thetize the patient and feed him through a pharyngeal tube passed through the nose. Large doses of the bromide of potassium or of this drug with chloral give the best results. Other drugs that have been used with some success are gelsemium, morphia, curare, injections and fomentations of tobacco, physostigma, anæsthetics, cocaine, and cannabis indica. An ice-bag to the spine somewhat relieves the girdle-pain. Hot baths have been advised.

Yandell says, in summing up Cowling's report on tetanus :1 "Recoveries from traumatic tetanus have been usually in cases in which the disease occurs subsequent to nine days after the injury. When the symptoms last fourteen days, recovery is the rule, apparently independent of treatment. The true test of a remedy is its influence on the history of the disease. Does it cure cases in which the disease has set in previous to the ninth day? Does it fail in cases whose duration exceeds fourteen days? No agent tried by these tests has yet established its claims as a true remedy for tetanus.”2

It is now claimed by some observers that we have a remedy which fulfils the requirements of Yandell in the tetanus antitoxine of Tizzoni and Kitasato. To prepare this antitoxine animals are rendered immune to tetanus by inoculations with mitigated cultivations of the microbe; the bloodserum is treated with alcohol and dried in a vacuum. This is used hypodermatically in doses of from 15 to 25 centigrammes. Cures seem to have followed its use, and if it can be obtained it is our duty to try it in acute tetanus.

XII. TUBERCULOSIS AND SCROFULA. Tuberculosis is an infective disease due to the deposition. and multiplication of the bacilli of tubercle in the tissues. 1 American Practitioner, Sept., 1870.

2 Quoted by Hammond in his Diseases of the Nervous System.

of the body. It is characterized either by the formation of tubercles or by a widespread infiltration, both of these conditions tending toward caseation, sclerosis, or ulceration. A tubercular lesion may undergo calcification.

Bacillus of Tubercle.-A tubercle is an infective granuloma, appearing to the unaided vision as a semi-transparent gray mass the size of a mustard-seed. The microscope shows that a gray tubercle consists of a number of cell-clusters, each cluster constituting a primitive tubercle. A typical primitive tubercle shows a centre consisting of one or of

several polynucleated giant-cells surrounded by a zone of epithelioid cells which are surrounded by an area of leucocytes. When the bacillus obtains a lodgment the fixed connectivetissue cells multiply by karyokinesis, forming a mass of nucleated polygonal or round cells, called "epithelioid" from their resemblance to epithelial cells, and at the same time the bloodsupply of the growth is limited by occlusion of surrounding vessels

FIG. 30.-Synovial Membrane, through multiplication of their endothelial coats. Some of these epithelioid cells proliferate, and others attempt to, but fail for want of blood-supply. Those that fail succeed only in dividing their nuclei and enormously increasing their bulk (giant-cells). Giant-cells, which also form by a coalescence of epithelioid cells, are not always present. The presence of this mass of cells causes surrounding inflammation and the exudation of white blood-cells (Fig. 30).

The bacillus, when found, exists in the epithelioid cells, and sometimes in the giant-cells; it may not be found, having once existed, but having been subsequently destroyed. It is often

overlooked. In a lesion of active tubercle, even if the bacillus be not found, injection of the matter into a guinea-pig will produce lesions in which it can be demonstrated. A tubercle may caseate-a process that is destructive and dangerous to the organism. Caseation is due to a coagulation necrosis arising from direct microbic action upon a cellular area which contains no blood-vessels, and the nutrition is cut off by obliteration of surrounding vessels. This process starts at the centre, and the entire tubercle becomes converted into a soft yellowish-gray mass. Caseation forms cheesy masses which may soften into tuberculous pus, may calcify, and may become encapsuled by fibroid tissue.

A tubercle may undergo sclerosis, which is an attempt on the part of Nature to heal and repair. Coagulation necrosis occurs in the centre of the tubercle; "hyaline transformation proceeds, together with a great increase in the fibroid elements, so that the tubercle is converted into a firm, hard structure" (Osler). Infiltrated tubercle is due to the running together of many minute infective foci or to widespread infiltration without any foci. Infiltrated tubercle tends strongly

to caseate.

The bacillus of tubercle, discovered by Koch, is a little rod with a length equal to about half the diameter of a red blood-corpuscle. It can be stained by aniline, and this stain is not removable by acids (it being the only bacillus except leprosy which acts, in this way.) In its growth the tubercle bacillus forms ptomaïnes, toxalbumins, and an antitoxine. These bacilli exist in all active lesions: the more active the process the greater is their number. They may be widely distributed, but are rarely identified in the blood. They exist in enormous numbers in phthisical sputum, but are not found in the breath of consumptives. Their great medium of distribution is dried sputum mixed with dust. They are

found in the milk of tuberculous cows, and sometimes in the meat of diseased animals.

Infection may be due to hereditary transmission. Congenital tuberculosis is occasionally, though rarely, seen. Tuberculosis is apt to appear in young children. Some think this is due to infection from without upon tissues whose resistance is lowered by hereditary predisposition; others think it is due to a tardy development of the germs transmitted by heredity. That the disease may be present in a latent form is shown by the experiment in which the viscera of the foetus of a consumptive mother showed no tubercles, but produced the disease in guinea-pigs when inoculated. Tuberculosis may arise by inoculation, inoculation tuberculosis being seen in leather-workers and in those who dissect tuberculous bodies (butchers and doctors are liable to anatomical tubercle). Osler mentions as other causes of inoculation the bite of a tuberculous patient, the washing of infected garments, and circumcision in which suction is employed. Infection through the air is very common. The bacteria of the dried sputum adhere to particles of dust and are carried into the lungs. Infection by meat, milk, and other foods may arise by this dust settling upon them in quantity. Commonly, however, it is due to disease of the animals. Milk is a common vehicle of contagion, and it can be infected even when an ulcerated udder does not exist.

Infection is favored by hereditary predisposition—that is to say, by hereditary tissue-weakness, which, by maintaining a lowered momentum of nutritive processes, lessens the normal resistance to infection. Two types of these predisposed persons are mentioned: (1) the sanguine type of scrofula, or those with oval faces, clear skin, large blue eyes, long lashes, a nervous manner, precocious minds, but little fat, and with long slender bones, these children being often graceful and 1 Quoted by Osler from Birch-Hirschfeld.

beautiful; and (2) those with stolid countenances, thick lips and noses, thick muddy skin, dark coarse hair, swollen necks, heavy bones, clumsy gait, and ungainly figure. The latter type is the phlegmatic form of scrofula.

There is no doubt that an inflammatory area in a person can become infected when a sound area would escape, the process of phagocytosis being in this spot limited in power, and the organisms, which are destroyed by healthy cellactivities, are victorious when those activities are diminished. Catarrhal inflammations of the air-passages favor phthisis, and traumatism is not unusually followed by a development of tubercle. Lowered health, impure air, and bad food all favor the development of tubercle. Any tuberculous process tends to spread locally and to produce inflammation. A tubercular area is always a danger to the system; from this as a focus dissemination may occur, tuberculous lesions appearing in a distant part or general tuberculosis setting in. Tuberculous pus is not pus. True pus means a secondary infection (see Cold Abscess, p. 100).

Scrofula is not a disease. It is a condition of tissues in which low resisting power makes them hospitable hosts to invading bacilli of tubercle. Some observers teach that scrofula is tuberculosis of bones, glands, and joints; others teach that it is latent tuberculosis until some cause lights it into activity; while still others say that it is a tendency rather than a disease. It is certain that some lesions of scrofula are not tuberculous (eczema capitis, facial eczema, corneal ulcers, granular lids, and chronic catarrhal inflammations), and that they result from ill-health, poor nutrition, bad air, and improper diet. A person who is recognized as of a scrofulous type may never develop tuberculous lesions. It is unquestionable, however, that strumous subjects are peculiarly apt to develop true tuberculous lesions. These lesions often appear after a tissue or an organ has become