that he could by a careful examination and improvement of the drainage and sewerage of the entire premises, remove all probable or possible causes of typhoid fever.

"In proceeding to do this he first removed the lower floor of the house and found there the earth saturated with sewage matter which through an improper arrangement of the pipes had been suffered to escape.

"The error rectified, the house is in every way unexceptionable as a residence."*

Many a fine residence, and many of our farmers' houses as well as those of our mechanics, are exposed to similar danger.

The physicians of Connecticut should be educated to the importance of making accurate observations respecting the sanitary condition of their several localities. I know from experience how difficult it is for a physician in full practice to find time for observations, not immediately connected with his daily business. But we never know what we can do till we make an earnest effort. No one should be satisfied with a superficial observation and performance of merely routine duties. He should with great care investigate the cause of every disease coming to his observation; and if any sensible and removable cause is found, to insist upon its removal. If this was done many wells would be found where the water is rendered impure by drainage from privies, sink drains, and hog-stys.

This is the case sometimes when the water is free from bad taste or smell.

We need sewerage on a small scale in rural towns as well as more extensive ones in cities.

Every farmer and every mechanic should have air-tight sewers to conduct off filth to some distance from his residence, there to be mixed with dry earth or ashes to make manure for his garden or his farm. Privies should be so constructed that they can be frequently cleaned and deodorized. Few know the value of excremental matter for manure.

Every well acts as a drain upon the soil and subsoil for a considerable distance around-few persons are aware of its extent. In some soils it is claimed that it extends one hundred feet in all directions.

In conclusion I would remark that the subject of drainage and

*Gen. Viele's Address.

sewerage cannot be fully treated within the proper limits of a report to this society. It would require a volume to contain all that is important.

I cannot flatter myself that I have given much that is original, but if I shall succeed in securing the attention of the members of the profession to this important subject, so far as to induce them to make accurate observations, and record important facts relating to the prevention of disease I shall be rewarded for the effort I have made.

B. H. CATLIN,

Chairman of Committee on Drainage and Sewerage.

17

LARYNGEAL PHTHISIS.

C. W. CHAMBERLAIN, M. D., HARTFORD.

This term was formerly used to include all chronic affections of the larynx involving ulcerative or destructive changes of its tissues, especially the cartilages, nor was it until the time of Louis that the pathological lesions of the larynx accompanying phthisis were at all accurately described, although various monographs from a clinical standpoint had previously appeared. A most complete and exhaustive resumé of all then known on laryngeal affections under this general title, was published by Trousseau and Belloc, in 1837, nor were any very important additions made to our knowledge until after the utilization of the laryngoscope in practical medicine. The facilities it offered for the study of the various diseases of the throat awakened an unusual activity in this depart. ment, as by its aid, the commencement and progress of laryngeal disease could be watched and studied upon the living, when before its results were only revealed after death. Thus rendering scientific accuracy and precision possible in the recognition of laryngeal affections, it opened an inviting field for study in a new and to a great extent unknown region. Since then the term laryngeal phthisis has been shown to be of a much more limited applicability. It is not, perhaps, strictly correct as implying a separate and independent disease, rather than a local manifestation, or complication of a general condition. I shall use it to include all the affections of the throat associated with pulmonary consumption; the same general conditions underlying the changes in larynx or lung, the dyscrasia striking now at the one organ, now the other. The earlier symptoms, dry cough with indications of laryngeal irritation occurring alike when tubercular deposit involves either, renders it difficult often to prove its existence in the larynx before any affection of the lungs. It is, however, generally admitted, that decided and grave disease of the larynx often precedes any

lesions of the lung that can be made out by the most careful physical examination. These cases occur in persons predisposed to phthisis, and give early indication of the pulmonary symptoms that will sooner or later supervene. A careful examination will determine the phthisical nature of the laryngitis.

Without entering into the relation of tubercle to phthisis, the latter might be defined as a disease characterized by a deposit, or thickening, which exhibits great proneness to degenerative changes, depends on a systemic cause, and is markedly inheritable. While the multinuclear giant cell of Schüppel is fast traveling towards the limbo of Lebert's tubercle corpuscle, and other specific elements of disease, and the tubercular nature of any lesion is not to be decided by the presence of any one specific element, nevertheless the histology of tubercular growths is characteristic, and is thus given by Wagner:

"Tubercle is an infiltrated or nodular, almost always multiple, round or irregularly formed, for the most part miliary, non-vascular new formation, of varying size, consisting especially of nuclei small and large, indifferent cells and giant cells, all imbedded in a reticulated tissue; it constantly passes, after long duration, into softening, and appears rarely as a local affection, but most often as a constitutional disease."-(General Pathology.)

A similar reticulated tissue is described by Burdon Sanderson, although he ascribes it to an overgrowth of natural adenoid or lymphatic structures, and its cells as not differing from normal lymphoid cells. The lymphadenoid nature of tubercle, and the presence of lymphatic tissue in the normal membrane of the larynx, as shown by Heitler, would be very significant, especially as he shows this tissue to be most abundant in the ary epiglottic folds, over the arytenoid cartilages, and the first parts of the ventricles of Morgagni, the precise locations where tuberculous ulcerations and deposits most frequently occur. This brings us to a disputed question; do tubercular deposits occur at all in the larynx, and if so, do they play any important role in the production of the laryngeal lesions, or are these all adequately explained by catarrhal or follicular inflammation and ulceration?

In the literature of the subject very conflicting views are found, as might be easily inferred from the widely differing theories concerning the pathology of phthisis. The views concerning the relation of tuberculosis to the lesions in the larynx vary pretty uniformly with the author's opinions concerning the nature of the

changes in the lungs, although strangely enough, Louis, finding no evidence of miliary tubercle in the larynx in any of the large number of cases he examined, attributed the ulcerations to inflammation, which might be caused by the sputa excoriating the mucous membrane. Similar negative testimony is given by Alison, Rühle, and others; on the other hand, Cruveilhier decided the lesions to be non-tubercular from the absence of caseous degeneration. Andral, Laanec, Trousseau, and others of the older writers considered the ulcerations which occur late in phthisis as undeniably of a tubercular nature, and Hasse carefully demonstrated the similarity of the anatomical elements which the microscope revealed, to others which were admitted to be tubercular. The views first promulgated by Rheiner have had a very wide acceptance, and undoubtedly are correct in a certain number of cases, while others are incapable of satisfactory explanation in any such way. He describes a catarrhal or follicular inflammation followed by ulceration, attended with a thick cellular infiltration of the mucous and submucous tissues, produced by a rapid multiplication of already existing elements, the thickened margin of the ulcers caused by serous infiltration. (Lebert Anat. Pathologique, p. 594.) Mackenzie modifies this by assuming imperfect cellular elements, and a special constitutional condition inherited or acquired. Rindfleisch accepted substantially this view, admitting however the presence of tubercular granulations in the larynx, occurring especially where two surfaces are rubbed together, but considered they acted only as a permanent irritant, the changes being due mainly to inflammation, although in Ziemssen's Cyclopædia he describes a tuberculization of the larynx which is secondary to catarrhal inflammation, and occurs in scrofulous subjects.

Rokitansky and Virchow assign a much more important place to tubercle as a cause of the pathological changes in the larynx; the latter indeed recommends this as the best place to study true tubercle, and explains much of the negative testimony by the fact that the granulations so soon break down into shallow ulcerations. Jaccoud, whose classification is followed essentially by many of the modern French writers, † describes a primary tuberculosis of the larynx with discrete tubercles, and a laryngitis of the tuberculous with infiltrated tubercle. Isambert qualifies this by denying that

* Anat. Pathologique.

† Fauvel, Mandl, Thaon, Eugéne and Boeckel.