Vol. XXIII. No. i2.] 



POPULAR SOTEITCE NEAVS. 



187 



H^ediciiie aijd Ptjarnjacy. 



[Original in The Popular Science jVewjs.J 

 TUBERCULOSIS. 



BY JOHN CROWELL, M. D. 



The word tubercle is as old as anatomy, meaning 

 simply a little tuber or nodule — an indurated, pro- 

 jecting mass. The term tuberculosis, as designating 

 a specific disease, is modern. The term tubercle 

 was used by the ancient writers simply in its ana- 

 tomical sense, and the use of the word is misleading 

 when applied to disease, in the early history of med- 

 icine. It is not possible to fix the exact time when 

 the term tuberculosis began to be strictly confined 

 to specific disease, but probably it begins with Boyle 

 and Ltenner, 1810-1819, when they declared that 

 "tubercle is the cause, and constitutes the proper 

 anatomical character of pulmonary phthisis." These 

 two great investigators devoted their lives to the 

 study of this disease, and to them belongs the right 

 to fix the name. The word " tuberculosis" was first 

 employed by Schonlein, in 1839, ^'^^ ^^ '^^^ ^ '1'^" 

 believer in the specific character of the disease. The 

 question as to the specific nature of the disease has 

 been sharply discussed for over a century, and some 

 of the most brilliant writers have advocated the 

 alternate sides of the controversy, and the literature 

 upon this phase of the disease forms a most interest- 

 ing feature of medical study. 



The first epoch in the history of the disease may 

 be said to have begun with Baillie, who gave his 

 description of tubercle in 1794. The names of 

 Boyle, La;nner, Vischen, and Villemin are familiar 

 to all students who have followed the discussion of 

 this subject through the interesting controversy of 

 the last fifty years. Of much more use and benefit 

 to science have been the microscopical examinations 

 first instituted by Addison. He was the first observer 

 who made a minute and exact microscopical exami- 

 nation of tubercles. He regarded tubercles as a 

 collection of epithelial cells, originating from the 

 white blood-corpuscles, which are arrested in the 

 small capillaries, where they undergo a change into 

 epithelial cells. By the impulse of his suggestions, 

 histological examinations of tubercles were more 

 carefully followed up, especially by Labert, Rein- 

 hardt, and others. But it was finally reserved for 

 Robert Koch, the results of whose investigations 

 sent such a thrill of excitement throughout the civ- 

 ilized world, to illustrate, in his work published in 

 1883, more definitely and satisfactorily the nature of 

 tuberculosis ; and the amount of anatomical and 

 experimental work set forth in his investigations is 

 among the marvels of modern research. As a result 

 of his experiments, which only supplement and 

 round out those of his worthy predecessors, we may 

 safely define tuberculosis as "an infectious disease, 

 caused by the tubercle bacillus, and characterized by 

 the production of tissue, and of inflammatory pro- 

 ducts, which appear both in the form of nodules, 

 and as a more diffuse infiltration, and which rapidly 

 undergo caseation." 



The tubercle bacilli are short rods, about one-half 

 as long as the diameter of a red blood-corpuscle, and 

 about one-tenth as broad as they are long. Their 

 diameter does not vary, and they do not have the 

 enlargement at the ends which is seen in many 

 bacilli. They are usually curved, or comma-shaped. 

 Koch gave his first description of them in 1882, and 

 furthur investigation has not materially changed 

 his iTiinute analysis. 



These bacilli are found in all tuberculous lesions, 

 and in fluids which come from the diseased parts, as 

 in the sputum which comes from tuberculous lungs; 

 in the urine, when the urinary tract is the seat of 

 tuberculous affections; in the blood, in cases of 



miliary tuberculosis ; in the pus from tuberculous 

 joints, and in the stools, in cases of tuberculous 

 ulceration of the intestines. They cannot be easily 

 detected in the fluids or tissues, except they have 

 been colored by a process which distinctly stains 

 them, leaving uncolored the other bacteria with 

 which they are mixed. The staining process estab- 

 lished by Koch is interesting, and is described at 

 length in his works. It is interesting to inquire 

 how the bacilli enter the tissues of an organ, and 

 this question has given rise to a vast amount of 

 conjecture and speculation. They may, of course, 

 enter the body in various ways. They may enter by 

 means of the respiratory tract, and thus the lungs 

 be primarily attacked. They may enter by means 

 of the intestinal canal, producing a primary ulcera- 

 tion of the mesenteric glands ; or there may first be 

 tuberculous lesion of the skin, with an infection of 

 other parts secondarily, through the blood or lym- 

 phatic vessels. 



The number of bacilli that enter an organ is also 

 important. Koch found that they were present in 

 large numbers in those places where the tuberculous 

 process was just beginning, or was progressing 

 slowly. They are then crowded together closely in 

 small groups, sometimes in the form of bundles. 

 They are found mostly in the interior of the cells, 

 but may also be found in groups not in the interior 

 of the cells. After tubercles become more fully 

 developed, and degeneration sets in, the bacilli be- 

 come less in number, being found only in small 

 groups, or isolated, along the margins of the tubercle 

 centres, and side by side with bacilli very faintly 

 colored, and which are either dead or nearly so. 

 The lungs may be said to be the primary seat of 

 tuberculosis, and the pathological changes which 

 the disease here produces are so great that the term 

 tuberculosis, with most practitioners, has reference 

 only to the pulmonary manifestation of the disease. 

 When the lungs are the centre of the primary attack, 

 the bacilli enter them from without by the bronchi. 

 They can also be conveyed from a focus in a distant 

 part of the body, by the agency of the blood-stream. 

 They can also enter by means of the lymphatics 

 from a tuberculous gland. It is not probable that 

 primary tuberculosis of the lungs can be induced by 

 bacilli taken into the tissues from the alimentary 

 canal, for they would be likely to become lodged, 

 either in the liver or in the mesenteric glands. 



From the lungs the bacilli can be easily carried to 

 other parts of the body. They are conveyed with 

 the sputum along the bronchi and trachea, which 

 organs are often aflTected, as is also the larynx, along 

 its posterior wall, when the ulceration is manifest, 

 according to the investigation of Conheim. When- 

 ever the sputum comes in contact with mucous 

 surfaces, there is danger of infection, and the tuber- 

 culous ulcerations of the pharynx, tongue, and lips, 

 are due to this contact. The small intestines afford 

 a favorable soil for the action of the bacilli. Thev 

 develop in the lymphatic tissue of the intestines, 

 and where this tissue is most abundant, there we 

 find the frequent manifestation of their presence. 

 By these glands the bacilli are carried to the mesen- 

 teric glands, producing tubercles and a carious 

 inflammation. 



From this cursory survey, we are forced to the 

 conclusion that tuberculosis is an infectious disease, 

 and, in the lesions produced by the virus, the tuber- 

 cle bacilli may assume a great variety of forms. It 

 may produce miliary tubercles, or a diffuse forma- 

 tion of tubercular tissue, or the inflammation may 

 be formative, with the production, of fibrous tissue. 

 Of course the primary seat of the disease is most 

 often the lungs, where the bacilli enter with the 

 inspired air. Their introduction into the system by 

 the food is also an important fact to be noticed. 



A prime factor in the treatment of tuberculosis is, 

 of course, the prevention of the infection, for, 

 although according to Cheyne and Ziegler, the par- 

 asite does not live outside of the body, yet the spores 

 are capable of overcoming, for a limited time, condi- 

 tions unfavorable to their development. The spu- 

 tum of phthisical patients should, at all times, be 

 disinfected, by allowing germicidal solutions of gly- 

 cerine and water to stand in the vessels for expecto- 

 ration. All cloths or handkerchiefs used should be 

 placed in a solution of bichloride of mercury (i to 

 1,000) before being washed. It is safer to burn all 

 cloths and rags immediately after their use by the 

 patient. The patient should not occupy the same 

 bed as the attendant, and this caution should be 

 forcibly impressed upon husband and wife. Infants 

 should not be nursed by mothers infected with the 

 disease, and great care should be taken that the 

 milk used for domestic purposes does not come from 

 tuberculous cattle. This is a matter of vital impor- 

 tance, but it is very difficult to eflfectually guard 

 against this danger, as probably no large herd of 

 cows is absolutely free from the contamination of 

 tuberculosis. Pure air is an essential element in the 

 treatment of this disease, and Parkes observes that 

 the large decrease of lung affections in the British 

 army since 1846, is largely due to the less frequent 

 overcrowding of the barracks. The necessary air- 

 space for each individual is given as from 1,000 to 

 1,200 cubic feet, and in hospitals about 1,400 cubic 

 feet, depending, of course, upon the frequent chang- 

 ing of the air by ventilation. This should be done 

 at least three times an hour. Formerly, the climate 

 sought for phthisical patients was warm and moist, 

 at about the sea-level, but modern science advises a 

 mountain elevation, cool and dry, — the question 

 being one of altitude rather than latitude. The 

 advantages of a high altitude are set forth by Weber 

 in the physical features of the atmosphere, as fol- 

 lows : First, purity and aseptic nature ; second, 

 dryness of air and soil, and comparative absence of 

 mist; third, coolness of air and warmth of sun 

 temperature; fourth, rarity of atmosphere; fifth, 

 intensity of light; sixth, stillness of air in winter; 

 seventh, large amount of ozone. The main objec- 

 tions against a higher level are, great advance in 

 the disease, advanced age of the patient, febrile rise 

 of temperature, Bright's disease, continued loss of 

 weight, irritable nervous system, and co-existence 

 of heart disease. 



Food in this disease is such an important element 

 as to demand the special attention of the medical 

 adviser. The amount of carbon and nitrogen in the 

 daily food of an average healthy working man is set 

 down as 750 grains of carbon and 317 of nitrogen, 

 and these amounts should be taken as standards in 

 regulating the diet of the patient. The three great 

 functions of man must receive constant and special 

 care : the development of tissue change, the supply 

 of sufficient aliment, and the removal of waste. 

 Whatever will fulfil these conditions, — whether in the 

 way of medication, or in the management of diet, 

 and the general sanitary surroundings of the patient, 

 — will be wise and humane. Alternate stuffing and 

 starving, and excessive trials of popular nostrums 

 and highly lauded specifics, will be guarded against 

 by every careful practitioner. In cases where the 

 system is attacked at every point by the bacilli, and 

 where the final result is inevitable, the physician 

 will do all in his power to relieve symptomatic con- 

 ditions, and make the last days of the patient as 

 free from acute suffering as is possible. 



According to a London correspondent of the Citin. 

 Lancet-Clinic, a young medical student in that city, 

 after careful ophthalmoscopic examination of a glass 

 eye, discovered " choroidtis with detached retina." 



