OH THE NATURE AND CURABILITY OP PULMONARY PHTHISIS. BY WM. GLEITSMANN, M. D., OP BALTIMORE. BALTIMORE: PRINTED BY HANZSCHE & COMPANY. 1874. COST THE Nature and Curability OF PULMONARY PHTHISIS. TRANSLATION OF A LECTURE DELIVERED BEFORE THE GERMAN MEDICAL ASSOCIATION OF BALTIMORE. BY WM.-CJLEITSMANN, m. d., OF BALTIMORE. Reprint from the July No. of the Richmond and Louisville Journal. PROF. E. S. GAILLARD, Editor. BALTIMORE: PRINTED BY HANZSCHE & COMPANY. 1874. COST THE NATURE AND CURABILITY PULMONARY PHTHISIS OF But few other departments of internal pathology have un- dergone so great, and we may say so beneficial a»change during the last ten years as the doctrines of pulmonary phthisis, which I purpose thisevening briefly to sketch. Views that up to that time had been considered infallible dogmas, were overturned, the number of their adherents growing less from day to day. In the field of pathological anatomy the new theory has been generally accepted, chiefly through Virchow’s labors. Not- withstanding the stern antagonism with old,deep-rooted jweju- dice, it has gained strength continually by the force of its own merit, so that now the truth of its principals is acknowledged by almost all authorities. I have endeavored in so far as the literature was accessible to me, to do justice to all views of importance and to classify them. To this end I will commence by briefly reviewing the old theory, and after relating the facts and investigations, which induced its overthrow, proceed to explain the new doc- trine in accordance witli the conceptions of various scientists. As the views of the etiology of the disease have changed with the new pathology, I must touch upon this point also, before passing to the sympomatology. I beg to remark at the outset, that it is not my intention to give an exhaustive description of the symptoms and course of the disease, but to discuss these only in so far as it may be requisite to distinguish the differ- 4 PULMONARY PHTHISIS. ent morbid processes and phenomena. Nor shall I in thera- peutics enter into details of* the various remedies generally recommended and adopted, hut merely enlarge on those prima- ry principles, which alone can serve as a basis for a cure of the disease. t When you take up an old hand-book of the practice of med- icine and turn to the chapter on pulmonary phthisis, you will generally find two paragraphs upon the subject, the one treat- ing of chronic, the other of acute tuberculosis of the lungs, the former being sometimes styled chronic consumption, the latter acute miliary turberculosis. The first disease commences by a deposit of miliary growths, called tubercles, which, according to their metamorphosis, as well as their slow or rapid develop- ment, produce the well-known symptoms. It was Laiinnec, the estimable father of percussion and auscultation, who rep- resented the formation of tubercle to be the primary patholo- gical symptom in a lung diseased by phthisis, considering all further alterations as secondary consequences of tubercle. According to his idea, consumption and tuberculosis were one and the same disease, having always a constitutional ba- sis, but never being.developed from other local disorders. A chronic catarrh presenting the symptoms of phthisis in its further development, was according to his view, caused by secondary irritation due to deposit of tubercles. It was in like manner his opinion, that in all cases where the first tra- ces of consumption closely succeeded a bronchial haemorrhage, tubercles were developed simultaneously or even previous to the htemorrhage. Laennec regarded, as indeed we still do at the present day, the tubercle-granule to be a new growth, but he attributed to it special qualities, which do not in reality pertain to it. The most frequent alteration to which the tu- bercle is subject, is the caseous metamorphosis. The fresh, grayish, transparent tubercle does not possess any blood-ves- sels of its own ; as it is therefore nourished with difficulty, it becomes all the more readily a prey to caseation and ana3- mic destruction, when its nourishment is impeded by pressure or the close proximity of other tuberculous deposit. PULMONARY PHTHISIS. 5 As it was the belief in former times, that tubercle alone pos- sessed the capability of undergoing this caseous metamorphosis, the logical deduction was drawn from this assertion, that all such caseous deposits were the result of former tubercular for- mations. It was this opinion, however, that, by presenting the point of attack, gave the first impulse to reform and total sub- version of the doctrines of Laennec. Virchow has proved, that not only tubercle has the property of assuming the caseous metamorphosis, hut that other growths of entirely different nature, as for instance old cancer-knots, swelled lymphatic glands, hmmorrhagical infarctus, etc., can show quite the same changes,—that this is therefore no spe- cific quality of the tubercle. The assertion, that every such caseous alteration was a tubercular infiltration, a tuberculiza- tion, became obsolete; Niemeyer having for some time argued in opposition to it. As a further proof against the identity of consumption and tuberculosis of -the lungs, it has been frequently dem- onstrated upon minute examination, that, what had been form- erly considered tubercles, showed themselves to be the small- est bronchi with caseous contents or condensed alveoli with caseous infiltrations. In numerous post-mortems of consump- tives, the remarkable fact was established, that not a single tubercle could be found in the lungs, but all changes found were the results of other processes, chronic and indurating pneumonia, on which I will touch later. In such cases, where besides condensation and destruction of the lungs, tubercular deposits are to be found, an unpredjudiced examination will frequently elicit the fact, that the tubercles, when accom- panied by those pathological changes alluded to, have been developed at a later stage. The tubercle is to be most fre- quently met with and in closest proximity at those places, where the destruction is most advanced, that is to say, where the original disease had its commencement and first seat. In like manner caseous deposits are found almost without excep- tion in other organs, when tuberculosis appears in lungs pre- viously sound and free from caverns, this being surely a proof 6 PULMONARY PHTHISIS. of the dependence of tubercle on other products of caseous metamorphosis. That the miliary tubercle finally can not be considered au exclusive characteristic of individual disease, has been proved by the inoculations of various experimenters. Villemin in the year 1866 published the results of his attempts at inocu- lation in the “ Gazette Hebdomadaire” ; he injected the mat- ter of tubercle as well as caseous substance. Others, and amongst them Lebert, confirmed and extended these researches. According to Villemin the mere injection of caseous substance was sufficient to produce miliary tubercles in rabbits and guinea-pigs. He obtained the same result with tubercle- substance. It was afterwards shown that by injection of mat- ter, as Lebert did, or by embodying blotting-paper or gutta percha (Cohnlieim and Frtenkel), sponge or cork (Ruge), mer- cury and coal (Lebert, Wyss,) granular anilin (YValdenburg) miliary bodies can be produced. These experiments positively teach us the non-specific qualities of the tuberculosis, and the local production of tubercle in consequence of various inter- ferences. The former assumption of a constant constitutional basis of tuberculosis must be therefore relinquished. In these words the main principle of the new doctrine is expressed. Whilst Laennec traces all the caseous knots and caverns in the lungs back to previous tubercles, the conviction has been obtained by reason of the above data, that in most cases the basis of consumption does not in the least consist in tuberculosis, but nearly always originates from various pneu- monic processes. Although scientists without exception adopt the opinion that consumption seldom or in very rare cases commences with tu- bercular deposits, their views nevertheless diverge in regard to the pneumonic processes giving rise to consumption ; nor lias an agreement so far been arrived at. The greater majority, with Virchow in the lead, declare, that during pneumonic changes the primary exudation is deposited in the free spaces of the smallest bronchioles and alveoli, and is observed in croupy, acute and chronic catarrhal pneumonia. On the other PULMONARY PHTHISIS. 7 hand, two investigators of our day, Rindfloisch and Buhl, look upon the inflammation as parenchymatous and interstitial. Last of all I must mention, that Niemeyer, although he co- incides with Virchow in all other respects, believes bronchial haemorrhage, by irritation of the alveolar walls to be produc- tive of inflammation and consequent caseation If we proceed to regard the various forms a little closer, it will be found, that amongst the abnormal terminations of croupy pneumonia, tuberculization, or to designate it more correctly, caseation was known long ago. The conditions re- quisite to its appearance are not yet elicited, since healthy persons, as well as those already possessing casaeous deposits and caverns, are subject to this termination of pneumonia, which, however, takes place but seldom. Emphysematous patients are more liable to it than others. In acute catarrhal pneumonia, where we have an extension of the catarrhal process from the minutest bronchi into the alveoli, these latter become crowded with young, newly- grown cells; the tissue of the lungs condenses, assuming at first a brownisli-red color on account of the hyperaemia; and later growing paler. The diseased parts can, as in croupy pneumonia, again be made accessible to air and restored to soundness through changes in the exudation leading to the formation of mucus, through fatty degeneration and resorption of the deposited cellular exudation. In unfavorable cases, however, the cells crowd together still closer, the fatty meta- morphosis remains incomplete, and in turn the tissue of the lungs changes to a dull, yellow, caseous mass. Catarrhal pneumonia, appearing mostly during childhood as a compan- ion of measles, whooping-cough, croup, rachitis and scrofulo- sis reveals, according to the careful researches of Ziemssen, its complication with catarrhal bronchitis by an increase of tem- perature up to 104° E. and of the fever-symptoms generally. Not only children are liable to it, but particularly weak, deli- cate adults, with whom there is a tendency to repetition. Strong, healthy persons can likewise become subject to its at- tacks, running the risk of consumption by the change of the 8 PULMONARY PHTHISIS. profuse cellular exudation into caseous substance. Such cases, taking a very rapid course, are vulgarly termed galloping consumption. Chronic catarrhal pneumonia is succeeded by symptoms that were formerly considered tubercular infiltrations and gelati- nous infiltrations. The disease is quite as frequent as was formerly asserted of tuberculosis of the lungs. The patholo- gical action is the same as described above. It can be readily understood, that, during the tedious progress of the disease and the massing of cells in the alveoli, these deteriorate by ad- jacent pressure, and shrinking become subject to the caseous infiltration. Here fatty metamorphosis and resorption of the exudations are possible, but it is apparent that this takes place with less ease and frequency. In such cases condensation of the lungs would again disappear and the patient recover. All that has been said of the acute form applies as well to attacks of chronic catarrhal pneumonia, to which, however, grown persons are more disposed. While in previously heal- thy persons this form of pneumonia forms the foundation of all those disturbances of nutrition that lead to consumption, in already diseased constitutions it becomes the means of ex- tending and increasing degeneration and condensation. Before I proceed to investigate the views of Rindfleisch and Buhl respecting the pneumonic processes favoring consump- tion, permit me shortly to review all that has been treated of. 1. We see that a neglected, protracted catarrh can very easily extend into the alveoli of the lungs, inducing caseous infiltrations and consequent consumption by deficient fatty change or through pressure exerted by the cellular exudation. 2. That as a rule the condensation and destruction of the lungs of consumptives are in the majority of cases the results of pneumonic processes. 3. That the patients are more subject to the danger of such disease and deleterious products in proportion as they are weak and badly nourished, inasmuch as the inflammatory processes have a decided tendency to cell-proliferation. In passing over to the views of Rindfleisch and Buhl, I beg PULMONARY PHTHISIS. 9 to request you not to forget, that, however they, and especially the former of them, again approach the old opinion, neither of them believe in the dependency of consumption on the primary appearance of miliary tubercle in the tissue of the lungs, accord- ing to Laennec. In the Transactions of the Medical Society at Bonn and at the meeting of German Physicians and Professors of Natural Science, held at Wiesbaden in September last, Rind- fleisch has expressed his opinions, maintaining that those forms of inflammation causing phthisis and the primary caseous de- posits, are occasioned by a parenchymatous inflammation, to which he ascribes a tubercular nature from the beginning. He argues this by reason of the similar histological construction of the miliary tubercle and caseous deposits, which both exhibit great accumulation of the lymphoid cells and granules in con- nection with giant cells. The process is said to have its rise in the bronchial walls, extending over the alveolar septa. As the miliary tubercle has its favorite seat in the walls of the blood-vessels, the vessels are likewise the starting point of the inflammation, which he consequently designates as peri- vasculitis or tubercular inflammation. The change from in- filtration to caseation he assumes to be caused not so much by pressure, as by chemical alteration of the protoplasma and the nucleus of the cell. Whilst Buhl also looks upon the inflammation in question as parenchymatous, he denies the possibility of a transition of croupy or catarrhal pneumonia, of chronic bronchial catarrh and bronchial hmmorrhage into caseation; the latter, according to his representation, always having a parenchymatous inflam- mation as its foundation. He holds, that this inflammation does not consist of superficial secondary disturbances, as in catarrhal and croupy pneumonia, but of a gelatino-albuminous infiltra- tion and alteration of the alveolar walls and interstitial tissue. He calls this desquamative pneumonia, because it is accompa- nied by generation and shedding of bronchial and alveolar epithelium, the exudation consisting of desquamative epithe- lium. Buhl here further describes an inflammatory process of the finest bronchi, called peribronchitis, which, with a pre- ponderating development of connective tissue corpuscles, has a 10 PULMONARY PHTHISIS. tendency to terminate in scaly induration,cirrhosis ofthelungs, hut which in connection with cellular development in the ad- ventitia of the minutest vessels leads by the interruption of the circulation to tissue-death and caseation. The desquamative inflammation is often connected with peribronchitis. In opposition to the views of both Rindfleisch and Buhl,Vir- chow maintains his standpoint with decision insisting that the parenchymatous processes they speak of, it'they exist at all, are of secondary character. The histological criterion which Rindfleisch finds for the tubercle, lie declares untena- ble, and he warns earnestly against the introduction of old expressions into terminology, as this can only result in con- fusion. In regard to Niemeyer’s opinion, that bronchial hieuioir- hage leads to inflammatory irritation and caseation, many contrary views have been advanced. After the injection of blood into the air-passages of animals (by Somrnerbrodt), cel- lular elements were nevertheless found in the alveoli as a sign of catarrhal pneumonia. Niemeyer’s view might, consequent- ly appear correct, and the more so, as clinical experience often shows perfectly healthy and sound persons to have been seized with phthisis immediately after a bronchial haemorrhage and dying of it after a few months. When caseous deposits have formed in the lungs through one agency or another, they can become cretaceous during rapid formation of connective tissue, or can exist for some space of time before they break down and give occasion to the formation of caverns. By far the greatest danger threatens the patient from the fact, that the existence of these caseous deposits favors the appearance of tubercle, thus tuberculosis being added to consumption. Tubercles so frequently appear in lungs containing the residues of chronic inflammation, that their frequent appearance leads us to conclude on a casual con- nection conditional on the caseous metamorphosis of the pneu- monic processes. The reason why tubercles have a greater tendency to form in the lungs than in other organs, is ex- plained by the fact, that lungs are much more easily inclined to diseases followed by caseous deposits. PULMONARY PHTHISIS. 11 Acute miliary tuberculosis, which T have not mentioned so lar, being base:! upon the formation of numerous minute tu- bercular bodies in the lungs and other organs, is explained by Buhl as a disease of infection through preexisting caseous de- posits, with which view the clinical results might agree. Nev- ertheless, many observations have proved its appearance with- out the existence of sucli deposits, and a constant dependency on these latter can not always be traced. Having detained your attention by such lengthy patholo- gical explanations, I crave your kind indulgence on the ground, that on this basis I can more freely explain all re- maining etiological, clinical and therapeutic deductions. As to etiology, 1 shall only touch on the hereditary ten- dency, on the connection of scrofula with consumption, the influence of want of pure air and the inhalation of various dusty products,—passing over all other points, as we have already seen that delicate constitutions and all influences that materially impede the nutritive process, predisjiose to those diseases, which, by inducing a profuse formation of cells, give rise to consumption. According to the views I have developed, you will concede, that we may speak of an hereditary tendency to phthisis, but not to tuberculosis. Those parents who were consumptive or suffering from other exhaustive diseases at the time of gener- ation, can beget children who possess only small power of re- sistance. On reaching the age, when diseases of the menin- ges, the skin, the bowels, etc., are replaced by pneumonic pro- cesses, such children become more readily a prey to these dis- eases, than healthy children, being more subject to such dan- gerous influences on account of their constitutional anomaly. Hereditary tuberculosis can only be assumed in those cases where the children acquire tubercular meningitis from disea- sed parents; but even in such cases we shall seldom fail to find degenerated bronchial or lymphatic glands. I add the observation, that the statistic data represent about ten per cent, of hereditary tendency. As scrot'ulosis has a tendency to copious accumulation of 12 PULMONARY PHTHISIS. cells in lymphatic and bronchial glands, which are with dif- ficulty absorbed, those persons will be open to greater dan- ger, who are at an age, when former scrofulous products have not yet been absorbed and lung diseases become more fre- quent, than healthy persons or such as have entirely recover- ed from previous scrofula. The pernicious influence of impure air may be daily gath- ered from the reports of prisons, barracks, factories, found- ling and orphan asylums. I will give you a few proofs in figures, which I have gleaned from Hirsch and Brehmer. Although mental depression has great weight with prisoners, its influence is nevertheless acknowledged to fade from day to day during confinement. Accordingly Baly states, that in the Millbank Penitentiary in London, amongst 1000 prison- ers, there died from phthisis and scrofula during the— First year of imprisonment 6 Second year of “ 31 Third year of “ 49 Fourth year of “ 52 Fifth year of “ , 63 To prove that incarceration is the cause, it is shown, that of’ 3,249 prisoners admitted in 1844, only 15—viz., 4.6 (per thou- sand) Avere already subject to the disease. In the prison of Petonville there died on an average up to the year 1844, 11.14 persons, and the disease disappeared almost entirely as soon as better ventilation was introduced. Even animals are influenced by privation of fresh air. In Paris, for instance, those monkeys which were kept in magnificent hut close cages, died of phthi- sis, whilst others, which were subjected to all the inclemency of an out-door habitation, enjoyed comparative immunity. I could easily increase these examples, hut will only add one point more, which shall, at the same time, lead us to the last subject still to be discussed. In the whole State of Massachu- setts the mortality by consumption averaged annually between 1841-49 3.0 of the entire population, whilst at Boston and the manufacturing city of Lowell alone it reached 3.8. We can PULMONARY PHTHISIS. 13 therefore recognize the unwholesome influence of factories, the air of which is burdened with dusty particles. I add the re- mark, that according to an assertion of L. Hirt, amongst 100 sick laboring men, who have dusty work, 22.5 suffer from phthisis, and amongst 100 sick workmen, who are otherwise engaged, only 11.1. The changes in the parenchyma of the lungs have been designated by various names, according to the quality of the dust that has penetrated, thus, for instance, coal- dust produces anthrakosis, gravel-dust chalicosis, iron-dust siderosis, or as Zenker also calls it, pneumonokoniosis sidero- tica, designating by these names the various forms of scaly induration and cirrhosis of the lungs. Hirt again has shown the connection of dust with development of consumption. Me- tallic as well as cotton-dust has a specially detrimental influ- ence on phthisical pneumonias, on account of its mechanical irritation. Coal-dust acts less unfavorably and produces most- ly bronchial catarrh. As a discussion of the symptomatology of phthisis does not belong to the tendency of my lecture, I will confine myself to proving the existing difference in the phenomena of a simple consumption and the disease, when complicated by tubercular deposits, although the latter may have accompanied the case- ous deposits from the commencement, or made their appear- ance secondarily. I 3hall, in like manner, add a few remarks on the acute miliary tuberculosis. In these explanations I make use of a small comparative ta- ble which I have constructed. Although possessing no claims to exhaustive accuracy, it may, nevertheless, serve to throw some light on the subject, as the differences are thrown out in stronger relief here than at the sick-bed. 14 PULMONARY PHTHISIS. PHTHISIS. PHTHISIS With CONSEQUENT TUBERCULOSIS ACUTE MILIARY TUBERCULOSIS. The frequency of respiration we know Intense frequency of respiration and dis- Increased frequency of respiration with- to be accounted for by reduction of the tressing dyspnoea succeeding previous out dullness on percussion and without breathing surface, by accompanying ca- slight shortness of breath, without evi- bronchial respiration. tarrh, by the painfulness of respiration and chiefly by the fever. dcnce of increased condensation of the lungs are the most important symptoms. Cough and expectoration begin only Cough and expectoration frequently If cough and shortness of breath have, precede the disease, and are succeeded by from the beginning, been accompanied by after the patient has rapidly grown weak, fever, emaciation and pale skin. fever and emaciation, before the expecto- ration grows profuse, we may suspect tu- bercular phthisis. pale and thin. Sputa are numerous, being clotted and Hoarse, dull-sounding cough is always Hoarse, dull-sounding cough from its sinking to the bottom of a vessel. Elastic suspicious in advanced stages of phthisis. commencement, with tough, transparent flbres in the expectoration always point to Sputa consist purely of phlegm, being sputa, without marked physical signs in destructive processes in the lung. tough and transparent. the chest. Intestinal aud laryngeal symptoms are Intestinal and laryngeal symptoms ap- Intestinal and laryngeal symptoms rare. pear in the course of the disease. show themselves at an early stage. Fever sets in when catarrh extends from Fever differences of much less account Fever and emaciation begin before ex- the bronchial mucous membrane to the at morning and night, therefore a contin- pectoration. alveoli. The fever is of remittent type, ued type of fever gives a much worse prognosis. the difference between morning and even- ing temperature 1° to 1.5° Cels. At first, negative physical resuits with Dullness, bronchial respiration, coarse The percussion sound not dull but rales; increase of these symptoms keep empty; rapid respiration and scanty ex- unusual shortness of breath, fever; later pace with the advance of the disease. pectoration point to a decrease in the air capacity of the lungs through tubercle. High fever and emaciation without cor- responding progress of dullness. symtoms of condensation. Differential Diagnosis Between ' PULMONARY PHTHISIS. 15 In order to guard against misconception, I once more re- peat, that the symptoms rarely appear in the decided and un- mixed manner set forth above. In practice, the boundary will rarely be so clearly defined, especially between the two first diseases. I believe, however, that a consideration of the above remarks may assist in a decision in doubtful cases, which may be of importance to the physician as well as the patient; therefore I request that my remarks may be looked upon in this light only. In turning to the last part of my subject, I shall make a few communications as to the spread of consumption, from which you will observe the existence of the disease in almost every country under the most diverse climatic conditions In speak- ing of the regions that enjoy immunity from phthisis, we shall have to trace those conditions that are favorable to a cure of this disease. If we take up the excellent historico-geographical patho- logy of Hirscli, and turn to this subject, we will find phthisis to be spread over all the five great divisions of the globe. The mortality amounts from 1.7 to 7.00 per thousand of the population, moving mostly between the figures 2.5 and 3.5. The last report of the Philadelphia Board of Health shows a similar proportion. In Philadelphia there died in the year 1872, of a population of 725,000 souls, the total number 18,987, of which 2,249 deaths resulted from phthisis, and accordingly 3.10 of its population. Baltimore, with 303,000 inhabitants, shows a total mortality of 8,851 in the year 1872 and 7,614 in the year 1873. The deaths by phthisis in 1872 amounted to 972, therefore 3.20, and in 1873 to 1,008, therefore 3.32 of the population. As other statistics correspond near- ly to these figures with only slight variations, I will not fur- ther claim your attention by tedious iteration, but merely present you with a combination, showing, at a glance, the independency of phthisis from climatic influences. Hirsch gives three columns of figures representing the mortality by phthisis among 1,000 choosing those countries the tempera- ture of which offers the greatest contrast to each other. The 16 PULMONARY PHTHISIS. degrees of temperature represent the average yearly standard, and are given according to Reaumur (4° = 9° Fahrenheit). SCALE OF MORTALITY. 1. Amongst entire population— 3.6—3.8 in Boston (7.3), London (8.4), St. Louis (10.3), Charleston (15.2). 3.3 in Copenhagen (6.0), at Malta (15.4). 2. Amongst English troops— 3.5 in Newfoundland (2.8), Ionian Islands (13.0), Gibraltar (15.8). 3.9 in Canada (5.6), Mauritius (20.7). 4.3 in New Brunswick (3.6), Malta (15.4). 6.2 amongst European troops at Jamaica (20.5), and amongst the cavalry of the Guards in England. 3. Amongst North American troops— 2.4 in the western inland States, West, (8.4); in the western inland States, South, (13.0), and on the southern boundary of Texas (17.9). As these tables are constructed on older data, a few discrep- ancies with recent reports may exist, but they are not in any case of so much account as to deteriorate the present value of these figures. Hence you will gather that not only the lati- tude of places, but also dampness of air, as well as social con- ditions and mode of life, are without positive influence. Of those places where immunity from phthisis exists, I have to mention the island of Iceland, the Faroe islands, the Kirgh- is-steppe, near Orenburgh, and elevated mountain altitudes. In the first three countries no conditions are to be met with that favor exemption from the disease. The long winter of Iceland and the Faroe islands, the severe storms, which are so intense as to upheave boulders and rocks, the air impregna- ted with salty particles, the intensely filthy habits of the peo- ple, who consume their meat and fish in a partially putrid state rather than when fresh—whilst the Faroese washes his woolen clothes in urine —are surely influences that can in no wise he advantageous to patients. Nor can we apparently find any favorable conditions in the Kirghis-steppe, where the air is loaded with fine sand, and the coldest month shows -11.5° R., the warmest +16. 1° R., on an average; in nine days, PULMONARY PHTHISIS. 17 from 17th to 26th December, 1839, a medium temperature of -24.8° R. was observed, the lowest point of cold being-350 R., and the greatest warmth in August +37° R. in the shade. The endeavor has been made to explain the immunity of these three places by the mode of life of their inhabitants, as fat and fat-producing substances are consumed by the two former, and by the latter the koumiss or fermented mare’s milk is consumed in enormous quantities. The dietary influences ap- pear, however, to possess some intimate connection with the people’s habits, as Icelanders, who have emigrated to Den- mark, were attacked by phthisis. Many attempts have also been made to prepare the koumiss in other countries for the use of patients, but with little success. Only quite lately Dr. Simon in Berlin has advertised an establishment of this nature. In turning our attention to elevated countries, we find that von Tschudi was the first to point out the non-existence of consumption on the Andes of Peru. Muehry, in his Clima- tological Researches, and Fuchs, in his Medical Geography, followed the subject further, finding immunity in many places. Of these I will only mention the table-lands of the Rocky mountains and their southern continuation, the Cordilleras de los Andes, further in the tropics the mountainous boundary of the northern coast of South America, the towns Santa Fe de Bogota, 8,100', Quito, 8,970', Potosi about 12,000', and particularly the Puna region of the Peruvian Andes, 11,000'— 14,000', with the towns Caxamarca, Micuipampa, 14,000', Cerro de Pasca, 13,228'. In Europe the line is lower, and can be found in many places at 2,000' already, as for in- stance, on the highest points of the Harz, the Erzgebirg, the Carpathians, the Spessart, many places in the Alj)s, that have become known on this account, as in Pinzgau, Styria, Carni- ola, on the western section of the Pyrenees, in Switzerland, at an elevation of 4,500', whilst in many places below the level of 2,000' in the Vosges, the Jura valleys, the Odenwald, phthisis very frequently occurs. In Africa immunity exists, on the plateaus of Abyssinia; in Asia, on the high plateaus 18 PULMONARY PHTHISIS. of Armenia and Persia; on the highest points on the western Ghats and Nilgherry mountains in Lower Bengal, 4,000'— 7,000'; in less degree also in the mountain districts of Java and the table-land Nuwera Ellyia of the Island of Ceylon, 6,500. From this combination you will conclude, that constancy of the element of altitude is exhibited in the most varied latitu- des. Moreover you will observe, that the nearer we approach the equator, the higher the elevation at which immunity commences. Before concluding, allow me to impress upon you once more the fact, that altitude is the cause of immir nity. The want of connection between phthisis and temper- ature is clearly proved by the tables quoted from Hirsch. The same frequency of consumption in the United States as in other countries show that the greater dryness of the atmos- phere in high places is not the reason alone. (The dryness of the air in America has been shown by the American natu- ralist Desor in a brilliant lecture delivered before the Swiss Meeting of Naturalists in the year 1853). The purity of the mountain air can not be accepted as the reason either, as the same influence fails to exempt the lowlands from disease. Nor again can the ozone of the air he made accountable, as just in winter-time, when the ozone is considerably increased, consump- tion so frequently takes its commencement. We can there- fore deduce only the one fact of altitude, or what is synonymous, rarefication of the air, the influence of which must be explained as follows. As I have endeavored to prove, phthisis is based upon a caseation of inflammatory products, which disposition to caseation is most probably to be found in a certain dryness or relative bloodlessness of the lung-parenchyma. The rare- fled air produces a greater flow of blood in the peripheric organs, and especially in the lungs and consequently in the heart also. Therefore it acts in direct opposition to those con - ditions, which engender a disposition to phthisis, as I have already indicated in my article, giving a description of Wal- denburg’s portable pneumatic apparatus.* * Baltimore Physician and Surgeon, March 1, 1874. 19 In addition, mountain life induces an increased exercise of the chest in consequence of the increased respiration produced by the rarefied air. It will not he needful to explain more fully, that rich, nutritious diet especially of fat-producing substances, the greatest possible amount of fresh air, antipy- retics in the widest sense, amongst which I also count the use of cold water, are not to he left unheeded. On these principles several climatic establishments have been founded, whose happy results have amply proved the sound- ness of these theories in practice. The oldest of these is Dr. Brehmer’s Institute in Gcerbersdorf, Silicia, Prussia, founded by him in the year 1854 under great difficulties. He has, up to 1869, treated 958 consumptive patients. Of these 315 were already in the colliquative stage (these at Madeira are quite excluded from the statistics). Of the total number of 958, only 47 patients died, or 4.4-5 per cent.; if you deduct 18 pa- tients who were subjects of tuberculosis from these 47, a per- centage of 3 deaths by phthisis remains, whilst 20 per cent. were permanently cured during the comparatively short treat- ment of eighty-six days. Besides Gcerbersdorf, Davos in Swit- zerland has also gained a good reputation by its successful cures. PULMONARY PHTHISIS. Believing that I have shown you the curability of phthisis by conclusive facts, I beg only to observe to the practitioner, that he will be much more quiet and successful at the sick-bed in knowing the greater number of cases to be no deleterious new-growths, but only pathological processes, which are capa- ble of amelioration by careful treatment, Nature herself having provided a climatic means of cure. Note.—A most conclusive, logical and satisfactory demonstration of the effects of locality upon the origin and curability of phthisis.—E. S. G.