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THE MEDICAL WORLD.

Among the predisposing factors may be mentioned: Heredity; age; occupations necessitating the breathing of impure air, or air containing irritants, such as dust, iron-filings, etc.; residence in low, damp localities; catarrhal inflammation and traumatism of the lungs; physique; general diseases which lower the vitality. These matters can be more fully elaborated in order to fully understand the development of the disease.

The pathology is of importance, since along this line investigations can most accurately be made. In the examination of tuberculous tissues the bacillus tuberculosis is invariably found, alone or associated with other microorganisms. It is a very minute rod, about one-fourth or one-half as long as a red blood-corpuscle. It is often slightly bent or beaded, and for absolute determination depends upon its power to resist decolorizing acids. An An oil-immersion lens is necessary for satisfactory examination.

When the bacillus is lodged in the terminal bronchioles of the apex of the lungs a proliferation of the fixed cells is excited, and these become somewhat polygonal in shape. These are termed epithelioid cells, and often contain bacilli. Giant-cells are the next step, formed by the fusion of these cells or by the overgrowth of individual cells.

This aggregation of new cells has an irritative effect, and the natural result of the formation of a surrounding wall of leukocytes soon follows. This constitutes the gray tubercle of Laennec, a gray, translucent mass, with the new cells centrally situated in the surrounding mass of white blood-cells. The next step in the process is the usual coagulation-necrosis, starting in the center, and spreading to the periphery, and converting the tubercle

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into a yellow, cheesy mass. The degenerated tubercles next unite and form the uniform cheesy mass so commonly seen at autopsies.

Here one of two things may occur: The mass may soften and break, being evacuated thru a bronchial tube, leaving a cavity with ulcerating walls; or a growth of connective tissue may form around it, and calcification later ensue. In addition, the lung-tissue in the vicinity of these processes is often the seat of a pneumonic inflammation; the connective tissue is always more or less proliferated; the bronchial tubes are inflamed; and the pleuræ over the areas affected are nearly always adherent.

The infective process usually begins at the apexes of the lungs.

In the acute form, sometimes called cheesy pneumonia, acute phthisis, phthisis florida, or chronic catarrhal pneumonia, the process is invariably tuberculous, altho the attack may be terminated in a period varying from a few weeks to a few months. This rapidity is generally the result of extreme vulnerability of the tissues, permitting rapid infiltration.

In some cases the lungs are solidified by a dense yellowish-gray infiltration, which the microscope will show to be composed of closely-aggregated tubercles. In other cases the consolidation appears in more or less discrete patches which have had their origin in the smaller bronchial tubes; in a third form one or both of the lungs are studded with discrete tubercles, many of which are still gray and translucent.

In the variety termed fibroid phthisis, the lung-tissue appears to be resistant, and the process is limited by an overgrowth of connective tissue, forming dense bands around the foci of infection. This is a very gradual form of the disease, and lasts many years. It has been known in some sections as "old folks' consumption," since its existence has been demonstrated in persons of advanced age, who give a history of having long had the disease in this slowly progressing form.

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1866

Smallpox.

The profession is watching with grave concern the increasing number of cases of smallpox, together with the recrudescence publisht an argument ingenious in con

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have been taken even in this city directed against this measure. Even a writer of such mark as Alfred Russell Wallace has

Comparative mortality per 100,000 from smallpox in Prussia and in Austria in the twenty years from 1865 to 1884. In 1874 revaccination was made obligatory in Prussia.

of antivaccination ideas. The opposition has not yet become so markt in this country as in England, but among a certain number of pseudo-scientists overt steps

struction, and apparently without sophistry, in which he claims that vaccination is a delusion.

That those who are interested in anti

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nationists attribute all the decrease in the death-rate from this sometime scourge of humanity.

In this connection we append two diagrams, for the use of which we are indebted to the courtesy of the Philadelphia Medical Journal, and which will show at a glance, and better than any array of words, the effects of compulsory vaccination. These are in the form of comparison of cases occurring before and subsequent to the inauguration of the compulsory system of vaccination in the countries represented, and also a comparison of the rates between Prussia and Austria, with differing legis

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itive beyond peradventure, and this should be done whenever there is any doubt about the efficacy of the original vaccination or when a considerable time has elapst. Facts bearing upon this matter can readily be obtained, a notable instance being the supplementary Health Report, issued by the Marine-Hospital Service, January 6, 1899. Among other points forcibly brought out is that in 1871, Germany, with a population of about 50,000,000 lost 143,000 lives by smallpox. In 1874 vaccination was made compulsory, and last year only 116 deaths were reported from an increast population. This is also illustrated most

clearly by the accompanying diagrams In fatal cases such complications as

before referred to.

capillary bronchitis, catarrhal pneumonia, and pulmonary collapse are frequently observed.

The period of incubation is usually about two weeks and the attack is generally ushered in by prodromes of chilliness, coryza, watering of the eyes, complaint of the light hurting the eyes, cough, and drowsiness. This prodromal period lasts about three days. Usually the fever, which had risen rapidly at the beginning of the prodromal stage to 102° or 104° shows on the second or third day a decided remission which generally continues until the fourth day when the eruption appears. The temperature now may reach so high as 105°, at least considerably higher than at the first, and may remain at this height for several days, falling either by crisis or lysis. Desquamation lasts about 14 days. The pulse is generally from 140 to 160 per minute and is full and bounding.

A point in diagnosis is the development of the so-called Koplik sign, the appearance on the buccal mucous membrane of small irregular red spots with a bluishwhite center. They are to be differentiated from the reddened mucous membrane of scarlet fever, the large white spots of thrush, and the sore mouth of stomatitis. They do not appear in rotheln. They should be lookt for in a good light. They lose their peculiarities as the skin becomes involved in the eruption, and merge into a more diffuse redness which entirely disappears before the skin has returned to its normal state.

The ravages of smallpox among the unvaccinated residents of Montreal beginning February, 1895, and raging until the close of the year, during which thousands were stricken with the disease and 3,164 died, is yet fresh in the minds of many of us. Particulars of this are given in Osler's

Practice of Medicine.

The objections to vaccination on the score of impurity of the lymph are no longer valid since the perfection of glycerinated vaccine-lymph, which is far more aseptic and active and less calculated to induce inflammations than the old-fashioned "points." In the most approved brands that are on the market the virus is put up and produced under aseptic precautions not less stringent than those the modern surgeon employs in a major operation. Every parcel is tested physiologically and is put up in hermetically sealed capillary tubes which effectually exclude germcontamination.

Measles.

This acute contagious disease is chiefly characterized by catarrh of the respiratory tract, a moderate fever, and a red papular eruption which appears on the fourth day and terminates in about 60 or 70 hours by branny desquamation.

The method of its transmission has not been definitely determined, but it is known to be transmitted thru the clothing and other fomites. The bacillus determining the disease has not been isolated, and until this is determined its modes of action cannot be definitely defined. It is most commonly observed in children, but unprotected adults are also likely to be affected. One attack is fairly protective, but does not confer positive immunity. It is essentially an epidemic disease, but now and then sporadic cases will occur.

The lesions consist chiefly in catarrh of the entire respiratory tract, and gastrointestinal catarrh is not uncommon.

The rash of measles is more dusky than that of scarlet fever. It appears first in macules upon the forehead or face, then upon the neck, trunk, and limbs in the order named. The macules, which often coalesce, are arranged in crescents which are slightly raised and red, but become somewhat yellowish on pressure. There is nearly always seen to be some uninvolved skin, the entire surface not being covered as in scarlet fever.

To differentiate measles the following

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The prognosis should be guardedly favorable, this because complications which would lead to a fatal result are quite possible.

points in diseases resembling should be borne in mind.

Rotheln: The prodromes are often absent; the fever and the catarrh are slight; and the sore throat is markt. The rash appears on the first or second day as a diffuse red blush or as small pale-red spots which do do not form crescentic-shaped patches; the desquamation is scarcely noticeable.

Scarlet-fever: The fever is high and lacks the pre-eruptive remission; sore throat is present instead of general catarrh; the eruption appears on the first or second day as a diffuse punctiform rash; the pulse is out of proportion to the fever; and the is a much greater tendency to nephritis

Measles is by no means the trivial disorder it is usually considered. Even in mild cases want of care may result in a serious danger during the acute stage, or may lead to a complication that may be fatal or leave the patient with some serious chronic affection. Every case should therefore be seen by a physician as soon as possible, and be cared for by an experienced nurse.

The usual idea that it is well to expose children to the measles in order that they may have it and "have them over with," should by all means be discouraged. This arises out of the popular idea that the disease is more severe in its manifestations in children of more advanced years or in adults than in infants. This notion is not susceptible of proof, however.

Altho the diagnosis of measles is usually easy if the case has been seen from the beginning of the catarrhal stage, there are certain possibilities of error that should be carefully guarded against. This is true particularly of small-pox, and error can only be avoided sometimes by a careful investigation of all the possibilities of infection, and, by watching the course for a few days, care being taken to institute such treatment, hygienic and otherwise, as will give the greatest protection to all concerned.

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Treatment of Diphtheria.

There has been but little discussion for some time past upon the methods to be used in the various stages of this disorder that has not centered around the matter of antitoxin, for and against, with a constantly increasing weight in favor of its use. Yet it must be conceded that the degree of advance in favor of the serum treatment is not so high as has been anticipated by those interested in the progress of medical science. This may possibly be due to the fact that not all makes of serum are standardized in the same way, and that hence an element of doubt exists as to the relative strengths of the preparations supplied by the different makers.

Statistics are conscientiously and consistently gathered as to the effect of the use of the serum, with varying results, which, however, seem to be relatively determinable by readily accessible means of comparison. For instance, an analysis by a disinterested chemist would give the relative strength of the preparations in use in this country, thus affording data as to the amount to be injected of each in any given case to produce a given effect. Again, a comparison can be, and has been, made as to the degree of the efficacy of the serum at different stages of the development of the disease, and this would be a most valuable index as to its use.

As a result of the treatment (according to investigations conducted by the American Pediatric Society and a number of home and foreign Boards of Health, acting and co-operating with various hospitals), the death-rate for this disease has been reduced from 10 to 15 per cent. below the lowest figures quoted previous to its introduction, and where the cases were seen early in the disease, the antitoxin being given before the fifth day, the death-rate has fallen, in hospitals, to so low as 5 per cent. of the number of cases treated. Still.

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