CULOSIS.

(Jour. A. M. A., Oct. 6, 1900.)

The paper of Mircoli, abstracted below, seems worthy of at least passing comment. The striking results with so large a series of cases, nearly 3,000, from the use of the Maragliano antitoxin in the different forms of tuberculosis are better shown in his tabulated statements than in our abbreviated report. Over 14 per cent. of the cures added to nearly 50 per cent. of "“improved" is a good showing. When we analyze the figures further and find that the disease progressed during the treatment in only about 18 per cent., and that the disease in the cases rated as improved tends to be permanently checked, it is still better. Even in the advanced cases with cavities already formed, only in about onethird was the disease still progressive during the treatment. Besides these results, which, it must be said, were attained with the additional aid of general hygiene and dietetic treatment, the paper reports other facts of great interest. One of these is that while blood-serum of the normal individual has an antitoxic action toward the tuberculous toxins and that of the tuberculous patient has not, the latter regains this after a month or so of treatment with the Maragliano serum, thus showing that the latter puts the system into a condition to assist in defending itself. Mircoli's opinions as to tuberculin are also noteworthy. He holds that it directly increases the amount of toxins already in the organism, and in tuberculous individuals it may need "only the fraction of a gram to overthrow the already unstable equilibrium." When we remember that the use of tuberculin is being advocated by some for a diagnostic purpose, these statements are deserving of careful consideration. If we accept, with Mircoli, the views of Naegeli that practically all persons are or have been infected and still carry the latent foci in their bodies, this possibility of stirring them up to activity is a very serious one. While all the views and facts contained in Mircoli's article are not new, yet it is worthy of careful attention as an important contribution on the therapeutics of tuberculosis. Something must be allowed, however, for a possible enthusiasm in such a paper, and it may be perhaps considered as somewhat of an ex parte view of the method.

The Abstract: Mircoli tabulates the results of this treatment in 2,899 tuberculous patients, mentioning the results on the bacilli, the local lesions and the weight. He classifies the cases as circumscribed apyretic, circumscribed febrile and diffuse tuberculous bronchitis with and without microbian associations, and broncho-pulmonitis with cavities. Out of 250 circumscribed Out of 250 circumscribed apyretic patients, 95 were cured, 110 improved, 30 remained stationary and 35 grew worse. In circumscribed febrile patients, 168 out of 938 were cured, 511 improved, 163 remained stationary and 96 grew worse. Out of 332 patients with diffuse

associations, 31 were cured, 142 improved, 98 remained stationary and 61 grew worse. In diffuse tubercular bronchitis without microbian associations, 91 out of 665 patients were cured, 301 improved, 166 remained stationary and 106 grew worse. Out of the 712 patients with bronchopulmonitis with cavities, 20 were cured, 281 improved, 102 remained stationary and 240 grew worse. The improvement obtained with antitoxin treatment is usually permanent. It seems as if the organism, once assisted to effectively defend itself, is able to continue the struggle successfully for years afterward alone. The antitoxin does not act on pyogenic associations nor in cases in which the system is unable to respond to the stimulus of the anti-toxin. The aid of hygienic and dietetic measures is also indispensible. The best results were attained with I c.c. injected on alternate days. The anti-toxin not only neutralizes the toxins, but stimulates the production of "alexins." Its power is shown by examining the blood of patients before and after treatment. The serum of a normal person has a toxic power and also a specific antitoxic power on the tuberculosis toxins to a certain extent. In a tuberculous subject, the former property is above normal, while the latter is nearly if not entirely absent. This condition tends to enhance the effect of the tuberculosis toxins in the system. A month or so after treatment with anti-toxin both properties are the same as in a normal subject. This artificially-induced antitoxic power must be due to the active participation of the organism as the potential must be hundreds of times greater than the small amount of anti-toxin actually injected. Experimental tests show that the anti-toxin also has a direct action on the bacilli, inhibiting their growth and virulence. None of the bacilli develop or produce infection after being kept in anti-toxin for twenty days in vitro. Tuberculosis intoxication may be conquered without medication, but when the physician is not positively sure that a spontaneous cure is impending, he should bear in mind that nature can be aided and the intoxication conquered more rapidly and more energetically with anti-toxin treatment than with any other. It is applicable to all cases and all stages. Tuberculin, on the other hand, adds to the toxins already in the organism, and may prove the last straw to upset an already tottering equilibrium. The recent research on hemolysins has confirmed Maragliano's fundamental conceptions of anti-toxin treatment and the autoserotherapy it induces. Naegeli's statements are also confirmatory; he found with improved methods of postmortem investigation that 100 per cent. of the adults examined presented evidences of tubercular lesions, and claims that every adult is tuberculous. The strong are able to transform an active lesion into a latent, inactive process, and Maragliano, by supplementing the natural resources. re-enforces the weak and enables them to accomplish the same result.

Vol. II.

By J. H. Stuart, A. M., M. D., Minneapolis.

I do not propose on this occasion to present any elaborate plan of treatment to be followed out in the management of pulmonary tuberculosis, but simply to present a few ideas on the subject as they may be gleaned from current literature. They are from the contributions of leading, up-to-date authorities, and may be accepted as far as they go as showing the trend of advanced thought and practice in regard to this disease.

It may be truthfully said in this instance that "old things are passing away and that all things are becoming new." In the place of despair and the calm resignation of helplessness with which the consumptive has heretofore been. treated by the profession to a routine supply of cough syrup, cod liver oil, its emulsions, hypophosphites, &c., to say nothing of the multitude of "cures" and "specifics" that have attained more or less notoriety, we observe a growing confidence on the part of the physician in his ability to do something, and we hear him speaking words of cheer and hope, and inspiriing courage and gladness.

"Consumption is both preventable and curable." This is the response from many quarters. Already the death rate in some places is said to be perceptibly on the decrease. Percentages of cures are being shown that are most encouraging.

According to Knopf's statistics the most favorable results are, "Absolute cures, 14 per cent, relative cures, 14 per cent, amelioration 42 per cent." The same author, before the assembled Board of Health at Detroit, said, speaking of the results of post-mortem examinations: "The chances of the disease being healed without having been discovered are between 20 and 25 per cent;" "That 9 per cent of those dying of nontubercular diseases have been shown to have had phthisis at some time in their lives" and "That

Paper read before meeting of the Hennepin County Medical Society, November 5, 1900.

No. 12.

the greatest chance of a predisposed individual being taken sick is between the ages of puberty and thirty."

Dr. Clifford Allbutt, quoting Birch-Hirschfeld, shows that in 40 per cent of 4,000 autopsies, taken consecutively, tuberculosis was found. The disease was also found in 27 per cent of cases dying from non-tubercular diseases. The same author quoting from Turban's statistics, shows that patients treated in the very first stages are relieved, if not cured, in 84 per cent.

Dr. Knopf says: "Tuberculosis is a preventable and curable disease. Let us emphasize these important points in our crusade against it."

But in view of what is said here in these statements it must be remembered that they are only made of the early stage or stages. The disease is conveniently divided into three stages The first, or early stage, the second stage, when consolidation may be determined by means of physical diagnosis, and the third stage, that of cavities, secondary infection, toxemias, &c.

Dr. Allbutt, quoted above, says, that patients in the third stage are probably incurable. Patients in the second stage, i. e. of physical signs of consolidation, if curable at all, only by at least 18 months of long persevering treatment.

It is, therefore, with reference mainly to the first stage that these inspiring statements are made, and, therefore, it is to this stage that the physician is to direct his efforts for the cure and eradication of this disease. Right here has existed the difficulty in the past, and it still continues. The first stage is commonly passed, or well established, before the patient presents himself before the physician. During this period he has not regarded himself, nor have his friends allowed themselves to regard him, as being sick, or in need of a physician's aid, notwithstanding his family history and his symptoms, even, have altogether aroused anxiety and apprehension in the minds of them all. But a change in these matters is being brought about. Much, however, remains to be done in the way of education and even of active interference of the physician. The educational process will, no doubt, be long and difficult, but it must go on. A general public scare begotten by newspaper articles, by sanitary legislation and the grosser appearances of the disease, is by no means sufficient to bring the

victim to the timely notice of the medical adviser. If the physician himself in his own person might pass beyond the stage of safety without heeding it, and he does sometimes, because either of his indifference or of his lack of nice apprehension of significant signs and symptoms, much more might this be the case with the lay

man.

Treatment and prophylaxis run into each other and become in a sense one and the same, but that matters not, for both devolve alike upon the physician. There is, however, a matter of even greater difficulty encountered which I would not even in a cursory way allude to were it not so intimately blended with my topic, and that is the early detection of the first symptoms of the threatening sickness, that the proper interference may be had. On this discovery the matter of treatment must depend. It is the treatment and the kind of treatment this stage calls for that is now more particularly under consideration. It is from such conditions that the favorable results above referred to are to be expected. This is some times spoken of as the pre-tubercular stage, because in it are not often to be found either Koch's bacillus or it's toxins, and it is doubtful, in many instances, if the microbe may have even formed a lorigment, nevertheless we are morally certain it will, and that speedily, unless the vulnerable territory becomes rightly fortified against it. What, then, constitutes this stage? What is the nature of this susceptibility? Why does it exist in one instance and not in another? Why do certain families. produce members regularly, generation after generation, in whom it is found in such ready activity? Why do certain environments not only quicken it in this class, but also beget it in an otherwise non-susceptible class? These and other kindred questions I must pass by now.

An editorial in the Medical News of January 1ast, under the title of "Pretubercular Stage of Consumption," says: "The possibility of diagnosticating the preliminary pathological conditions denominated the pretubercular stage is now quite within the physician's grasp. Certain signs of the nervous system occur, before other symptoms are noticeable. Reference is made to interference with the vaso-motor system which disturbs peripheral circulation, which, when manifested in the pulmonary system, provides suitable conditions for lodgment and culture of tubercular bacilli. The toxins of tubercular bacilli possess this aptitude of disturbing peripheral or regional circulation; hence, the bright hues and brilliant eyes with dilated pupils seen in consumptive families; the readiness to perspire, neurasthenia, capricious appetite, the intestinal blush', supposed to account for the occasional looseness of bowels incident to excitement and emotion, which have their source in these vaso-motor disorders."

Dr. Freudenthal, of New York, in the same Journal of February last, sald: "There is another

point which has not been brought out, so far as I know, in this connection, viz: the trophoneurotic condition of the consumptive. I am of the opinion," says he, "which has been ventliated by others, that consumption is in the first instance a trophoneurotic condition of a general and local nature. It is only later that an invasion of the tubercular bacilli takes place. It is supposed that the vagus is in some way involved, but there is a general trophic insufficiency of the consumptive. Thus the soil is prepared for the specific infection of the tubercular bacilli. It is this condition we are called upon to correct, if we are able to detect it, by a change of surroundings, open air, rest, ample nourishment and right occupation, i. e., one which shall be specially enjoyable. This latter suggestion is a good one, better, I think, than a surfeit of forced rest in non-febrile periods, and routine walking and exercise.

Dr. Allbutt believes that heredity, or predisposition, is an important factor in the origin of the disease, but that this hereditary proclivity, other things being equal, is of no great importance in prognosis, i. e., I suppose, the disposed and non-disposed are alike curable.

At the tuberculosis congress, held in Naples, last April, the subject was discussed amidst enthusiasm by the masters in Europe.

Prof. Guido Baccelli, Minister of Public Instruction of Italy, in his inaugural address said: "A holy war is inaugurated against tuberculosis. The discovery of the tubercule bacilli was one of the most colossal achievements of our time,

but it did not, in itself, furnish anything like a complete solution for the problem. Koch's bacillus is only the historic exponent of tuberculosis, it is not the whole of tubercule, much less of phthisis."

Prof. DeGiovanni, who initiated the great movement against tuberculosis in Italy, pled for the systematic treatment of persons predisposed to the disease, in special hospitals or institutions closed against other diseases. He would examine all children with greatest care that all physical characteristics leading to phthisis might be discovered. Prophylaxis in infants is even more important than in the adult.

Landozy, of the Academie of Medicine, said: "The importance of soil in connection with contagion made it imperative at any price to establish a regular system of puericulture or hominiculture in order to render the human family refractory against this disease, or to teach it how to defend itself."

Petruschky insisted that doctors should learn to prediagnose the disease and make the first symptoms widely known as possible.

The discussion on sanatorial institutions for the exclusive treatment of consumptives is said to have been full of promise of the rich fruitage. yet to come through this source.

It was carried by acclamation that a chair for the experimental and clinical study of tuberculosis should be established in one of the largest universities.

An editorial in the British Medical Journal says, "The success of the movement against tuberculosis seems to be dependent mainly on the education of the people in regard to the means of prevention. Baccelli holds that compulsion is necessary wherever the arm of the executive can reach, as in public offices, the army and navy, schools, factories, work shops, cattle markets, slaughter houses, and even in private dwellings. Here the state should suppress consumption vi et Armis."

But the less fortunate should not be overlooked. Finding themselves with phthisis, they should be persuaded that society proposes and is anxious to help them.

Dr. Knopf strenuously opposes the proposition to have all consumptives reported and kept under surveillance. Should such be necessary every patient should receive all the tender care he needs.

Dr. Alfred Hillier, London, in an article in the British Medical and Surgical Journal, on "Tuberculosis, its Nature, Prevention and Treatment, with Special Reference to Open Air Treatment," says: "All phthisis therapeutists will concur in the conclusion that the benefit derived in every case is chiefly dependent on the extent to which the patient is continually kept in pure air." To which I may add, that the question of climate has no great signification, I believe, beyond that of the presence of malaria.

Dr. Walther, of the Nordrach Sanatorium, Germany, says: "Sanatorium treatment should be largely educational, to teach what can be practiced hereafter." This is an important statement, and its verification has been repeatedly observed.

Dr. Hillier summarizes the object to be obtained in sanatoria thus: "Pure and abundant open air by day and night, indoors and out; such good and plentiful food as the simple open air life may enable a patient to digest; rest, frequent and prolonged rest."

Dr. Alfred Meyer, in the Medical News, Oct. 27, 1900. strongly urges, with valid reasons, that New York City should without delay devise and supply means for a municipal sanitoria outside the corporate limits for its consumptive poor; that the expense should not be allowed to remain an obstacle to such a procedure, which would in truth become a real saving to the community. The state has already set about a work of this kind.

In proof of the hopefulness of the medical profession of the curability of this disease, Dr. Meyer points out the result of sanatorium treatment coming in from all parts of the world. "In the German sanatoria about 20,000 incipient cases can receive treatment for three months each, and 72 per cent. of these return to the ranks

of the wage earners.' "The German Invalid Insurance company has established sanatoria as a life and money-saving measure."

An editorial in the Medical News forcibly speaks of the lingering consumptive death of the laboring poor man as being more cruel than the sudden terrorizing plague. There are 8,000 deaths from this disease in New York City every year, and 30,000 more likely to die.

Where shall the tuberculous patient be treated? It must either be at his home, by change of climate, or at a sanatorium. By the last is meant a consumptive sanatorium closed against all other diseases, built and managed in the interest of this class only. These institutions are multiplying rapidly both in Europe and in this country. It is in them that the excellent results already alluded to are obtained. But they should multiply and grow in number until one may be found near or accessible to every community whose magnitude and needs call for it. Few if any districts need go far from home to find a suitable spot on which to erect a sanatorium.

There is no climatic specific for consumption in itself. The value of sanatorial treatment depends on the regime and methods prevailing in and about the institution.

Dr. Wm. Osler, Jour. A. M. A., November last, says: "Ninety-five per cent of patients cannot afford treatment away from home.' He also says: "Arrest or cure is a question entirely of nutrition, and the essential factor is to improve the resisting forces of the body so that the bacilli cannot make further progress, but are hemmed in and either effectually prevented from breaking through the intrenchments, or in rare cases are forced to capitulate."

Dr. Hazelton, in Med. News, of April last, succinctly states the points to be borne in mind in reference to treatment of phthisis pulmonalis. He says: "The germicidal treatment has been proven by experiment and clinical experience to be utterly valueless. Tuberculin has as yet no well proven field of usefulness as a cure. The The antitoxin treatment is yet in the stage of trial waiting future developments. Hence we are left to attack the tubercule indirectly by improving the patient's condition, by the aid of food and hygienic living in the open air."

Osler says of diet that the stomach controls the situation in pulmonary tuberculosis. Overfeeding, or stuffing, when possible, should be practiced and the patient should be encouraged to pay little attention to his subjective gastric sensations.

I can conceive that overfeeding or stuffing, might be injurious in their literal sense, but by these is meant no doubt full feeding, or all that the patient can take care of in an assimilative

manner.

For an account of various sanatoria in Europe and this country the recent work of Dr. S. A. Knopf, on "Prophylaxis and Treatment of Pulmonary Consumption," published by Blakiston's

Son & Co., is valuable and full of interest, and profitable reading to every physician who wants up-to-date information on this subject.

But what can be done for the advanced and far-advanced cases? The sanatoria of which we are speaking are designed for the incipient cases.

Besides giving a list of sanatoria, special hospitals, camps, etc., with descriptions, as they are to be found in this country, in Europe and elsewhere, Dr. Knopf, in his work alluded to above, gives a description of an ideal sanatorium. Due account and consideration are also given to aërotherapeutics, the rest cure, exercise, the use of the pneumatic cabinet, hydrotherapeutics, personal hygiene, dress dietetic treatment, symptomatic treatment, etc., etc., the mere enumeration of which suggests their importance and usefulness. Every practitioner of whatever specialty ought to read this book, or one equally good, on this subject.

Dr. Trudeau, of Saranac Lake, N. Y., speaking of the treatment and its results in the sanatorium at that place, says: "Of this so called advanced class II per cent recovered, while none of the far-advanced. Of the incipient 68 per cent

recovered."

These more advanced and for the most part hopeless cases are beseeching the physician to relieve their distressing symptoms. Their fevers, the result of tubercular toxemia and associated bacteria, their sweatings, their diarrhoeas, their coughs, their anorexias, etc., call imperatively for relief or palliation, and often severely tax the physician's resources.

No remedy has the confidence of the profession so much as creosote by inhalation or internal use, not that by it Koch's bacilli can be destroyed, but rather for its influence against the other bacteria and their toxins, and for its stomachic effects.

Hydrotherapy, fresh air, sunshine and rest furnish good evidence of their value in these

cases.

Notwithstanding, as above shown, spontaneous recoveries have taken place, and cures have been effected, yet we are seeking better things, and need greater facilities. No one can reason

ably expect to effect many cures if patients are left in their homes under their own management or that of their friends. The reasons are obvi

ous.

Take a case, in illustration of the dilemma in which the physician often finds himself placed: A young man with a family, holding a very good position as clerk, who, it may be, has saved something from his earnings, or who mayhap consumes his income as it comes to him month by month, with little or nothing left over, comes to consult you in regard to a cough that troubles him some, and is persistent, or it may be some stomach derangement, a tired feeling, loss of weight and strength, scarcely mentioning a slight cough or hacking on going to bed at night or on arising in the morning.

It does not require much time, as the history of the case is unfolded to you, as you proceed with the physical examination, to convince you of the gravity of the situation. The patient may not even suspect it, but you feel morally certain, under existing circumstances, in a year, more or less, he will become incapacitated for his work, his place will be filled by some one else, and a decline, more or less rapid, will terminate in death.

Now, what are you going to do? What can you do?

There are at least two courses open to you: (1) Without giving utterance to your opinions, or a statement of your diagnosis, or even permitting your impressions to materialize into definite and clear judgments, unwilling to be the bearer of bad news, you may prescribe and give such directions as will quite likely be followed by a relief of the symptoms and a degree of improvement, and you may, permit the patient to leave your office inspired with the hope that is little short of an assurance that he will soon be all right-but I need not follow the history of a case of this class.

Or (2), you may, after your own manner, open up to your patient in the clear light of your good knowledge, his case fully, its nature, its dangers, and the best course to be pursued in order to obtain the best results. Only in this way can you have in the management of the case the necessary coöperation of the patient.

To the physician who feels that he is helpless in the presence of this fell destroyer the firstnamed course is the logical procedure. To the physician who is convinced of the curability of the disease the second, or a similar course is imperative.

But granting that there is a full understanding between the physician and the patient, and that the latter is ready heartily to cooperate with the former, what is to be done? What advice is to be given, and how can the physician be assured that it will be properly and faithfully carried out? Ah, there is the rub! There is no money with which to send him on the very doubtful quest of health to other countries. If he has the money to pay for advice and medicines he has not the facilities and incentives at home, where, had he all these, the cares and anxieties of his family would outweigh them all, and eventually overwhelm him. In view of all these things, he would most likely return to his labors. work as long as he has the strength, and then

return home and finish out those most melancholly of days, the last of the consumptive. Such an issue is always pitiful, but what is worse, is becoming culpable.

The thing that is needed to relieve these cases, and the only thing that will avail, is the sanatorium above mentioned. There should be one or more in the vicinity of every centre of a considerable population, maintained at public expense, or by private munificence, for those with