former cases there

was

no external discharge of pus. Again, some cases of typical miliary tuberculosis have recently been under observation, whilst coxitis was still recent, at the clinic of Professor Langenbeck. His assistant, Dr. Busch, intends to publish the report shortly. Phthisis

is much more frequent when protracted suppuration has been established in the course of coxitis, and is usually ascribed to cachexia. In such cases it will have to be determined whether we are dealing with true tuberculosis or with simple phthisis (cheesy pneumonia), and also whether or not the lymph-glands are in a state of caseous degeneration, because it is only by instituting a comparison between all the factors that we can discover the cause of phthisis. If true tuberculosis be present, then it is referable to the resorption of shrivelled pus-corpuscles from the affected joint, or of cheesy matter from lymph glands; if simple phthisis, then the constitutional abnormality will be specially taken into account, although there is a possibility that it also may have originated from resorption.

(e.) Chronic abscesses: - Chronic abscesses, especially when connected with caries of bone, stand on the same footing as joint inflammation, and in this respect caries of the petrous bone is pre-eminently hurtful. The latter is usually considered as tubercular, but, as Troeltsch justly insists, without trustworthy evidence being advanced to support such a view. The cheesy masses which are found in the cells of the petrous bone can be ascribed more simply to purulent inflammation than to a tubercular process; and it is urged by Troeltsch that chronic otorrhoea usually precedes the bone disease, and that the latter is entirely caused by neglect of the former. The experience of aurists who have a rich field for observation goes to show that a large proportion of persons suffering from chronic otorrhoea die from tuberculosis, and that the tubercles are situated very frequently or exclusively in the membranes of the brain. The relation between caries of this bone and meningeal tuberculosis was too striking to be regarded as accidental. Accordingly Troeltsch some years ago arrived

at an independent interpretation which harmonises tolerably well with Buhl's theory and my own.*

It follows from all this evidence that tuberculosis very frequently makes its appearance as a secondary disease after purulent inflammation, and that it does so especially in those cases where the pus cannot be discharged externally, and is therefore retained in the organism. My theory explains the phenomena in the simplest way; they are due to the resorption of shrivelled pus-corpuscles, or granules of detritus. Whether the retained pus, or part of it, must of nceessity be caseous in order to produce tuberculosis is a problem which awaits solution by means of further researches.

7. "TYPHUS" AND THE ACUTE EXANTHEMATA.-Phthisis has at all times been not unfrequently observed as a sequel of "typhus" fevers and the acute exanthems, especially measles. This fact is in complete consonance with my theory. The former affections set up cheesy swelling of the lymph-glands or ulcers in the bowel with cheesy enlargement of the mesenteric glands, which form the startingpoints of tuberculosis. The latter class of cases are frequently complicated with bronchitides which result in either catarrhal pneumonia or circumscribed pneumonical induration, and thus induce phthisis or tuberculosis, or they excite glandular swellings which become caseous, and then tuberculosis follows from resorption. Hooping-cough is on the same footing as the acute exanthemata.

8. ULCER OF THE STOMACH.-Diettrich has called attention to the frequent complication of round ulcer of this organ with tuberculosis. It is not difficult to bring this fact also into harmony with my views, if we assume that abnormal elements are resorbed from the lesion. The same explanation applies to those rare cases of carcinomatous ulceration, especially of the stomach and bowel, in which tuberculosis appears secondarily, according to the observations of Diettrich and of Martius. It is, however, a matter

* Waldenburg gives Troeltsch's views, but it is unnecessary to publish them in this place.-G. M.

for further inquiry whether we are here dealing with true tuberculosis or with caseous pneumonia.

9. DIABETES MELLITUS.- -This disease is one of the most frequent antecedents of phthisis. Phthisis then depends usually on cheesy pneumonia, for diabetic patients are disposed to inflammation, and, it is very likely that the considerable loss of fluid which is constantly going on is the chief reason why the purulent products become cheesy. If cheesy deposits are present, tuberculosis arises, of course, as a consecutive disease. But it is still an open point whether or not primary miliary tuberculosis appears directly in diabetes, without the intervention of cheesy pneumonia. The observations hitherto made are, in my opinion, insufficient to solve the problem, because in published reports phthisis is generally confounded with tuberculosis. If the question be answered affirmatively, we can explain the fact by saying with Dittrich, that the regressive metamorphosis of the tissues is abnormally increased, and that the degenerated elements are resorbed into the blood in the corpuscular form.

This explanation would be all the more plausible if it should be proved that tuberculosis frequently results from an enforced "Banting-Cur," in which rapid reduction of the weight of the body occurs within a short time. The reports communicated up to this day, as far as they are known to me, are much too inexact to enable me to arrive at an opinion as to their credibility, and especially as to whether they have reference to simple phthisis or to tuberculosis.

10. SUPPRESSION OF HABITUAL DISCHARGES, &c.-The moderns not only deny, but smile at the opinion that phthisis and tuberculosis are caused by the arrest of discharges, the healing of ulcers, &c.; and yet it was entertained by the most eminent and experienced authors up to the beginning of this century, including Morton, Sauvages, Cullen, and by Portal, and Schönlein more recently. Portal, for instance, refers to the frequent occurrence of phthisis after the healing of skin eruptions, under the name of phthisis exanthematica." He also speaks of "phthisis VOL. XXXII, NO. CXXVII.—JANUARY, 1874.

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metastatica" as the consequence of drying up old abscesses ́ in any part of the body, and of quickly healing chronic ulcers, issues, purulent surfaces produced by vesicatories, &c., whether the cure of these lesions is brought about spontaneously or by medical treatment.

And Schönlein classified tuberculosis, according to its causes, into the following forms :-(1) simple pulmonary tubercle; (2) menstrual tubercle, with its variety, puerperal tubercle; (3) tubercle from cold drinks; (4) exanthematic tubercle: (5) impetiginous tubercle; (6) arthritic tubercle; (7) inherited tubercle. I am far from assenting to these views in their full scope, but I should like to obtain for them an unprejudiced examination with the aid of all the means of research at our command.

I shall now review the individual factors on which our predecessors laid the most weight.

(a.) Suppression of the catamenia.-This usually takes place in the course of phthisis, most frequently in the advanced stage, more rarely soon after the onset of the disease, and is always a "signum mali ominis." This fact was not less known to our ancestors than to ourselves; surely, therefore, they did not refer to such cases when they maintained that phthisis arises in consequence of suppressed menstruation. In reality, we cau take into account only those instances in which cessatio mensium traceable to any cause whatsoever brings on the disease in previously healthy persons. The following notes illustrate this point:-Frau G, æt. 29, family quite healthy, mother still living, father robust and died of apoplexy. Patient has always been strong and healthy; has had two children, the youngest is two and a half years old. Of late menstruation has been somewhat irregular, but has never stopped. In August, 1867, at a time when the period was expected, she took a cold bath for the first time in her life. On returning home after the bath she noticed a few drops of vaginal blood, but no more came; menstruation was arrested at its commencement and has

not since made its appearance. Some time afterwards dry cough set in, slight at first and gradually getting worse. In the middle of December she became hoarse, and at a

later period lost her voice; then followed high fever, night sweats, and excessive wasting. On February 17th, 1868, percussion gave marked dulness at both apices, where there were also loud bronchial breathing and metallic rattles. Examination with the laryngoscope disclosed perichondritis of the arytenoid cartilages and ulceration of the larynx. In these circumstances all treatment proved useless, and the patient died on February 28th.

There can scarcely be the least doubt that in this case the suppressio mensium produced by the cold bath at the menstrual period was the cause of the subsequent phthisis and tuberculosis. In this patient there was no hæmorrhage from the lungs in any part of her illness. In many persons suppressed menstruation brings on hæmoptysis, especially where a disposition to bleeding or the phthisical habit exists.

Hæmoptysis may then be the point of departure of a later phthisis. We frequently observe that persons who are already phthisical are disposed to hæmoptysis at the menstrual period, when menstruation is delayed or scanty— a fact which has a close analogy to those cases of primary hæmoptysis which introduce phthisis after suppressed catamenia.

(b.) The tendency of chlorotic patients to become phthisical is beyond doubt. Here also, in at least many cases, secondary phthisis may be ascribed to retentio mensium, but the conditions are too complicated and the causes too obscure to enable us to enter at present into the details, except with great reserve.

(c.) The suppression of habitual hæmorrhoidal flux may also lead to phthisis. On this matter I have no experience of my own, but this much I have frequently observed, that arrest of bleeding from the hæmorrhoidal arteries excites various chest and abdominal complaints, increases existent bronchial and pharyngeal catarrh, creates oppression of the chest, &c., and that all these symptoms disappear when the bleeding returns. I have also often observed that bleeding piles give temporary relief in phthisis, but in some cases no effect is produced on the disease. Further obser