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dition might be accounted for on some other basis. DR. H. JACOBSON said the reason the smaller cyst was not evacuated was because the large cyst demanded quite an extensive incision, and after evacuating that and removing it the smaller cyst was easily removed without puncturing. He said he agreed with Dr. Meisenbach that these cysts rarely attain a great size now, though Keene reported one of 111 pounds--84 pounds fluid and 27 pounds solid. He supposed this case was probably like his own-the patient did not come under observation until the cyst had grown to a large size; then again, some of these cases refuse to be operated on until the cyst had reached a good size. The question of the removal of ovarian cysts during pregnancy was one of importance. He considers removal advisable when the tumor reaches the size of a child's head, causing pressure and preventing the rise of the uterus out of the pelvis. The cause of the ascites he did not believe due to the twisting of the pedicle. In this case he said it was due chiefly to the cardiac lesion. She was cyanotic, had dizzy spells, heart sounds weak, murmur marked; the pulse was irregular and thin, ready compensatory hypertrophy of cardiac muscles had not taken place, and he believed the ascites, which clouded the diagnosis to some extent, was partly due to this trouble and partly due to pressure of the tumor. The tumor was a very large one and pressed on the different vessels of the abdomen and also on the bowels, liver and stomach, and this pressure interfered with the return flow of the blood and the lymph, causing ascites. He had gone

over all the points mentioned by Dr. Meisenbach also; the condition was one combining both troubles, and made the diagnosis a little more difficult. The possibility of malignant degeneration was, at her age, also suspected.

IT is claimed that Prof. Wright's inoculations for the prevention of typhoid fever, which have been performed at three stations in India-Bangalore, Pindi, and Lucknow-have proven highly efficacious. The history of three thousand troops who have been inoculated, and who are stationed at the places named, it is claimed conclusively proves the value of the inoculations.

A BILL has recently been introduced into the French Chamber of Deputies for the establishment of a bacteriological laboratory in every department of France. This means the establishment of nearly a hundred stations where the study of infectious diseases can be carried on according to laboratory methods. In founding these stations, it will be the special effort of the French sanitarians to study infectious diseases, especially tuberculosis, and their prevention.

Current Medical Literature

TUBERCULOSIS

Phthisis Pulmonalis and Tuberculosis. — In this masterly article, C. H. BAEUMLER* discusses the conditions under which a tuberculous individual is apt to become a phthisical one. He strongly recommends the disuse of the terms consumption and phthisis and the adoption of the word tuberculosis, especially for the purpose of leading the general attention of the public to the fact that tuberculosis need not be phthisis, and that to prevent the establishment of the latter, the early recognition and treatment of the former is of the utmost importance. The greatest danger which threatens a patient with pulmonary tuberculosis is that he may become consumptive. What are the circumstances bringing about this change? The pathologic process originally is purely local, causing only slight symptoms or none whatsoever, until, under the influence of some bodily exertion or a severe constitutional disturbance, a grave pathologic process suddenly puts in an appearance, the characteristic points of which need not be recapitulated here. Lobular pneumonia, or even lobar infiltration, precedes the end. In cases of limited extension, a healing of the involved areas (cicatrization) is possible, the patient afterwards appearing entirely well. The former offers the picture of the so-called galloping phthisis, anatomically an aspiration pneumonia, which should not be confused with acute miliary tuberculosis. Fortunately they are rare, and the ordinary run of the disease is chronic, the patients under proper treatment recovering for longer or shorter periods. Mostly, a too early return to unfavorable surroundings, conditions of life and modes of work, however, brings on relapses, which finally lead the sufferer to the descending portion of the curve, to a point from which an ascent to normal conditions is impossible. It must not be forgotten that a number of pathologic processes may simulate the picture of lung-tuberculosis. Of these, the author discusses the chronic processes, caused by the inhalation of all kinds of dust, leading sometimes to bronchiectasis, with acute or chronic putrid bronchitis. To them belong cases of chronic interstitial pneumonia, pleuritic exudations, etc., metastasic cases of ileo-typhus, of septic infections, and above all, of syphilis. Very often, too, polymorphous erythema, pleural, pulmonary or mediastinal tumors, actinomycosis and hydatid disease give rise to erroneous diagnoses. Especially valuable are Baeumler's remarks on hemoptysis in cases of mitral stenosis, the consequence of stasis in the circulation, which disappears after the administration of

*Deutsche medicinische Wochenschrift, May 25, 1899.

digitalis. Aortic aneurysms, ulcerative endocarditis, and infarction of the lung must all be mentioned in this connection. An early diagnosis of suspicious cases, a diagnosis before phthisical symptoms set in, is posssible by (1) very painstaking and often repeated auscultation and percussion of the whole lung (an important point of early infiltration is posterior); the portion between the posterior end of the spine of the scapula and the vertebral column of the configuration of the latter must be considered, since even a light scoliosis may alter the percussion sounds, etc.; (2) careful and repeated examination of the sputum; (3) temperature-determinations during a longer period at various times and in varying positions (rest in bed, under the influence of bodily exertion, etc.); (4) determinations of the body-weight at regular intervals; (5) if the results of the above experiments remain negative, and a suspicion still exists, the diagnostic injection of tuberculin is to be made.

The Frequency of Deaths From Tuberculosis in Germany and Some Other Countries.*-1. The general tuberculosis mortality (reduced to each thousand of the living population) has decreased since 1880 in almost all of the European countries. 2. This decrease goes along with a considerable decrease of the mortality of the persons between 15 and 60 years of age. 3. In Prussia the greatest number of deaths from tuberculosis of persons between 15 and 60 years of age occurred in the influenza year, 1890. A steady decrease of these deaths is observed since 1893. 4. (a) The number of deaths from tuberculosis in Prussia from 1887 to 1895 decreased more in the rural than in the city districts. (b) The decrease was least noticeable in Berlin, Western Prussia and in Hohenzollern, most in Sleswig-Holstein and Hanover. 5. (a) For one thousand living inhabitants, the death rate (tuberculosis) of people between 15 and 60 years was smallest in Eastern and Western Prussia, greatest in Westphalia and the Rhine province. This holds good for the census of 1890-91 and of 1895-96. (b) The general death rate from tuberculosis (irrespective of age) is greatest in Westphalia, Hesse-Nassau, Rhine province; smallest in Eastern and Western Prussia and Pommerania. 6. (a) In Bavaria and Saxony the death rate among adults up to 60 years of age was highest in 1890 (the same in Prussia). It was less in the following years, but higher in 1894 than in the two preceding years. (b) In Wurtemberg, Hesse and Alsace-Lorraine, among adults up to 60 years of age, it was highest in 1894 (since 1892). 7. The number of deaths from tuberculosis of adults had increased during 1893 and 1894 in several German countries, but at the same time the death rate from inflammatory diseases of the respiratory tract had decreased. 8. From the six largest components of the *Veroffentlichungen des Kaiserlichen Gesundheitsamtes,

No. 39.

German Empire, for ten years the death rate from tuberculosis has been highest in Hesse; then follow Prussia and Baden; it is of less consequence in Bavaria and Alsace-Lorraine, and smallest in Saxony. 9. The deaths from tuberculosis (between 15-65 years of age) in England has been smaller from 1893–95 than from 1887-89, but in the same proportion the number of deaths from influenza has increased during these years. 10. In Italy the death rate (20-60 years) has increased during the last years. 11. In the Netherlands the highest death rate from tuberculosis was found in 1890. It has steadily decreased since. 12. In Norway the general death rate (all ages) from tuberculosis as well as that of people between 15-60 years of age has steadily increased since 1891. 13. In sixty-eight of the largest cities of France, the respective death rate has increased from 1893-1896. The absolute death rate from tuberculosis was highest in 1895 and 1896. 14. In ninety-one cities of Sweden the death rate (persons of 20-60 years) decreased steadily since 1888, but of each one hundred deaths in 1895 a greater number was due to tuberculosis than before. 15. In the seventy-four cities of Denmark the tuberculosis deathrate was highest in 1890; since then a steady decrease of the general tuberculosis death-rate as well as that of persons between 15 and 65 years has taken place.

Pulmonary Tuberculosis in the German Army. -DR. SCHIERNING* reviews the conditions existing in this respect in the German army. He shows that the principles culminating in Laveran's thesis, "La Prophylaxie de la Tuberculose dans l'armée n'est qu'une question d'hygiène et de recontement," have been followed for a long period, and that the rigorous measures taken in enlisting and hygienically guarding the enlisted men have succeeded to a surprising degree. In 1898, of 514,832 men enlisted only 950 were found to be suffering from tuberculosis. Since 1882 only once (1890–92) an increase of tuberculous morbidity occurred, due to the then prevailing epidemic of influenza. The figures decreased since then and were lower in 1898 than ever before. This is to be considered as exceedingly favorable in two directions. First, it would tend to prove that the means of early diagnosis have been extensively employed. On the other hand, the last years are the ones in which an enormous increase of the number of men enlisted took place. The figures obtained from army and civilian statistics are not to be directly compared. They show, however, indisputably, that since 1885 in both classes of people a decrease of the morbidity due to tuberculosis has occurred. In 1890, of the army, 0.42 per thousand died from this disease; in 1897 only 0.24. It is very interesting to see that the different army corps suffer differently in this regard. differently in this regard. Some or them show a higher mortality in direct proportion to the higher tu *Deutsche medicinische Wochenschrift, May 25, 1899.

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berculous mortality of the districts from which their recontement was accomplished. It cannot be denied that the garrisons of large cities are proportionately more affected, as in most cases the infection is altogether acquired outside of the military service.

Koch's Treatment of Tuberculosis. P. F. KRAUSE reviews the results, which during a period of six and one-half years he has achieved by means of tuberculin injections. Of twenty-seven patients, who received therapeutic injections, twelve were cured temporarily, thirteen improved considerably, one remained unchanged, while one became worse. The twelve cured patients have been observed for from two to five years, and offer no suspicious symptoms whatever. As to desirable degree of reaction produced by the injections, Krause comes to the conclusion that a rise of temperature of one-half degree (or a little more) is quite sufficient. Since 1897, eleven other patients were treated with T. R.; definite conclusions cannot yet be formed; the author believes, however, that the effects are more lasting, and that the temperature is influenced less than with the old tuberculin. Great caution must be exercised not to overload the

patients with toxin. The author's explanation for

the tuberculin action is as follows: The tuberculin possesses a specific affinity for the newly formed granulation tissue surrounding the tuberculous foci. Here the substance produces an inflammation varying from leucocytosis to complete destruction of the tissue. The degree of this inflammatory process is in proportion to the amount of tuberculin injected. If the dose is gauged so as only to produce a moderate local inflammation, a pronounced leucocytosis results. If repeated the granulation tissue pervaded with leucocytes begins to form connective tissue, finally giving a solid cicatrix. The disintegration products of the tubercle are finally surrounded by this wall, and in the course of years the tubercle bacilli die. Therefore the final cure, although initiated by a specific remedy, is not the consequence of an immunity produced by it, but it is what may be called an anatomic cure.

Climate and Sea Voyages in the Treatment of Tuberculosis. HERMAN WEBER† says that, while climate is an important factor in the treatment of tuberculosis, the medical, hygienic and dietetic treatment must be carried on in connection with it. In

the tropics higher altitudes are required than in the temperate zones. The chief points to be considered in the selection of the proper altitude are low atmospheric pressure, small amount of humidity, low temperature in the shade, warmth, rarity of clouds and purity of air. The physiologic effects of high altitudes are amplification of respiratory movements,

* Deutche medicinische Wochenschrift, May 25, 1899. + Philadelphia Medical Journal, June 16, 1899.

strengthening of muscles of respiration, the heart and circulation, increase in amount of water vapor and carbon dioxid given off, increased activity of the skin, increase in appetite and digestive functions, improvement of the blood and the activity of the nervous system. Spengler reports 66.1 per cent. of recoveries. (absolute and relative) at Davos in Switzerland. In the author's experience, forty children born of tubercular parents, properly cared for in high altitudes, did not develop tuberculosis in but four instances. Inland climates and low elevations should not be selected because of the great moisture of the soil and the diminution of light and frequency of rain. The exhalations from the trees, the protection they afford from the winds, etc., are advantages offered by such localities. The desert climate offers favorable advantages, in a great measure offset by disadvantages. The air is pure, rich in ozone, there are great warmth, light, dryness, rarity of rain, etc., but there are also violent winds, clouds of dust, lack of shelter, and a comparatively short duration of the medical season. Ocean voyages are not to be recommended excepting for the mental rest they offer. The purity of the air is limited to the deck, there are violent and sudden changes of atmospheric conditions. In concluding, the author classifies the various sorts of climate to be

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The Infectious Quality of the Milk of Tuberculous Cows, and the Value of the Tuberculin Test. In contradiction of the assertion of Nocard that an infectiousness of the milk only exists in cows of clinically demonstrable tuberculosis of the udder, L. RABINOWITSCH and W. KEMPNER* experimented with fifteen cows, in the majority of which no mastitic involvements could be shown clinically and histologically, but all of whom had reacted to the tuberculin-injections. In 66.6 per cent. animal-inoculations made with their milk resulted positively. The authors come to the conclusion that: (1) In beginning tuberculosis without involvement of the udder, and (2) in latent tuberculosis demonstrable only by means of a tuerculin-injection, the milk may in a great number of cases contain tubercle-bacilli. The milk of cows reacting to tuberculin in each case must be considered suspicious. Therefore, we

*Deutche medic. Wochnschrift, May 25, 1899, and Zeitschrift für Hygiene und infections Krankheiten, 1899, Vol. 31, Heft 1.

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be hoped that in our country, too, by private and municipal efforts, old and absolutely unjustifiable prejudices will be more and more overcome,, and a means adopted to generally avert one of the greatest dangers to the welfare of mankind.

Do the Tonsils Frequently Form Points of Entrance for Tubercle Bacilli?-v. SCHEIBNER* has made extensive investigations into the frequency of primary tonsillar tuberculosis, a subject which, ever since the researches of Strauss in Paris, who found living tubercle bacilli in the nasal and pharyngeal secretions of a great number of people coming in contact with tuberculous patients (nurses, physicians, etc.), has continued to arouse the highest interest. The summing up of Scheibner's experiments is as follows: Among thirty-two tonsils histologically examined (removed by operation or autopsy) only two, or, if the cases operated upon are included, of sixty only four,

cases could be found in which in all probability there

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existed a primary tonsillar tuberculosis (one of them being certainly a tuberculosis produced by food material). These three primary aspiration tuberculoses form 5 per cent. of the cases examined. Sixty-two cases, which were examined only bacteriologically (negative), are not included in this calculation. may infer from these facts that the findings of Strauss, relating as they mainly do to sick-rooms, have no bearing on the conditions of every-day life and intercourse, or, what is less probable, that the danger of infection by nasal secretion containing tubercle bacilli is slight. Strauss intended to extend his examinations on persons of different modes of life and profession which, however, do not come in contact with phthisical patients. But it seems that his untimely death prevented him from carrying out his plan. It would be of great interest and certainly allow of definite conclusions as to the general transmissibility of tuberculosis if his experiments, properly arranged, would be repeated in a resort for consumptives.

The Prevalence of Tuberculosis a Statistical Study. GEORGE MYER† makes a further contribution to his article on the mortality of phthisis in Berlin in the ten-year interval between 1880-1889. Since 1884 the number of individuals who have died from consumption has steadily declined. In 1883 the number per thousand was 3.42, while since 1892 it has diminished to 2.30. If the population of Berlin be taken as 1,800,000, then there is a gain in human life in Berlin of 2,268 persons. Together with this decline in mor

* Deutsche medicinische Wochenschrift, 1899, No. 21. + Ber. klin. Woch., May 22.

tality, there goes a definite decrease in the number of deaths from all causes in the years from 15-60 years. In London, in 1851-1860, 2.86 people per thousand died of consumption; in 1895 the mortality had sunk to 1.83. This decrease in England is more noteworthy for the reason that in London most of the precautions observed in Germany are not thought necessary. causes at work to explain the decline in mortality are numerous. The improvement of the general condition of the people, the completion of great sanitary undertakings, and especially the recent social labor laws, and the Krankencasse law, which makes it possible for every one to have competent medical assistance at the first indication of any illness.

The

Human Tuberculosis Infection.—E. AARON* considers the question of tuberculosis from the broad standpoint of social hygiene. According to the discussion of this question in the last year, the following three views for the care of consumptives were brought out: First, hospitals should have a separate department for phthisical patients, Schafer's idea. Second, Von Leyden advocates the establishment of special

hospitals for phthisical patients. Third, P. Guttmann, Furbringer and Lazarus do not believe that the isolation of tuberculosis is necessary. The tuberculous infection cannot be decided from bacteriologic experiments alone. If the results from such experiments were applied to human beings, then scarcely anyone, and certainly no physician, could keep from being infected with the tubercle bacillus. Therefore, it is to be supposed that the human organism can defend itself in some way against bacterial invasion. Especially so, as it has been proven beyond doubt that the tubercle bacillus is scattered about everywhere. Experience has taught us that the danger of infection is by no means so great as might be supposed. This is explained by the fact that a man possesses in his own body a number of protective agents a portion of these is well known to us-ciliated epithelium of the respiratory tract, lymph glands, phagocytosis, etc. These have received their just importance in the consideration of the question, Cornet has proven in the most direct way that the tubercle bacilli can enter the organism without causing tuberculosis, and can be eliminated without any bad effect following. So it is seen that the public has no especial cause for worry on this point.

Evidently there must be some other factor to be considered, which has been known under the name of constitution or disposition. This disposition may be hereditary or acquired through influences which tend to weaken the resistance of the organism. If the results of animal experiments were logically applied to the human race then all phthisical individuals would, of necessity. be regarded as dangerous to the common *Berl. klin. Woch., May 22, 1899.

It

good, and therefore should be shut up in closed institutions. That this is not necessary is evident. The decrease of mortality in the last decade can hardly be explained by the introduction of spit-cups and the prevention of soiling the handkerchief with sputum. is more likely that the social conditions of the poorer classes and the improved position of the laboring people can account for this improvement. The introduction of the Krankencasse system, whereby, at the first sign of a disease, the laborer can receive the best medical attention, and so take precautions against its increase, has done wonderful service. Our efforts for the future should be directed, not so much towards the destruction of the tubercle bacilli, but towards the strengthening of the restoring power of the people by means of a betterment of the social condition of the working man, by attention to nutrition and the hygiene of the dwelling, and by trying to minimize the harm which the industrial and factory life of the people bring with it.

The Surgical Treatment of Tuberculosis of the Lung.-K. TURBAN* describes a case where, under surgical treatment by means of resection of the 7th, 8th and 9th ribs, the diseased lung being thus mobilized, the pathological process was brought to a standstill. There are certain cases of tuberculosis of the lung which show a tendency to shrink and to the formation of scar tissue, but this tendency can not act to sufficient advantage because the thorax is so large and well built that it does not permit of the decrease in space of its interior. Experience has taught that often in just such cases of well built and powerful chests the process of lung destruction is more malignant than in those cases where the thorax is smaller and weaker. In the case described the result, while not being a perfect cure, yet allows the patient to be active and busy. The following indications for the operation is suggested by the author: In a practically small number of cases of complete, or almost complete, affection of one side when the other lung is in strong and normal condition, this operation may prove of benefit, provided, after long observation of the case, a tendency to shrinking with a good resistance power but an inelastic thorax has been observed.

The Relation Between Menstruation and Tuberculosis of the Lung.-NEUMAN† advises that all phthisical women should be examined in regard to their lungs during the menstrual period, and immediately after and before. In general, it may be said that tuberculosis does not particularly influence the course of the menstrual flow. The following observations were made by the author in phthisical women: First, many tuberculous women become

*Berl. klin. Woch., May 22, 1899. †Ber. klin. Woch., May 22, 1899.

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feverish during the menstrual flow. This is always to be regarded as a suspicious sign, even if in the intervals the woman remains perfectly normal. Second, the catarrhal condition in an evidently affected portion of the lung may increase during the menstrual period without rise of temperature. Third, in suspected cases, or often in anemic patients, portions of the lungs before thought to be perfectly healthy, show, during the menstrual periods, latent foci of disease which may be proven by auscultation. slight increase of temperature may be observed. Fourth, there are tuberculous patients who in the beginning of the menstrual period show no change in their condition, but in whom during the decline of the flow a noticeable decrease in the pathologic lung symptoms may show itself. The practical conclusions to be drawn from these observations are: During and immediately before and after the menses the patient should avoid everything which would tend to increase the irritable condition of the lung tissue. Rest in bed, avoidance of all exertion, careful diet, etc., are to be recommended.

care.

Hemoptysis in Tuberculosis.-E. GERHARDT* discusses the importance of hemoptysis in consumption. Although this symptom is found in many other diseases, as in bronchiectasis, echinococcus, syphilis, cancer, and aneurism, yet it has come to be considered as almost pathognomonic of phthisis. It is this symptom, more than any other, that causes the patient to seek the doctor's aid. In this respect this symptom may be looked upon as a fortunate one, as it serves to put the patient immediately under medical Many causes may precipitate an outbreak of hemoptysis-hard manual labor, other muscular exertion, excitement, trauma of the breast; whatever the cause, hemoptysis is a symptom of a tuberculous cavern and of hemorrhage from an aneurismal widening of the pulmonary artery. Concerning the frequency of hemoptysis, Gerhardt draws his figures from the second medical clinic of the Charitè in Berlin. Of 879 tuberculous patients, 30% had hemoptysis. Hemoptysis is rarely fatal; less than 4%. Rise in temperature after the hemorrhage is an unfavorable symptom. Hemoptysis as an early symptom is regarded by some as being prognostically favorable. Treatment is absolute quiet, and morphin to control the coughing. When the patient is still under the recollection of the influence of his attack, he should be advised to seek proper treatment, either by going to a suitable health resort cure or to a different climate.

Acute Paranoia.-M. KÖPPEN† discusses this much-debated question from the standpoint of the *Berl. klin. Woch, May 22, 1899.

Neuroglische Centralblatt, May 15, 1899.

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