived from Jetiology in support of my theory.

The causes of phthisis and of tuberculosis have hitherto been usually divided into the constitutional and the occasional. The former were always placed in the front rank, whilst the latter were kept in the back ground, sometimes more, sometimes less so, according to the views which were held respecting the disease. Those who regarded phthisis as an inflammatory affection could not but take cognizance of the immediate or exciting causes, such as taking cold, &c., whereas, on the other hand, those who looked upon tuberculosis as a new formation had to consider such influences as unimportant.

We now recognise only the essential causes, that is to say, those factors and affections which occasion the taking up of fine foreign particles into the blood. The constitutional causes coincide in part with the essential, but with this difference that, according to my views, it is not the constitution but the already existent constitutional disease which is the causal force; in other words, tuberculosis results not from the phthisical or the scrofulous habit, but from existent phthisis (cheesy pneumonia), or from scrofula (cheesy lymph glands). The constitutional abnormality is the first instigator to the primary disease (phthisis, scrofula, caseous inflammations of divers organs), and therefore stands in an indirect relation only to the secondary affection, •e. e. true tuberculosis.

The exciting causes are similarly circumstanced. Under this head come cold, excesses, residence in vitiated air, bad and deficient food, mental emotions, excessive exertion, &c. They cannot, according to my theory, directly excite tuberculosis, with the exception, perhaps, of living in foul air; but they can very easily develop the primary affection, and then tuberculosis arises afterwards. Cold, excess, over-exertion, and the like, set up catarrh and pneumonia, which leave behind cheesy products, and in this way generate tuberculosis subsequently. The same causes may likewise arrest meustruation, start an haemoptysis, &c., and thus lay the foundation of tuberculosis, or bad air, deficient nourishment, &c, bring on scrofula, from which tuberculosis originates later. Accordingly, the causae occasionales are, to my thinking, by no means unimportant; they are the excitors, not of tuberculosis itself but of the primary diseases that lead to its development.

Let us now review seriatim the different primary affec


tions wliich are followed more or less frequently by tuberculosis.

1. Pneumonia.—It will not be necessary to enlarge on this subject here, because in an earlier part of my work I fully discussed the important part which cheesy pneumonia plays in the production of tuberculosis, and also because it is a well-established fact that nothing is more common than the combination of both acute and chronic tuberculosis with cheesy pneumonical products. We know that cheesy pneumonia both alone and when associated with tuberculosis constitutes by far the most frequent form of pulmonary consumption. We also know that the pulmonary inflammation which paves the way for phthisis need not be a special kind from the first, but that even simple croupous or catarrhal pneumonia may run on to caseation, and thus lead to phthisis. I have pointed out in a former discussion that the constitutional cause of phthisis is not tuberculosis, but cheesy pneumonia solely; whilst the most common exciting causes, such as cold, excess, over-exertion, &c., likewise point to cheesy pneumonia, as has just been stated.

The historical sketch of the doctrines held respecting pulmouary consumption which forms the introductory portion of my work plainly teaches us that the inflammatory origin of this disease was admitted, without the least doubt being expressed about it, by the majority of writers from Hippocrates down to our own time. This doctrine was first shaken by Bayle and Laennec, but was again stoutly upheld by other authorities, including Broussais, Andral, Cruveilhier, Bernhardt, &c. The disbelief on this matter was based on the recognition of miliary tubercle as a specific formation, and on the fusion of cheesy deposits (infiltrated tubercle) with true tubercles. We who now regard miliary tubercle as a secondary non-specific growth, and oppose the fusion just referred to, give our support to the old dogma that most cases of phthisis, i. e., those beginning with cheesy pneumonia, have an inflammatory origin.

2. Scrofulosis.—This is one of the most common causes of tuberculosis, although rarer than cheesy pneumonia. The connexion of tuberculosis and of phthisis with scrofulosis was a recognised doctrine for more than a century, and the two morbid processes were almost regarded as one and the same. This view was doubtless based chiefly on anatomical structure, especially on the cheesy condition of scrofulous glands being analogous to that of the lung nodules, or "tubercles" of phthisis. Clinical observation also taught that this connexion undoubtedly exists; for the strong tendency of scrofulous persons to become phthisical is a matter of every day experience. This clinical fact will always remain uncontested, although the theories explaining it may undergo ever so many changes.

A. Hirsch, comparing the geographical distribution of scrofulosis and of phthisis, arrives .at the conclusion that "in the great majority of localities where scrofulosis prevails consumption also occupies a very conspicuous place in the mortality; whilst, on the other hand, in districts which are exempt from it, consumption of the lungs is little, if at all known."*

It should be understood that tuberculosis and phthisis follow not only the fully developed conditions of scrofulosis, but also when there is merely swelling and caseation of the lymph-glands. The ancients were familiar with this fact, and it has been corroborated both by recent experience and by the post-mortem researches lately carried out with reference to Buhl's theory. The celebrated F. Hoffmann reports several cases in which phthisis originated after the sudden resorption of the contents of cervical glands.f

My theory explains the connexion between tuberculosis and scrofulosis in the simplest manner; they stand to one another in the relation of cause to effect. I do not resort to the indefinite hypothesis of a general cachexia, or one common to both, and still less do I attempt to make the two morbid processes identical. But I defend Buhl's teaching that tuberculosis following scrofulosis takes place from the direct resorption of the cheesy matter contained in the lymph-glands. Yet I do not think, as he does, that this matter contains any kind of virus, my own opinion being that the indispensable and only sufficient condition for tubercular infection is the resorption of detritus, i. e. the corpuscular elements in cheesy masses. Scrofulosis is not a specific, virulent, or contagious disease; its matter when taken up into the circulation acts in no way differently from the finely divided corpuscular particles of non-scrofulous deposits.

* Handbuch der Historisch- Oeographischen Pathologie, Bd. II, p. 97. t Observations sur la Nature et le Traitement de la Phthisie Pulmonaire, Tome I, p. 99.

In order that scrofulosis may produce tuberculosis, it is necessary not only that cheesy or degenerated lymph-glands be present, but also that they should be situated in immediate contact with blood-vessels. If the glands are surrounded with a fibrous and non-vascular capsule, there is very little danger of resorption, and, consequently, of tubercular infection.

Moreover, as the admission of true corpuscular elements into the blood is essential, according to my theory, for the production of tuberculosis, it is easy to explain why under different conditions a resorption may be quite innocuous. For instance, if a tumefied or inflamed gland in which no cheesy matter has as yet been found is resorbed,- say by Iodine, the result is ascribed, according to the prevailing opinion, to the elements having undergone fatty degeneration and liquefaction. But if these elements are already shrivelled up in consequence of caseous metamorphosis, they are less capable of passing through a complete fatty and liquescent process; they, therefore, either remain in the organism as deposits unless expelled, or enter the circulation through open blood-vessels, or through lymph-vessels. Resorption of the former masses does not convey any foreign particles into the blood, and is, therefore, free from danger; whereas, when the latter are resorbed, the blood gets loaded with foreign stuff, and the organs in which this stuff is stored fall into disease.

Not only acute general miliary tuberculosis, but also subacute and chronic local tuberculosis follow scrofulosis, and that whether the cheesy glands are situated in the neck, the mediastinum, the mesentery, or in any other part.

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