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physical effects. But autopsical examinations revealed, besides “ulcerative destruction of the lung," nodular indurations from which they deduced "ulcerative and nodular consumption.”

Gradually smaller and smaller nodules (milia) came to be recognized more and more frequently, giving rise to the two forms — nodular (tubercular) and granular pulmonary phthisis.

These nodules were found to be so universally present that it gave rise to the conclusion that the oldest lesions always originated in these nodules. “And as the pulmonary is the predominant form of consumption, and produces the other forms, so all phthisical consumption came to be regarded as dependent upon the pulmonary form, and this also upon the formation of nodules or tubercular substance." All pulmonary phthisis was tuberculous.

Sylvius first recognized softening nodes, and speaks of larger and smaller tubercles, but associates these nodes with pulmonary glands, "and supposes that this form of consumption (tubercular) is produced by the swelling of these glands and their final conversion into suppurating tubercles.”

Over two hundred years ago Mangetus compared the tubercles found in the lungs, liver, spleen, and kidneys with millet seed, and also describes manifestly a miliary tuberculosis.

“Bayle uses the expression miliary tubercle; describes a granular as well as a tubercular phthisis. He also declares that tubercular phthisis is a specific disease.”'

Laennec comes nearer the modern idea, and states that the tuberculous matter is developed under two principal forms—that of isolated bodies and that of infiltration (both being neoplasms), but finally softening into pus, discharging through the bronchi, and thus forining tubercular cavities. He denies the inflammatory origin of tubercle, and that pneumonia could pass into tuberculosis.

Laennec's views became generally accepted, and in 1844 Lebert with his microscope discovered granular corpuscles, which he called "tubercular corpuscles."

Rokitansky in 1842 adopted Laennec's views, and declared tubercles to be neoplasms, and that “tuberculous infiltration differs from the tuberculous granulation in the fact that in the former the tuberculous substance is produced uniformly and in so solid a form that the pulmonary structure over a large extent becomes unrecognizable and impermeable.” Evidently a difference only of degree.

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Reinhardt in 1847 proved that the tubercle corpuscles may originate from pus cells, and by 1850 he had established the fact that many substances hitherto regarded as tubercle were identical with the product of inflammation, and Virchow had taught us to regard the “caseous metamorphosis tubercularization' as a general process of necrobiosis in tissues and exudations,” a view which is perfectly consistent with our present knowledge.

The term “tubercle” Reinhardt limited to miliary tubercle, and regarded it neoplasmic (Laennec). “ Tuberculous matterwas called “caseous matter," and "tubercularization,” “caseation," from which they got “caseous or scrofulous pneumonia” (of Virchow).

Neimeyer, in his text-book of Practical Medicine, makes a sharp distinction between “chronic tuberculosis of the lungs" and "acute miliary tuberculosis,” and treats of the two conditions in separate chapters.

I will quote very fully from his writings. He says: “The term ‘pulmonary tuberculosis' continues to be the expression most commonly used to signify 'consumption of the lungs,' a proof that the majority of modern physicians and medical teachers still adhere to teachings of Laennec, and only recognize one form of pulmonary consumption, the tuberculous. I have long contested this doctrine, and upon various occasions have declared, in direct contradiction to it, that destruction of the pulmonary tissues, the establishment of cavities, and consumption of the lungs are much more frequently a result of chronic inflammation than of tubercular deposit. And I hope that these views, of whose justice any one may easily satisfy himself who will only study the subject with calmness and without prejudice, will ultimately obtain general acceptation. The error into which Laennec and his disciples have fallen is not that they regard tubercle as a neoplasm, but that they look upon solidification of the lung, due to different causes, as products of tuberculosis. Even according to modern views, tubercle still ranks among the pathological neoplasms, although, however, but one form, the miliary form, and one mode of origin, miliary tuberculosis, is recognized.

“It is one of the characteristics of tubercle, that it always appears in the form of small nodules, scarcely as large as a millet seed, and that the individual nodules never grow into voluminous tumors. The larger so-called tubercular nodules consist always of an aggregation of many small miliary tubercles. All

All the extensive indurations and

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enlargements formerly described as tuberculous infiltrations, or as infiltrated tubercle, depend neither upon infiltration of the tissues with tubercular matter nor upon diffuse development of tubercle, but upon morbid processes of a different nature.”

From the foregoing we see that, previous to Virchow and Neimeyer, pulmonary phthisis and pulmonary consumption were convertible terms, but by them we are taught that a certain proportion of cases of pulmonary phthisis is not a tuberculous disease. (Flint.) These disputes rested for a time at this point, and until the communicability of the disease began to be considered. While its communicability has been believed by some for ages past, many observers have denied it. Flint says, “In my collection of 670 recorded cases of phthisis, the number of instances in which there was room for the suspicion of the disease having been communicated either from the husband to the wife or from the wife to the husband, amounted to only five." All of which is hard to believe at the present day.

A strong impetus was given to this discussion when Villemin in 1865 produced tubercle in the rabbit and guinea-pig by inserting beneath the skin tuberculous product. A momentary doubt arose when it was announced that tubercles had been produced in other animals by various kinds of non-tuberculous matter. Cohnheim and Fraenkel, however, proved that this would not be the case if the "non-tuberculous matter” had been taken from places where tuberculous animals had not been kept or the inoculated animals were kept from others that were tuberculous.

Klebs communicated the disease by mixing with the food of animals sputum from phthisical cases, and found the disease in other animals that had been fed with milk from cows affected with the so-called "pearl” disease (now known to be tuberculosis).

Cohnheim produced tuberculosis in rabbits that had been kept for a time in cages placed before cows that were tuberculous and allowed to exhale over them.

These experiments proved that tuberculosis was a specific disease, always reproducing itself, and that it was communicable not by contagion but by infection; it remained for Koch to describe the nature of the virus, which he did when he discovered the “bacillus tuberculosis,” and thus Laennec's “neoplasm,” Virchow's “caseation," and Neimeyer's “chronic catarrhal pneumonia” have passed into history, and we now stand to Koch and his germ.

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This brings us to the vital point of the whole matter. If all forms of phthisis, general or local, are tubercular; if tuberculosis is a specific disease and its contagium a germ that knocks daily at the door of our castle, waiting for the first invitation to enter, and after entering we inust entertain until death closes the scene-what, I say, are we going to do with it?

This is a question that must claim our attention, and for whose solution more that one hundred thousand human beings in the United States alone look in vain each year.

When statistics tell us that one quarter of all deaths are due to tuberculosis, and we see case after case slip through our hands in spite of all that we can do, we stand appalled, and manifestly must look to prophylaxis for our cure. If, then, we are all fit subjects for tuberculosis and the insane asylum, let us begin at once a strict quarantinemake it national or international.

You may call this chimerical, and at first thought it does seem so, but look back over history and see what has been done in so-called impossibilities. If only. the rich were our subjects, then the work would be easy, for they could do as we dictated; but what of “the poor ye have always with you ?” We say, give them to the Government and let her be their shield. This, you say, will take money! Of course; and so does our army of the “Grand Old Party" take $200,000,000 each year; but in the end she will profit by it, in that many lives will be saved through a long period of productiveness.

Let the Government set aside two or more reservations within her borders in localities that will best suit the cases in their various stages, and send all infected persons to them for proper care. It may be said that this will separate friends and families. This will be true in some instances, but how long does the bacillus allow them to remain here? About one year, and often less; while in some, by this change, they may live to an old age with perfect enjoyment. A wife may be allowed to go with the husband or the husband with the wife, but let not the children go. There should be no returning except for very short visits, if that, and the territory should be large enough to allow all some form of employment; for example, a physician in the earlier stages of the disease could practice his profession and render himself useful to his fellows. Suitable buildings could be erected for the reception of patients in the last stages of the disease, and after death the bodies should be cremated.

Many people would be restored to almost normal health, and the good done to others would be incalculable. We have often heard of the “one-lung" citizens in soine of our Western States actively engaged in business, and all know that it is almost suicidal for them to return to the locality in which they contracted the disease.

This I would call isolation, and by it contamination of our homes 'and public places would be reduced to the minimum, and in time rendered almost devoid of tubercle germs which are now being scattered over the face of the earth by expectorating multitudes.




This subject is one of especial interest to me, as I have had the opportunity to operate on two cases within one week. There were several points connected with these cases that impressed me: First, injury to the brain; second, extent and character of fracture; third, thickness of the skull; fourth, the urgency of immediate relief.

First: The brain can stand considerable injury and loss of substance and patients make uninterrupted recoveries. I refer to cases that recover from the operation and are apparently well, but we must not lose sight of the fact that a large percentage of such cases suffer at some future time. In one of my cases the brain was considerably damaged, and patient lost not less than an ounce of brain substance.

Second : It is not always possible to tell the extent and character of the fracture. We sometimes see quite extensive fractures without symptoms. In one of my cases the skull was badly fractured; the patient had no symptoms at the time I saw him, it being forty-eight hours after the injury.

I think an exploratory incision should be made in all cases of doubt. This brings us to the question, Should we make a compound out of a simple fracture? This question was settled more than ten years ago on the ground that it was not the broken bone that deserved our attention so much as the damage done the brain and its membranes by the bone.

Third: The thickness of the skull varies considerably. In one of my cases the thinness was a marked feature, the skull not exceeding one eighth of an inch.

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