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convenient method, but they may also be given by the rectum, and it is claimed by Fish that his serum may be administered by the stomach as well. Given hypodermically the effect is very much more prompt, but occasionally unpleasant symptoms supervene. I have had this frighten me several times, as well as badly frightening the patients themselves. This no doubt is due more particularly to the rapid introduction by the needle entering a small vein, the serum being thus introduced very rapidly into the circulation. When it is thrown simply into the subcutaneous tissue it is slowly absorbed; it will be half an hour before it all enters the circulation; but if the point of the needle enters a vein, of course in half a minute the entire amount of serum is in the circulation and the system is overwhelmed by it. The symptoms are sometimes alarining. I have had patients express themselves as if death were impending; the pupils become widely dilated; pulse exceedingly quick and weak; face fushed; respiration labored and hurried, and the patient expresses himself that he feels as if he were dying. While these symptoms pass off in fifteen or twenty minutes, these few minutes seem like an age to both the doctor and the patient. No matter how careful the physician may be in trying to avoid the superficial veins of the skin, he can not always expect to succeed. I have never seen any unpleasant effects from the rectal use of the serums, though it must be said that their effect when so administered is not as prompt as by hypodermic use. When given by the rectum, their administration may be intrusted to the patient; I have done that repeatedly. I have never tried the administration of serum by the stomach, and am unable to give any information upon the subject.

Dr. H. A. Cottell: I do not know that it would be considered proper for me to try to discuss a paper that I have not heard, but I suppose any doctor would find it easy to make a speech off hand upon the subject of tuberculosis. I do not know just the argument pursued by Dr. Skinner, but I assume it is the modern treatment, hygienic, etc., of consumption.

There are two things about tuberculosis that can not be questioned: One is its contagiousness, the other its incurability. Austin Flint contended many years ago that tuberculosis was a self-limited disease, and in many cases it certainly is. I think the management of tuberculosis of the future is going to be hygienic and not therapeutic. It is the dream of the hygienist that tuberculosis will some day be stamped off the face of the earth, and I do not see any reason why it should

not be realized. That tuberculosis is inoculable was not questioned even before the discovery of the bacillus of Koch; but since this discovery a great flood of light has been thrown upon the subject. I remember many years ago, before the discovery of the bacillus, a family in which five sisters one after the other in rapid succession succumbed to the disease, and there was no history of tuberculosis in the family. The mother had died a middle-aged woman of some acute trouble; the father was living at that day, a hale and hearty old man, and two brothers and a sister who lived away from the family homestead escaped. The first case was contracted by a young lady visiting her sister, whose husband was then suffering with, and subsequently died of tuberculosis. She went home, developed the disease and died, and then one after the other the sisters in rapid succession succumbed to it. I would consider that these cases proved, as far as five cases can, that the disease is contagious.

As to the serum treatment, I think that up to date it has done no good. The last thing I read on the subject was in a recent medical journal, in which an authority contended that some of the tuberculines on the market now had in them tubercule bacilli alive, and that some patients had been inoculated with tuberculosis in being treated with these agents. There is probably great danger in these tuberculines, though if they are filtered through porcelain, as I have understood they are, they ought to be free from bacilli.

The disease having a tendency to self-limitation, we see a case now and then that has practically gotten well, and I think such patients would have done as well if they had been fed on cream instead of cod-liver oil; and treated with palliatives and expectorants instead of being saturated with creosote and nux vomica.

Dr. Wilson speaks of having seen in the dead-house encysted tuberculous deposits, evidences of cavities in the lung which had healed, the patient dying of other troubles. I have seen such instances frequently. We are all familiar also with those cases of tuberculosis which break out, so to speak, occasionally; where a patient may go along for four or five, or it may be ten years without any evidence of the disease, and then have hectic and hemorrhage, or he may go on to old age or die of some intercurrent affection. I have in mind now a number of cases of that kind.

Dr. Louis Frank: If Dr. Skinner has made heredity of tuberculosis a study, I would like for him to say something about this feature in

closing the discussion. I believe there is nothing in heredity, as far as tuberculosis is concerned, and the fact that the children of tuberculous parents have the disease is explained by the fact of association and implantation of the germs in that way.

Dr. Cornelius Skinner: As to heredity, I do not think that even the older authorities believed much in the theory of heredity; they seemed to be in doubt. In searching the literature I could not obtain any very positive information, or positive expression, of the older authors as to whether tuberculosis, or phthisical consumption as some of them call it, was inherited. There are many cases where the disease appears to be inherited, and it is so believed by the laity; and looking at the subject from one standpoint superficially, we would naturally expect them to think so. For instance, where one or both parents have died of tuberculosis, if a child born to them develops the disease, it is naturally thought by other members of the family, and the public at least, that the disease is inherited. We know from the light of modern investigations that the disease is the result of association. I have in mind now a woman whose father, mother, and six sisters have died of tuberculosis, and at first thought one would be inclined to say that the disease was inherited. I do not believe that the disease is ever inherited, but is always acquired. But I do believe there is some peculiar devitalized condition of the system of the children of tuberculous patients which invites all diseases, not tuberculosis any more than others. We know that parents the subjects of inflammatory tendencies are prone to beget children having the same peculiar condition; surgeons do not like to see this, and if they operate upon one member of a family and the case turns out badly, they dislike to operate upon another member of the same family. Modern writers upon tuberculosis now disclaim any inheritance of the disease itself. There is undoubtedly a devitalized condition, you may call it what you please, diathesis, idiosyncrasy, or any thing else; but in every case of tuberculosis it must be understood that some other case has preceded it, and the infection has been thereby disseminated.

Drs. Bailey and Wilson have covered the ground fully concerning the dangers of occupying apartments previously used by tuberculous subjects, the importance of destroying the sputum, etc. I have in mind a case now which illustrates this: The patient attended the World's Fair in 1893; I was with him there for a month on my vacati on; he was as well apparently as I am now. He was a minister, and

went back to his charge in Alabama, he having been transferred to that State a short time previously from Texas. That fall he became sick, began to go down, finding great difficulty in filling his appointments; he soon began to have night-sweats and other unmistakable symptoms of tuberculosis.

A physician was called and found that the patient had some fever, and to which he was giving attention. He went down and down until about Christmas of the same year, and was sent to Florida. Then for the first time I was notified of his illness. He wrote me a description of his symptoms, and it became clear to me that the trouble was tuberculosis. I visited him and began to look into the history, as I desired to ascertain the reason for development of the disease. It turned out that one of the ministers before him in that charge, and who had occupied the same house, had a case of tuberculosis in the family. Evidently, then, he had become infected after his removal to Alabama from Texas. Cases of this kind are seen almost daily, where infection takes place months or even years after quarters have been occupied by tuberculous patients. I am aware of one chronic case of tuberculosis in this city. A man has been sick for years, and two of his children have acquired the disease and died of tubercular meningitis. Cases of this kind are familiar to you all.

In my paper I did not touch upon the treatment of tuberculosis except prophylaxis, and while some of the suggestions made are rather broad, I think you will agree there is a great deal more in the subject than has yet been said. The great question is what shall be done with the poor people? The rich we can handle, but the poor, we can not get rid of them, we can not turn them away, and yet something must be done to protect others. They are likely to infect everybody, expectorating in street-cars, sleeping-cars, and elsewhere, no care being taken to destroy the sputum. I recall a case with which Dr. Ray is probably familiar, a railroad man or a man who travels nearly all the time, sleeping in the sleeping-car most of the time, who has a tubercular laryngitis. In the last examination I made of this case, a few days ago, I believe I detected a cavity in the apex of his left lung. This is an undoubted case of tuberculosis contracted from sleeping-cars, in which there is very great danger always. None of the other members of his family show any evidences of the disease.



November 18, 1897.

Presentation of Specimen. Dr. Rufus B. Hall: This specimen is a multilocular fibroid, which I present this evening because it has some interesting clinical history connected with it. This was removed from an unmarried woman, aged forty, who had always enjoyed good health previous to about a year ago, when she discovered she had a tumor in her pelvis, and that worried her very much from the fact that a younger sister, a member of the family, had been through the same operation a short time before. She was referred to me from Chillicothe, O. The patient complained of pressure symptoms. On examination it was very easy to determine why she had these symptoms. She was a small woman, and the cervix could barely be felt, and well above the pubic arch we could feel this nodular tumor, which at first I suspected was the body of the uterus, and a portion the size of a small cocoanut fitted into the pelvis like a child's head about the second stage of labor. With a little investigation I could outline the uterus not at all enlarged, barely a quarter of an inch longer than normal. I could easily arrive at the conclusion then that the mass felt in front was probably another tumor, perhaps a subperitoneal fibroid. An interesting feature in the clinical history was that this tumor fitted so close in the pelvis I felt it was in the folds of the broad ligament, and the operation would be a very difficult one. The operation, when it was made about two weeks ago, proved to be the easiest operation for hysterectomy it has ever been my pleasure to make. You will observe the ovaries are attached to the specimen. When the abdomen was opened the tumor was easily rolled out of the pelvis. Before the operation I put the patient in the knee-elbow position, and with my fingers in the vagina it was impossible to move this mass, and that was what I based my conclusions upon, that it was probably in the folds of the broad ligament. The patient could only get a movement of the bowels when the stools were fluid. The temperature at the highest point was only 99.6°, the third day after the operation. The operation was a supravaginal amputation, leaving a portion of the cervix.

Dr. Withrow: How do you account, Doctor, for the fact that it was difficult or impossible to lift the tumor out of the pelvis previous to the anesthesia and yet so easy after the patient was anesthetized ?

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