Of these but thirty-five occurred before the sixth month, while forty came between the sixth and twelfth month, sixty-six from one to two years, eigthy-two from two to four years, after which period they again became less frequent. Demmer, in the course of twenty years, had under observation one thousand nine hundred and thirty-two cases of tuberculosis in children. Of these the greater number occurred between the second and fourth years, which is in accord with results obtained by Furst. Of all of these but one occurred in the third week, one in the seventh, and one in the eighth week. Neither record a case of tuberculosis in the newborn. Epstein's record of two hundred infants from tuberculous mothers does not furnish a case of tuberculosis at birth, and but one at the tenth week. On the other hand Dr. Jacobi has seen one seven months' foetus with numerous gray miliary tubercles in the tissue of the liver, peritoneal covering of the spleen, and a few on pulmonary pleura. The mother was of a consumptive family and died three weeks after confinement. While this case of Dr. Jacobi's is suggestive it appears to stand alone, and perhaps might have been accounted for by some abnormality in the placental circulation, had search been made at time of birth, as it is a well-known fact that, under certain circumstances the blood-vessels of the placenta are pervious, permitting a direct communication between the blood of the foetus and that of the mother. So far we have not considered the food problem as a causative agency in this connection. Infants being fed almost wholly on milk not unfrequently receive the bacillus into the stomach, whether it be from a tuberculous mother or a tuberculous cow. Far more frequently, however, it occurs that milk from a healthy cow becomes contaminated before it is received into the stomach. Thus a large percentage of cases that occur in early life are to be excluded from our list. Still another percentage of the same can be accounted for by direct contagion as the air passages of the newborn are far more susceptible than those of older children. Tubercle bacilli floating in the dry, warm air of the nursery find a fertile soil in which to reproduce when they are inhaled by the nursling. I It would seem, then, that in our present light we are justified in assuming that the bacillus of tuberculosis is not transmitted from parent to offspring. In making this statement I am aware that some eminent pathologists place the weight of their opinion on the other side of this question. While discarding the theory of the transmission of the bacillus of tubercle, hereditary transmission of the disease known as tuberculosis is claimed as a fact by common consent. believe this is because of the great number of cases observed in the same family. Also that the child of healthy parents in whom no tendency to the disease has been manifested, when living with a family predisposed, under the worst possible hygienic surroundings, often continues healthy while those of the predisposed family succumb to the disease. Many, if not all, of my hearers now have in mind one or more instances corroborative of this statement. Vogle looks upon heredity as the principle etiological factor in the production of this disease, and concludes that external influences are injurious to those only who are predisposed. There is little doubt that this is an extreme view, and the fact remains that many in whom no taint of heredity is traceable, die of this disease. However, this does not disprove the theory of transmission. Of all cases it is estimated that two-thirds occur in persons predisposed or, at least, in families in which there is a multiplicity of cases, which cannot be accounted for unless by the theory of contagion. Again referring to such authority as we have at command we find that, while some are apparently the result of direct contagion, in many cases this seems improbable as the first appearance, even in infants, is in the bones and lymph bodies. In fact this seems to be the rule when it occurs in the early periods of life. If such was the result of contagion by inhalation, would we not, as is pertinently asked by Dr. Jacobi, expect to find the deposit in the lungs instead. Further, children born of parents predisposed to, or suffering with, the disease often die early in life, even though they be at once placed under the very best hygienic surroundings-surroundings under which infants not so predisposed do well. While I have been striving, on the one hand to prove that the bacillus of tubercle is non-transmissible, on the other, my efforts have been equally great to sustain the theory of the transmission of what has been called the tubercular diathesis. If that is made clear I will now ask, Do you believe in the unity of phthisis pulmonalis and tuberculosis? Eminent authority is not wanting by which to prove they are dissimilar. If we refer to the definition of tubercle as given above and quoted from Dr. Jacobi, which seems to be the one most generally accepted, we shall see that "only such products as contain the specific bacilli deserve the name of tuberculosis." Those histologically the same, or similar, are not included among the genuine, from which it would seem, then, to be pretty generally admitted that bodies resembling tubercles in physical and gross appearances do exist. Also that these bodies tend to undergo caseous degeneration resulting in distinction of tissue quite similar to that of true tubercle. This change is not a neoplasm, nor is it intimately connected with a specific neoplasm, but is wholly a retrograde metamorphosis. Can we not have a condition of the system which can be transmitted from parent to offspring marked by the tendency to caseous degeneration and retrograde metamorphosis, which degeneration tends more frequently to be set up in the lungs than other tissues, and which manifests itself as a result of but slight causes operating in those in whom this condition of system has not been inherited,-are able to endure with impunity? In such the serous membranes inflame easily. Often slight exposure will precipitate a pneumonia which tends to become subacute or chronic, and necrotic patches frequently occur in the larynx and bronchial tubes. Again the lungs of such individuals furnish a ready and fertile soil for the planting of the bacillus, and then if they have not already a cheesy pneumonia, pulmonary tuberculosis follows. In such also in whom cascation has gone on to some extent, with proper exposure, an acute or chronic tuberculosis may supervene, thus presenting both forms in the same individual. This not infrequently happens. Indeed Niemeyer says that the greatest danger to a majority of consumptives is that they are apt to become tuberculous. Professor Gibbes, of Ann Arbor, says with reference to the pathology of consumption: "I am convinced that we must recognize two forms of disease which result in the formation of cavities in the lungs. One of these, pulmonary phthisis, occurring after broncho-pneumonia, is purely an inflammatory disease from beginning to end. Also from its incipiency to the close, each step in this form of disease is degenerative. In the other type, namely, pulmonary tubercu losis, the first step in the series of changes is a new growth of fibroid tissue derived from the connective tissue of the lungs. After this growth has reached a certain size, which varies with the chronicity of the process, the center undergoes a necrotic change. Although one of these tubercular masses appears to be homogeneous, it is in reality made up of an aggregation of tubercles, and this tubercular process is always progressing on the outside, while the center is breaking down." Etiology.-Relative to the causation of consumption I believe it is now generally agreed that a certain percentage of cases are the result of contagion or infection. Just what this percentage is I am not able to state. The investigations of Koch, Grancher, Nægele, and many others, show that the mere breath of tubercular patients does not contain the bacillus. Also that inhalations of vapor charged with cultures of the bacillus are highly infectious. Dried sputum of tuberculous patients contains bacilli in large numbers. Therefore, inhalation of air charged with dried sputum is dangerous even though the sputum be several months old. Gebhart asserts that sputum diluted to the proportion of one to one hundred thousand is still virulent. Those predisposed are far more liable to contract the disease when exposed to an atmosphere in which the bacilli are floating. Among the conditions favoring the development of consumption, impure air should be mentioned first. Professor De Forest, of Yale University, has collected a series of statistics bearing on this point. He says: "Of three thousand two hundred and fourteen cases at the Brompton Hospital, more than one half had had indoor occupations. The mortality in prisons is twenty-five to thirty-five per cent. higher than the rate for the rest of the world. In Germany in a poorly ventilated prison the death-rate from consumption was fifty-one and four-tenths per one thousand, while in a well ventilated prison it was only seven and nine-tenths per one thousand." Baer states that the air in the foot guards' barracks was in the proportion of three hundred and thirty-one cubic feet per The tubercular death-rate was fifteen and eight-tenths per one thousand, while in the horse guards' barracks with five hundred and seventy-two cubic feet per man the death-rate was only seven and three-tenths per one thousand. Also that proper ventilation soon reduced the foot guards' mortality. Next to quantity of pure air stands quality, as to the amount of moisture. A dry air being far more healthful to those with weak lungs. Dr. Bowditch was the first to call attention to this. In two contiguous health districts of Ontario, one of which is a plateau free from malaria, and the other a flat malarial district, the deaths from tuberculosis were in the former eight and five-tenths per cent. of all deaths, in the latter twelve and seven-tenths per cent. Next to the air supply, I would place the food supply. A sufficient quantity of wholesome food is very necessary. To keep the body warm is of the greatest importance. I have in mind a number of instances where children, half fed and poorly clothed, grew up. One family of six boys, I bear in mind, of which it was often remarked, "How can they live so?" They did not live, for before reaching manhood, four of them succumbed to this dread disease, the seeds of which, I believe, were sown in early life, as consumption is not hereditary in the family. With reference to the symptomatology I wish to inform you in advance that I have no startling disclosures to make. If I chance while enumerating some of the symptoms and physical signs, to call to the mind of any gentleman present, some point which he had nearly or quite forgotten, then shall I feel well paid for my labor. Following the views expressed relative to the pathology of consumption two varieties must be recognized. Of the two, the one in which tubercle centers as a causative agency is the more formidable. Let us suppose that in the fourth week after an attack of broncho-pneumonia, there still remain lobules which are crowded with exudate. Unless resolution speedily takes place the lung tissue in the center of these patches will be damaged beyond repair, and will pass into a state of caseation. In such a case as this there will be, from the beginning, numerous small and medium moist rales, and if the foci are thickly set, some dullness on percussion with bronchial respiration. Also some cough with expectoration, frequent chills followed with fever and sweating. As the deposit usually takes place first in the connective tissue and around the bronchioles, and may be confined thereto for some time, the period depending on the chronicity of the attack, it is not difficult to understand why, with even a relatively large number of tubercles formed, there may be no physical signs to indicate their presence. The air cells are not yet involved. No infiltration exists. There is only an increase of connective tissue, consequently no dullness on percussion, nor bronchial breathing. However, the patient grows pale, emaciates, is troubled with shortness of breath on taking exercise, has a dry, hacking cough and feels quite indisposed. There is perhaps a slight elevation of temperature. It is not until the disease has extended to the air cells and bronchioles that unmistakable symptoms arise. The clinical histories which have heretofore been widely separated converge at this point from whence they pursue the same course. The area of dullness increases, pari passu, with that of infiltration, With marked bronchial breathing over central portions, there may be broncho-vesicular respiration at the margins of the infiltrated patches. Unilateral dullness at apex is always very significant. This may be first detected in the supra-clavicular fossa. Often, however, in the back or in the supra-scapular fossa. Abnormal respiratory sounds and adventitious sounds will be heard in place of the normal respiratory murmur. vesicular breathing is merely modified, being diminished, interrupted or sometimes exaggerated with prolonged expiration. These associated with marked deficiency of the respiratory movement on the affected side greatly aid in the diagnosis. Evident contraction at one apex as revealed by inspiration, as well as numerous fine crackling rales, are very significant. Loud bubbling rales point to the presence of a cavity as they are definite indications of the occurence of rales in a larger space than is normally found in the apex of the lung. So also does metamorphosing respiration which begins as vesicular and suddenly becomes bronchial. Changes of percussion note as observed with the mouth opened and closed, as well as those alterations that take place with changes of posture suggest the presence of a cavity also. Fever is usually present but not unfrequently it is slight or absent throughout nearly the entire course. The more acute the attack, the higher, as a rule, the temperature runs. often a distressing feature of the disease, after which those depressing sweats follow. Those thin bony fingers, that pinched face, hollow cheek, with a hectic flush, those bright eyes, associated with that pitiable yet hopeful expression of countenance, forms a sad picture with which the general practitioner is but too familiar. TRANSACTIONS. DETROIT MEDICAL AND LIBRARY ASSOCIATION. STATED MEETING, JANUARY 11, 1891. THE PRESIDENT, GEORGE W. STONER, M. D., IN THE CHAIR. DR. F. E. WAXHAM, of Chicago, Illinois, read a paper entitled "Intubation of the Larynx." (See page 97). DR. E. L. SHURLY: My experience has been limited in these cases, and while I must congratulate the doctor on his brilliant record I cannot discuss the question from a practical stand-point. DR. C. G. JENNINGS: DR. WAXHAM has done a great deal by his earnest advocacy and brilliant record for this operation. His results have indeed been magnificent, but my own experience has not been so favorable, and I am inclined, although I recognize intubation as the more æsthetic operation, to still adhere to tracheotomy because I have had vastly better results from it than from intubation. I feel that in my practice I cannot conscientiously recommend intubation in preference to tracheotomy. Perhaps it is my own want of dexterity, or perhaps I have not thoroughly mastered the details of the operation, as DR. WAXHAM must have done. I sincerely congratulate DR. WAXHAM upon his record in intubation. DR. H. E. SMITH: I congratulate DR. WAXHAM on his brilliant record and able paper, and as to DR. JENNINGS, I would say that he does the operation of intubation well, and if his results are not good it is no fault of his. DR. A. N. COLLINS: My experience has taught me that tracheotomy is the safer and more reliable operation for the general practitioner. DR. WAXHAM: Out of twenty-five of my tracheotomies only two recovered, and I therefore will stand steadily by intubation. As to the membrane below the tube, it may break down and be easily removed, or it may be coughed up in casts, two or three of which I show you here. In either case it is as easily handled as after tracheotomy, but if the casts become very dense a tracheotomy may have to be made, but this, in my experience, has been an occurrence of extreme rarity. Some little time ago I had eight patients wearing intubation tubes at the same time, and of these five recovered. At the present time I have seven patients wearing the tubes, of whom four are convalescent. It is in the face of such results as these that I forsake tracheotomy and cleave to intubation. DON. M. CAMPBELL, M. D., Secretary. STATED MEETING, JANUARY 18, 1892. The President, GEORGE W. STONER, M. D., IN THE Chair. DR. DONALD MACLEAN exhibited pathological specimens-testicle, arm, etc. DR. J. H. CARSTENS: The case of atrophied testicle which DR. DONALD MACLEAN has detailed to-night bears an analogy to the diseased ovaries which we removed, and the ovaries should be removed just as much as the testicle. These H |