CONTINUATION OF A REPORT ON THE PRESENT 
STATUS OF THE TREATMENT AND 
PROGNOSIS OF 
ACCESSIBLE 
Surgical Tuberculosis 
B V 
JOHN R. McDILL, M. D. 
MILWAUKEE, WIS. 
REPRINTED FROM 
THE CHICAGO MEDICAL RECORDER, 
AUGUST-SEPTEMBER, 1897. CONTINUATION OF "A REPORT ON THE PRESENT 
STATUS OF THE TREATMENT AND PROG- 
NOSIS OF ACCESSIBLE SURGICAL 
TUBERCULOSIS," PUBLISHED 
IN THE RECORDER 
OCT., 1895 * 
By J. R. McDILL, M. D., Milwaukee, Wis. 
TREATMENT. 
Roswell Park says: "It is well to emphasize first of all that 
tubercular disease when circumscribed and accessible is a dis- 
tinctly curable affection." 
In Watson Cheyne's work on Tuberculous Diseases of Bones 
and Joints, 1895, which is the principal authority of the English, 
much is a reproduction of his Astley Cooper Prize Essay in the 
first part and in discussing the essential feature of the tuberculous 
deposit he gives his adherence to the view that the epithelioid 
cells are the characteristic histologic element of tuberculous tis- 
sue. Now that tubercles in tuberculosis have been so long un- 
derstood such discussion has lost all of its interest. Mr. Cheyne 
says: "The conclusion as regards arthrectomy and excision, 
which seems warranted by all the facts, is that arthrectomy is the 
proper radical operation in children up to the age of 15 or 16 
years, and excision in patients who have reached their full 
growth." Very little is said of the value of parenchymatous in- 
jections of iodoform, carbolic acid, chloride of zinc, etc., which 
probably expresses or implies his estimate of its value. The bor- 
rowed illustrations are altogether crude and the few original 
illustrations are of no greater artistic merit. It is a pity they are 
not more worthy of the text. 
General treatment and the technique of local treatment by in- 
jections remains materially the same as given in the article pub- 
lished in the Recorder in Oct., 1895. The development of the 
causal treatment of tuberculosis, by such men as R. Koch, Edwin 
Klebs and others has the greatest interest at present, as it is 
evident that these undaunted men, with their great knowledge 
*Prepared for the Wisconsin State Medical Society, May, 1897. 2 
and persevering labors would not venture to recur to this sub- 
ject without good cause. 
Schueller (1-2) repeats his opinion of the favorable consti- 
tutional action of guaiacol in connection with iodoform injec- 
tions for local tuberculosis, and Winkler (3) strongly endorses 
his views from his observation in the clinic of Mosetig-Moorhof 
(4), who also reports enticing results from local hypodermic 
injections of teucrin. For a good clinical study of injections 
of iodoform-glycerine in tuberculous osteomyelitis, see the 
work of H. M. Sherman and Agnes Walker (5). 
Faisan (6) reports a few cases to show that under certain cir- 
cumstances the treatment of tuberculosis with creosote gives rise 
to severe cerebral symptoms which may be mistaken for tuber- 
cular meningitis. He recommends that guaiacol be given in- 
stead. 
GENITO-URINARY TUBERCULOSIS. 
The subject of uro-genital tuberculosis has finally received 
the attention it merits at the hands of Senn, who has just pub- 
lished a work of 300 pages, appropriately illustrated, entitled 
"Tuberculosis of the Genito-Urinary Organs, Male and 
Female." This latest work by this master is put upon an 
etiologico-pathological basis, and the bacteriology has received 
much attention. The work was in press when compiling this 
paper and a few scattered notes on the subject were 
printed before the proof could be attended to. These 
are omitted in this reprint and this chapter of tuberculosis will 
soon receive attention in a separate article, now that Senn's 
work is at hand. 
LOCAL TREATMENT BY BIER'S METHOD. 
Many theories have been entertained as to the modus oper- 
and! of blood stasis as a curative agent. Bier says that perhaps 
the most plausible is the one propounded by Hamburger-that 
the blood highly charged with carbonic acid gas on account of 
its increased alkalescence is more destructive of bacteria than 
arterial blood. It is thus that Hamburger explains the immunity 
of the lungs in a state of stasis. Bier's method has also operated 
favorably in gonorrheal arthritis. 
Zirmatzky (106) combines with good results Lannelongue's 
sclerogenic treatment with Bier's method in the early stages of 
tuberculous osteo-arthritis. Advanced cases are not adapted to 
the treatment. 3 
Bier (7) reports his extensive experience in which he has had 
over 200 cases of tuberculosis under treatment by venous con- 
gestion. He still believes that this method is the most excellent 
one which we possess against tuberculosis and therefore deserves 
more consideration than it seems to have received so far. He 
says, whoever has once seen a painful and useless joint restored 
to function in a short time by this means and continue to improve 
can hardly doubt its worth. In one respect this method far ex- 
cels all other treatments; it secures to the joints, which recover, 
the best imaginable functional results. 
Mikulicz (8) reports 12 cases treated after Bier's method, and 
indulges in some very interesting speculations as to the manner in 
which these cases are favorably influenced. 
TUBERCULOSIS AND SYPHILIS OF THE TENDON SHEATH AND RICE 
BODY TUBERCULOSIS. 
In an extensive and profusely illustrated work, Riese (9) 
gives a review of former works concerning the nature and origin 
of these so-called rice bodies, to which Goldmann adds the 
microscopical appearances, etc. In regard to the compiled re- 
sults of his investigations, Riese agrees fully with the views of 
Koenig, Landow and their predecessors, that all rice bodies in 
tuberculous joints, tendon sheaths and mucous sacs are deriva- 
tives (Fibringerinnung) of fibrin, by coagulation. The chief 
groups are from fibrin coagulations which occur in the synovial 
fluid itself. The other chief groups arise from deposits on the 
wall of the synovial cavity and whose cells have become partially 
organized. That rice bodies have nothing to do with a benignant 
or low grade form of tuberculosis, as B. Goldmann believed, is 
shown by the inoculation experiments of Riese, who produced in 
animals, extensive tuberculosis with a very small number of them. 
Hence rice body forms of tuberculosis must be treated just as 
energetically as any other form. 
Tuberculosis of the tendon sheaths, Schuchhardt (96) differ- 
entiates the tuberculous fungus into the nodular and the rice body 
hygroma. 
(a) The tuberculous fungus always begins in a circum- 
scribed spot of the tendon sheath, generally following traumas 
and is transmitted to the spot through the circulation, very seldom 
from direct inoculation and readily extends to neighboring tissues 
as well as along the tendon itself. The tuberculous granula- 
tion tissue contains typical tubercles often free from bacilli, but 
also free giant cells independent of the tubercle growths or of 4 
the diffuse "tubercular inflammation." The affection recovers 
spontaneously or progresses to caseation, suppuration and lym- 
phatic infection, (3 cases). 
(b) In the tendon sheaths develop circumscribed firm growths, 
in resistance elastic, yellowish gray in color, with no tendency to 
caseation. They have been often described as sarcoma or 
fibroma. 
Extirpation gives favorable results. (3 cases). 
(c) Rice bodies are always tubercular in their nature and are 
peculiarly changed portions of the tubercular surface which have 
become detached. This change consists in a fibrinous transfor- 
mation of the connective tissue, in which the nuclei have perished 
and the substance gradually takes the character of threaded or 
flaky fibrin and takes the Weigert stain. There exists no abso- 
lute relation of tubercular rice body formation with the fibrous 
degeneration. There is not alone tuberculous exudation without 
rice body formations, but there is also a fibrous connective tissue 
degeneration without tuberculosis. Of this latter condition, 
Schuchhardt refers to subcutaneous hygroma, for example, as it 
occurs in the knee and again to the pseudo-arthrosis after fractures 
of bones; the resulting process of separation in the tissues is a 
result of fibrous degeneration. 
A striking feature in the histologic picture of these conditions 
is the enormous giant cells, which appear to have an osteoclastic 
function and produce resorption, and certainly have nothing 
whatever to do with tuberculosis. 
Schuchhardt recommends early surgical measures for all 
forms of these affections. 
In regard to syphilis of the tendon sheaths, according to the 
compilations of Schuchhardt, the literature is very scant, as far 
as the tertiary or gummatous form is concerned. In one case of 
undoubted tertiary Lues in a woman, Schuchhardt was able to 
demonstrate a necrotic tendo-vaginitis which could not possibly 
be confounded with tuberculosis. In this case also, numerous 
giant cells of Langhans were found in the connective tissues. 
This affection concerned, as is usually the case in syphilis, the 
extensor tendons of the fingers. 
BONES AND JOINTS. 
Koenig (11), published in 1896 a work on tuberculosis of the 
bones and joints of 186 pages and 42 wood cuts. 
The knee joint is treated by Professor F. Koenig. 5 
The statistical portion is worked out by Drs. F. Mertens and 
W. Koenig. 
Koenig has in view the publication in separate parts of a 
"Special Tuberculoses" of the joints and bones of the body. 
These communications are founded upon his own collective ex- 
periences of 20 years in the Goettingen Clinic. A work upon 
the hip joint will shortly follow the book upon the knee joint, 
dedicated to E. v. Bergmann. 
Koenig (io, 11), says: "He who has only a superficial acquaint- 
ance with the immense pathologico-anatomic differences in joint 
tuberculosis, as they are presented in their beginnings and during 
the course of their developments must be of the conviction, that 
there does not and cannot exist any perfectly uniform treatment of 
joint tuberculosis in general, and of knee joint tuberculosis in 
particular. The mode of treatment must be adapted to the indi- 
cations of each case and so much the more as during the clinical 
course, particularly through the occurrence of faulty position, new 
demands upon the treatment arise. 
During the last 18 years there have been treated 720 patients 
with knee joint tuberculosis, in the surgical clinic at Goettingen, 
but from only 615 have the final results been recorded. In 1893, 
410 of them were living, 66.7 per cent. To the present time 205 
of them have died, 33.3 per cent., of these, 140, 81.4 per cent, 
died of tuberculosis, 18 died of acute infections, 2.5 per cent. 
Of 498 cases, 257 were osteal; 241 synovial; 191 cases were 
treated conservatively, 27 per cent; 512 cases were treated by op- 
eration, 73 per cent; by arthrectomy, 150 cases, 21.5 per cent; 
by resection, 300 cases, 43 per cent; by amputation, 91 cases, 13 
per cent. 
Of 269 resections, 183 recovered, 85 have died, 58 of these of 
tuberculosis; 139 resected joints are described as very useful re- 
sults. Of 138 arthrectomies, 106 healed, 11 did not heal, 22 have 
died, 18 of them of tuberculosis; 67 operated cases had shorten- 
ing; 23 had very crooked joints; only one joint remained movable. 
Of 56 cases handled conservatively, only 36 showed good results; 
of 25 cases treated with carbolic injections, 20 recovered; of 40 
cases treated with iodoform injections, 13 are well, 8 with mov- 
able joints, 13 were operated later, 6 died. 
Koenig then discusses the processes, through which the 
fibrinous deposits upon the cartilages of tuberculous joints have 
an influence. He shows that the fibrin deposits itself particularly 
on certain areas of the cartilaginous covering of the joint sur- 6 
faces of the condyles of the femur from the patella downward, 
how it organizes on these places, beginning from the synovial 
border and in consequence of the manifold destructive occurences 
on the cartilage (cribiform perforations, formation of cavities and 
sinuses, etc.), extends from the surfaces to deeper parts and like- 
wise can be made responsible for similar processes on bone tis- 
sue; so that, the consequence is, the necessity arises of revising 
the question of primary bone foci upon the basis of these in- 
vestigations. Also the cicatrization and complete cure, the pe- 
culiar recovery with formation of a new capsule and apparently 
an entirely new joint, is to be attributed to these facts. 
From the statistical material dwelt upon, the entire amount 
was from the surgical and his private clinics, between October, 
1875, and October, 1893, comprising 720 patients under con- 
stant treatment. 
Koenig's standpoint on the question of combatting knee joint 
tuberculosis can be made plain in a few sentences. There is a 
recovery from knee joint tuberculosis with conservative treat- 
ment. Only a percentage, and not a very great one, of these 
so cured, obtain a perfectly normal function in the knee joint. 
If the disease lasted a long time and severe contractions en- 
sued, complete recovery of function cannot be hoped for, even 
should the cure follow a conservative treatment. The knee will be 
more or less stiff and also in a false position. In the majority, 
particularly in the aged, suffering from knee joint tuberculosis, 
it is advisable on economic grounds to eradicate the disease by 
curative treatment, if possible, in a definite time, after expectant 
treatment has been given a fair trial. Should the function of the 
joint be lost, it makes no difference, as after any other tedious 
treatment the result would have been the same, i. e., ankylosis. 
The nature of the procedure in these cases should be arthrectomy 
in children, resection in adults. 
In those cases in which the bone disease extends beyond the 
epiphysis, in which extensive abscess and fistula formation are 
present, probably complicated with liver and kidney affections, 
cure can only be achieved by excision of the diseased joint, or 
amputation. A number of excellent wood cuts accompanies this 
brilliant work. 
LIPOMA ARBORESCENS OF THE KNEE. 
The last work of Stieda, of Tuebingen, recently deceased, de- 
scribes in connection with the knee a lipoma arborescens of the 
hip joint connected with arthritis and osteitis deformans. Stieda 7 
claims this condition occurs in chronic inflamed joints affected 
either by tuberculosis, or arthritis deformans, etc. Radical op- 
erative treatment is the only remedy. 
HIP JOINT. 
The chiefest results of a most carefully prepared work, by G. 
Wagner (12), of Tuebingen, in 1895, have been already laid down 
by Bruns and is published under the same title in the Deutsche 
Med. Woch. XX. 17, 1894, and is freely extracted in my com- 
pilation on this subject in the October number of this Journal 
for 1895. 
Liermann (13), of Frankfurt, states that the chief fundamental 
indications of modern coxitis therapy consist in conservative and 
ambulatory treatment. These methods are always considered 
correct, as at the same time they are not only adapted to every 
specific treatment which may be combined with them, as for 
instance, the much practiced iodoform therapy, but they actually 
enhance their favorable effects. 
The diseased joint must immediately at the beginning of the 
treatment be made functionally inactive by fixation and repose 
and later also apply permanent extension. The ambulant treat- 
ment fulfilling these indications is achieved by a portable appa- 
ratus of which those of Hessing, Hoffa and Lorenz are par- 
ticularly worthy of mention. Lierman has also constructed an 
apparatus. 
Sasse (14) in his work last year has thoroughly examined no 
cases of coxitis from Bergmann's clinic. About half of them 
were under constant supervision, the remainder were treated from 
the policlinic. 53 of these cases Sasse followed personally; 21 cases 
have died, and 22 cases are still recent. Most of the patients 
were between 2 and 9 years of age: 
27 were resected, 83 were not. Of those resected 8 died, 29 
per cent; of those treated conservatively 13 died, 15.7 per cent; 
of the latter 50 recovered, 10 are near convalescence, and 7 left 
before the end of treatment. 
His conclusions are: 
1. Tubercular coxitis in children treated conservatively gives 
good results in 80 per cent of all cases adapted to this treat- 
ment; in the remaining cases, resection, etc., cannot be avoided. 
2. Recurrence after conservative treatment is relatively infre- 
quent and can usually be subdued by timely repetition of the 
treatment without resorting to resection. 8 
3. About one third of the abscesses arising during the course 
of the disease can be healed by iodoform injections, the other 
two-thirds require operative interference. Incidentally, he says, 
iodoform injections may give rise to a miliary tuberculosis, but 
does not instance cases. 
4. The main demands on conservative treatment are complete 
fixation of the joint, relief from harmful pressure, etc. Exten- 
sion is, aside from special indications, generally dispensable. 
5. Plaster casts from the toes to the nipple fulfills most in- 
dications of conservative and ambulant treatment and has the 
advantage of simplicity and cheapness. 
6. The results obtained by this treatment he considers de- 
cidedly more favorable than the progress of coxitis otherwise 
treated, as he attempts to show by comparison with Brunn's 
statistics. Separate clinical histories of the cases are given. 
ANKLE JOINTS AND TARSAL BONES. 
A recent work by Spengler (15) comprises 136 cases of tuber- 
culosis of the foot which were treated from 1873 to 1894 in 
Kocher's clinic. Patients' ages were from i| to 78 years. Half 
of the cases occurred between the age of 10 and 30 years. Men 
were oftener affected than women. 
About one-fourth had a tuberculous heredity. In about half 
of the cases there was a history of antecedent trauma. Half of 
the cases were primarily osteal, and one-fourth primarily synovial. 
30 cases were treated conservatively by injections, incision or 
ignipuncture. Atypical resection was oftenest performed. This 
work will repay close study. Treatments and results are care- 
fully tabulated. Every kind and combination of treatment was 
employed, according to the nature of the case, and each case 
must be handled according to its special indications. Results 
were generally very good. 
TUBERCULOSIS OF THE ALVEOLAR PROCESS AND INFERIOR MAXILLA. 
In all the cases in Czerny's clinic during the last twelve 
years, there have been only eight undoubted cases of tuberculosis 
of the lower jaw. He practices prompt resection in young 
people and cleaning out of the cavity in elderly patients, fol- 
lowed later by resection if necessary. 
Zaudy has collected from the literature 36 cases of this rare 
disease of the alveolar process of the jaws. Injection is usually 
through the teeth. Radical removal is advised. 9 
TUBERCULOSIS OF THE CALCANEUS. 
Finotti (16) reports 40 cases observed in the Innsbruck clinic, 
in which the tuberculosis either appeared only in the calcaneus 
or in which the disease began in the calcaneus. The tubercu- 
losis remains mostly limited to the calcaneus and only in rare 
cases or in the later stages of the tuberculosis does it invade the 
neighboring bones and joints. This is due to the somewhat iso- 
lated locations of the bone, whereas the other smaller tarsal bones 
with their numerous intercommunicating joints are so intimately 
connected that extension of the disease is exceptionally favored; 
further, the larger tendon sheaths run over the calcaneus, which 
structures are often and readily attacked by the disease. The 
tuberculous process has a special predilection for the anterior por- 
tion of the bone, and perforation occurs usually at the sides. Se- 
questration occurs very frequently in the calcaneus, whereas it al- 
most never happens in the other short bones. That the anterior 
portion of the calcaneus is most frequently attacked by tuber- 
culosis, is due to the fact that there is found a spongiosa soft 
with marrow and poor in vascularity, where aside from the slight- 
ly developed circulation and blood supply, a favorable soil in 
the tissue itself is offered for the development of wandering ba- 
cilli. The resistance to perforation of a focus is less at the lateral 
surfaces than elsewhere. In 14 cases the process had extended to 
the tendon sheaths and in 11 of these the peronei tendons were 
affected. As the disease remains a long time limited to the bone, 
the prognosis offers better results from partial or total resection 
of the calcaneus than when the other tarsal bones are involved. 
In children and very young persons cure is accomplished usually 
by partial osteotomy or currettement of the deposit followed by 
iodoform therapy. In adults total extirpation is recommended. 
The locomotion is thereby but slightly influenced. Tendon 
sheaths which are involved should be radically removed. 
WRIST JOINT. 
From the study of 71 cases of wrist joint tuberculosis in 
Ollier's clinic, Mondan (17) arrives at these conclusions: 
Tuberculosis of the wrist joint is almost twice as often osteal 
than synovial in origin. The osteal proceeds most frequently 
from the carpus, which generally exhibits the "basin shaped" erro- 
sions; infiltration and sequestration are infrequent. Caseous foci 
and wedge-shaped sequestra are found in the epiphyses of the 
radius and ulna. The tendon sheaths are usually secondarily in- 10 
fected. This joint affection is oftener in males between ages of io 
and 30 years and seems to favor the right side. Resection is 
recommended, but is contraindicated in very old and very ca- 
chectic persons who have marked visceral tuberculosis. 
Of 52 resections 1 died from the operation; 29 recovered com- 
pletely and have useful hands. 
TUBERCULOSIS IN EARLY CHILDHOOD. 
This is a special subject which has received considerable at- 
tention as such in the last 2 years by Cnopf (18), F. Goldschmidt 
(19), Rudolph Hecker (20), A. Wassermann (21), J. Walter Carr 
(22), Prof. Oscar Wyss (23), P. Simon (24), Louis Guinon (25), 
and Dr. F'ahm (26), who have collected, studied and arranged 
the enormous material of tuberculosis in children. 
The most interesting and instructive contribution to this sub- 
ject is by Rovsing (27), who has had several opportunities of 
seeing a typical and very peculiar form of joint tuberculosis in 
earliest childhood, which can be exactly described as "Pyarthron 
tuberculosum acutum," and which has an especially good prog- 
nosis in that the arthritis not only has an acute beginning but 
runs an acute course, so that a cure follows the same means em- 
ployed in tubercular peritonitis, namely simple incision or, as in 
these cases, arthrotomy. 
Rovsing had observed 10 lesions in 7 patients between the 
ages of 11 and 13 months. The disease begins suddenly in ap- 
parently healthy children with rapid swelling and marked ten- 
derness of the joint accompanied by fever. In all of these cases 
the diagnosis of tuberculosis was proven by microscopic and 
bacteriologic examinations and inoculation experiments. Two 
cases were of the shoulder joint, 5 in the knee, and the hip, ankle 
and sternoclavicular joints each 1 case. Complete function was 
obtained in all cases. This peculiar form of tuberculosis has not 
before been described. Probably some of Volkmann's cases de- 
scribed in i860 as "arthritis catarrhalis" belong in this cate- 
gory. 
From the experience in the Basel hospital for children, Wie- 
land (28), emphasizes the fact that best results in children are 
obtained by iodoform treatment supplemented by orthopedic 
appliances, by minor surgical operations and above all by con- 
stant attention to strengthening the general health, by good nour- 
ishment. fresh air and guaiacol or creosote. 
Results of iodoform treatment of tuberculosis in bone in the 
Basel hospital were as follows: 11 
Of 21 cases of para-articular abscesses treated conservatively, 
by punction and iodoform injection 16 were cured, 4 improved 
and one unimproved. Of 12 joint affections so treated, 9 recov- 
ered and 3 were improved. Of 9 cases treated by preliminary 
injections and later operated for abscess and joint disease, 4 re- 
covered, 3 were unimproved and 2 children died. Of 28 cases 
of bone disease operated first and later treated by iodoform in- 
jections 25 recovered. 
Conservative treatment of joints in children is most satis- 
factory in that the functional results are fair and even good in 
contradistinction to primary operative measures. 
THE DIFFUSE LESIONS OF LIMBS AFFECTED BY JOINT TUBERCULOSIS. 
Pilliet (29) has instituted very careful researches concerning 
limbs whose joints were infected by tuberculosis. In limbs the 
seat of far advanced tuberculous disease, no tissue. is exempt 
from changes. These appear in two entirely different forms: in- 
flammatory sclerosis or myxo-sclerosis and an inflammatory fatty 
degeneration. The sclerosis is rather to be regarded as an evi- 
dence of regeneration and the fatty degeneration as evidence of 
degeneration. Both are known results of chronic infections, but 
receive a special significance through their frequency, their ten- 
dency to spread and to their relations with tuberculosis. This 
is without doubt due to toxic material produced by the bacilli. 
In conclusion, Pilliet calls the attention of surgeons to the 
importance of careful attention to and examination of the entire 
limb when it has a tuberculous joint. 
It has long been observed clinically that the entire limb in 
which there is a tuberculous joint is almost always atrophied 
to a marked degree, and it has come to be regarded as of valu- 
able diagnostic significance. An interesting research by J. Pey- 
son Clark, of Boston, published in the Boston Med. and Surg. 
Journal in Oct., 1895, showed atrophy of the nasal mucous mem- 
brane in phthisis. This he found in over 200 cases and believed 
it to antedate the lung tuberculosis and perhaps contribute to its 
development. From what we know of atrophic processes in re- 
lated structures following a tuberculous disease of one of them 
it might be that the contrary was the fact. 
SPONDYLITIS AND OPERATION. 
Menard (30) in six cases of paraplegia complicating dorsal 
spondylitis, established a lateral drainage of the paravertebral ab- 
scesses instead of performing laminectomy. At the place of the 12 
gibbus one or several of the vertebral ends of the ribs were ex- 
posed and resected subperiosteally together with the correspond- 
ing transverse processes. Through this space thus gained the 
abscess was opened by working forward close to the vertebral 
bodies. In cases of 3 and more years standing showing paralysis 
an almost immediate result was noticed, which gradually com- 
pletely removed the motor and sensory disturbances. 
PERITONEAL AND ABDOMINAL TUBERCULOSIS. 
Koenig in 1884 was the first to recommend laparotomy as a 
routine treatment for tuberculous peritonitis which was justified 
by the clinical results following what Folet called the "happy 
error of diagnosis" that led Sir Spencer Wells in 1862 to open the 
abdomen in a case of tuberculous peritonitis which he thought 
was an ovarian cyst. Upon the speculative theory that the pres- 
ence of air exercised a destructive effect on the anaerobic micro- 
organisms, Folet,(Revue de Chirurgie, 1894, No. 12), inflated the 
abdomen with air after withdrawing the fluid, in a case of tuber- 
cular peritonitis that refused laparotomy. The patient eight 
months afterward was in a very satisfactory condition. Mosetig 
v. Moorhof employed this treatment in a child 4 years old but 
sterilized the air through a solution of carbolic acid. Folet ob- 
jects to this procedure and believes normal air is more efficient. 
Gatti who made experimental studies of peritoneal tuberculosis 
believes that laparotomy at a certain stage of the disease, which 
cannot be determined clinically, is followed by the best results and 
recommends that a second laparotomy be performed if a first does 
not seem successful. 
Israel (31) reports 3 interesting cases of rapid recovery from 
abdominal tuberculosis, one involving peritoneum and intestines 
with tumor formation. 
Loehlein (32) inquires why the post cervical vaginal incision 
into the abdominal cavity should not be preferred to celiotomy in 
establishing drainage for tubercular ascites. He had good re- 
sults in two cases. The advantages of this incision when feasible 
are apparent. This incision is much used and advocated for ex- 
ploratory and operative measures by W. R. Pryor of New York, 
N. Y. Med. Record L. 2, July 11, 1896; A. Mackenrodt, of Ber- 
lin, Volkmann's Sammi, klin. Vortr. N. F. Nr. 156, 1896; F. 
Henrotin, of Chicago, and others. 
Stchegoloff (33) has recorded experiments on dogs concern- 
ing the well-known favorable influence of laparotomy upon peri- 13 
toneal tuberculosis. Complete cure can only be obtained in cases 
not too far advanced, otherwise one must be satisfied with an es- 
sential improvement and a markedly increased lease of life. The 
favorable effect of a laparotomy has obviously to do with an ex- 
citation of the diseased tissue to a powerful reaction against the 
tuberculosis, and in this, different processes are concerned; the 
trauma and cooling of the peritoneum, the introduction of light 
and air, etc. 
Evacuation of the exudate cannot be the main factor, because 
laparotomy acts just as favorably in those cases where there is 
no exudate whatever present. 
Mader (34) does not consider laparotomy always necessary 
for peritoneal tuberculosis. He evacuates the exudate when pres- 
ent through a trocar; applies a firm cotton pressure dressing for 
a few days, allows the patient but little to eat or drink and puts 
the bowels to rest by opium. In 10 cases, 7 gave very good re- 
results. 
Dr. M. Jordan (35) of Heidelberg reports a case, 55 years old, 
of peritonitis sicca of a large hernia. Incision showed an inop- 
erable condition, the general peritoneum being also involved; the 
wound was closed and the mass, which was the size of a child's 
head, subsided, became reducible and the patient recovered and 
was well one year later. 
Jordan had another case of peritoneal tuberculosis in an 18 
year old girl, which had extended from the tubes; these were 
opened and left in situ. Complete recovery. He exhaustively 
reviews this interesting condition and discusses processes of heal- 
ing from every standpoint from 10 cases examined in vivo dur- 
ing 2nd and 3rd laparotomies and also from post-mortem studies 
but does not throw any light upon the great question of how 
simple laparotomy cures peritoneal tuberculosis. 
Vierordt (36) again takes up the subject of chronic peritoneal 
tuberculosis with 5 histories of children. Case V is interesting, 
as a vaginal discharge occured in a 5 year girl, and he is inclined 
to believe that infection through the genital tract is not infre- 
quent. 
Roersch (37) has put together the immense material of Aldi- 
bert, 308 cases operated for peritoneal tuberculosis, and added 50 
cases more. 
Of these 358 cases, 253 or 70 per cent were discharged as 
cured; 118 were well 6 months later, 79 after one year, and 53 after 14 
2 years; 83 cases died; of 20 dying soon after operation, 10 died 
from septic infection. 
HERNIAL TUBERCULOSIS. 
Altogether 19 cases of tuberculosis of hernia have been de- 
scribed up to this time, Tenderich reports 3 additional cases from 
the Greifswald clinic. 
1. Tuberculosis of the sac in a boy 3 years old, operation 
and good result. Death several years later from phthisis. 
2. Tuberculosis of the sac in a boy 7 years old. Operation. 
Good result. 
3. Gangrenous 'femoral hernia in a 54 year old woman. At 
the operation and later, during the resection of the bowel, the 
small intestine showed numerous tubercles. 
Tenderich (38) is of Brunn's opinion, that tuberculosis of 
hernias can appear as primary affections, but as a rule they are 
portions of general peritoneal tuberculosis. Operation is advised 
to remove the diseased area and radical cure can follow. Also in 
those cases where total removal is impossible, it being a part 
of general abdominal tuberculosis, the operation, nevertheless, has 
a most favorable effect on the entire disease and cures can be 
looked for in many cases. This disease is not easy to diagnose. 
Whenever the fluid contents of a thickened hernial sac can be 
returned to the abdominal cavity, this affection is probable. 
Dr. K. Roth (39), of Heidelberg, reports 3 cases of tuberculosis 
of hernias from the Heidelberg clinic, which increases the number 
of cases recorded to 22. The paper is treated very fully and will 
repay a study. 
TUBERCULAR MENINGITIS IN ADULTS. 
From 1884 to 1892, 45 cases of tubercular meningitis in adults, 
cases over 15 years of age, were observed in the medical clinic 
at Zurich; 34 men; 11 women. One patient was discharged be- 
fore end of disease; all the others died in the clinic and were 
dissected. This material was the basis of Kramer's (40) com- 
prehensive dissertation. Kramer gives 23 clinical histories in de- 
tail, and then discusses in an exhaustive manner the literature in 
respect to the origin, course, appearances, treatment, etc., of the 
tuberculous meningitis. 
INTRATHORACIC TUBERCULOSIS. 
Of all the organs the lungs are most frequently the seat of 
tuberculosis and as there is no lung affection that may not be 
complicated by tuberculosis it follows that pleural affections are 
most frequently tuberculous in character. 15 
Dr. George Ryerson Fowler, Brooklyn, N. Y., at the Am. 
Surg. Assn., 1896, says that few patients who had suffered from 
pleurisy, escaped tuberculosis and this fact increases the impor- 
tance of the surgery of pleuritic affections in their relations to 
tuberculosis. The consensus of opinion at the present day 
seemed to discountenance thoracotomy in tuberculous patients, 
preference being given to repeated puncturing or at most perma- 
nent siphonage by Bulau's method. 
PLEURITIS, EMPYEMA AND HYDROPNEUMOTHORAX. 
Dr. A. Aschoff (41) used the material in the medical depart- 
ment of the "Am Urban" hospital to produce his contribution 
on "the Etiology of Serous Pleurisy." He' attempts to answer 
three questions. 
1. Does a serous pleurisy exist without demonstrable cause 
which is not tuberculous? 
Answer: The so-called idiopathic effusions are almost always 
related to tuberculosis. These can recover spontaneously. 
2. Is there an acute isolated "rheumatic" pleuritis? 
Answer: Probably not. Those effusions in the pleural cav- 
ityoccurring during an acute arthritis are almost without exception 
due to heart lesions. Salicylic treatment has no therapeutic value 
here. 
3. Can a serous exudate contain pus producing substances and 
yet not become suppurative? 
Answer: Excepting possibly the pneumococcus exudate, no 
The serous effusions are almost always* free from pus germs, 
if they actually should contain them, they would sooner or later 
become suppurative, but can, nevertheless, recover without opera- 
tion. 
Eichhorst (42) seeks to ascertain, in the important and much 
contested question of serous pleurisy, how often it is tubercu- 
lous in nature. He injected from every case some of the exu- 
date, into the peritoneal cavity of guinea pigs. At the beginning 
as long as Eichhorst employed too small amounts of exudate, 
he got very slight and apparently misleading effects; when he 
employed greater quantities, 15 ccm., it transpired that at least 
two-thirds of the exudates were, tuberculous. Eichhorst's great 
astonishment at these findings is difficult to understand, as ex- 
perience proves the old rule that every "primary" pleuritis should 
be regarded with suspicion. 
How shall we proceed when empyema complicates phthisis. 16 
Baumler (43) at the congress in Rome went over the question, 
with citation of examples and arrived at the following conclu- 
sions: If the exploratory puncture shows the exudate to con- 
tain pus cocci-thoracoplasty with rib resection. Should no pus 
cocci be found, probably only a few tubercle bacilli, care and 
quiet are ordered. When marked compression of neighboring 
organs is suspected, the amount evacuated should be carefully 
considered; should no disagreeable symptoms arise and the col- 
lapsed lung appears to re-expand tolerably, after a certain time has 
elapsed, thoracoplasty may be ventured, and later, if necessary, 
obliteration of the cavity may be brought about by extensive rib 
resection. Should the condition deal with a large exudate of 
long standing in which the compressed lung at the same time 
shows no marked inclination to expand, frequent tappings of 
small amounts may be tried or an improvement may be effected 
by the permanent aspiration-drainage, according to Bulau. 
Baumler mentions those well known cases in which pulmo- 
nary tuberculosis is favorably influenced by the occurrence of a 
pneumo-thorax with serous effusion. 
Carriere instances a good example of this in his work, en- 
titled Sur un cas d'hydropneumothorax tuberculeux, resorption 
de 1'epanchement intrapleural, arret de 1'evolution de la tuber- 
colose pulmonaire. Arch. clin. de Bordeaux in. 6. p., 262, 1894. 
, In these cases a too hasty and aggressive procedure would be 
unjustifiable. 
RECTAL AND ANAL TUBERCULOSIS. 
Sourdille (44) recounts a series of examples to the effect that 
there is an anatomic condition of the rectum which is clinic- 
ally a characteristic tuberculous narrowing. This condition af- 
fects young people with hereditary taints; is sometimes primary, 
sometimes secondary and can be divided clinically into three 
stages : Proctitis, latency and stricture, and under certain condi- 
tions is amenable to operative measures. 
Hartmann (45) goes over the entire field of anal tuberculous 
fistula and abscesses, and has collected the entire material for 
years. It is an exceptionally readable work and is arranged in 
an original manner. He advised operation in all cases and has 
never seen dissemination or aggravation of tuberculosis in other 
organs follow. 
• ADRENAL TUBERCULOSIS. 
Letulle (54) reported an interesting case with post-mortem 
findings of adrenal tuberculosis. A young man who had. for- 17 
merly suffered from malaria, exhibited the symptoms of Addi- 
son's disease. Died suddenly. The adrenals were enlarged and 
caseous. Microscope showed giant cells and a few tubercle 
bacilli. 
He points out the difficulty of prognosis and that sudden death 
occurs in visceral tuberculosis, particularly in tuberculous ab- 
scesses of the brain. Binaud had also observed a similar case. 
A patient was operated for anal fistula and died suddenly on the 
next day with a hyperpyrexia. Necropsy showed adrenal tuber- 
culosis. 
Coleman (55) found in a case of phthisis, 36 years, tuber- 
culosis of both adrenals without bronzing of the skin and from a 
study of the changes present, is inclined to consider the adrenal 
lesion the primary and the lung lesion the secondary. 
Renner(56) calls attention to two hitherto undescribcd symp- 
toms in Addison's disease which are not mentioned in text-books; 
the intolerable pruritus and the presence of numerous wart-like 
elevations scattered over the surface of the skin. He describes 
a typical case of the disease in which these wart-like prominences 
grew more numerous towards the end. At the necropsy the 
left suprarenal capsule was found in a state of cystic degenera- 
tion, with a cavity containing caseous products. 
OPERATION FOR CURE OF ADDISON'S DISEASE. 
Addison's Disease cured by Extirpation of one Supra-renal 
Capsule. Hadra (107) removed a tumor "the size of a small apple" 
from a woman of 55, situated directly on the spine, on a level 
with the stomach. It was causing great pain, dyspnea, night 
sweats, emaciation and extreme muscular weakness, with edema 
of the feet. Examination after removal disclosed that it was 
nothing else than one of the supra-renal capsules affected with 
tuberculosis, and the complications made plain a case of Addi ■ 
son's disease without the pigmentation, which is not always pres- 
ent. 
A malignant retro-peritoneal tumor was diagnosed by 
Oesterreich (108) in thecaseof a woman presentingall the symp- 
toms of Addison's disease. When removed it was found to be a 
supra-renal capsule in a state of tuberculous degeneration. All 
the various symptoms disappeared completely after the operation, 
and the patient has enjoyed fine health ever since. There was 
no organic lesions except this tumor and an old tuberculous focus 
in the lung. It must be evident, therefore, that the condition 18 
of the capsule was responsible for the development of the disease. 
Hence, he says the removal of one or both capsules in Addison 
disease seems to be indicated. The operation should not be dif- 
ficult as a tubercular capsule is more easily separated from neigh- 
boring organs than a sound one. 
That tuberculosis of these bodies exists and causes Addison's 
disease naturally suggests the possibility of relieving such suffer- 
ers by surgical means and the two cases quoted show that sin- 
gle tuberculous adrenals can be, and have been, removed unin- 
tentionally, and in one case with a very happy result. It is 
impossible to avoid in this connection some reference also to 
treatment by opotherapy. 
Langlois believes from his observations of experiments by 
himself and others that they permit of the conclusion that opo- 
therapy is a legitimate treatment in Addison's disease. 
Opotherapy in Addison's disease when followed by improve- 
ment may be but temporary and should be submitted to rigid 
criticism as both glands may be involved. Improvement is some- 
times striking, but fluctuations in the activity of untreated Addi- 
son's disease are common, and in no given case is it easy to de- 
cide whether an arrest came spontaneously or through thera- 
peutic agency. 
Schilling (Munch, Med. Woch. February 16, 1897), dis- 
cusses the function of the supra-renal bodies, referring particularly 
to the recent researches of Muhlmann, who found pyrocatechin 
in the medulla of the gland. He believes this is not converted in 
Addison's disease into a harmless compound on leaving the 
supra-renal body and entering the circulation. Muhlmann be- 
lieves that in health the elimination of pyrocatechin occurs 
through the agency of the sympathetic ganglion cells. This 
theory offers the best explanation of the phenomena of Addison's 
disease, the debility, etc., being the signs of chronic poisoning 
with pyrocatechin. Thus Addison's disease is to be looked upon 
as an auto-intoxication. 
Osler has also written on this subject: 
If a patient's adrenals have been destroyed or permanently 
crippled it is hard to understand how feeding with sheep's or 
pig's adrenals for a short time will restore the patient to health 
which he will be able to maintain without the assistance of his 
own. 19 
GLANDULAR TUBERCULOSIS.-MAMMARY GLAND. 
Spediacci (57) gives an exhaustive review of tuberculosis of 
the mammary gland. It follows that this form of tuberculosis is 
quite infrequent, almost always appears in women who have 
borne and nursed children, and usually between the 25th and 35th 
year; and further, is secondary to a tuberculosis in some other 
part of the body. But one case in a man is known. 
Spediacci produced tuberculosis in rabbits and guinea pigs 
and studied on them the disease of the breasts. He found that 
the tubercles formed in the gland tissue proper, during which the 
connective tissues exhibited reactive disturbances principally. 
When nursing animals were infected the young died, but Spedi- 
acci thought, not alone from tuberculosis but from a poison, 
which the tubercle bacilli developed in the body of the mother.' 
Mandry (58) searched the literature and studied 7 cases of 
mammary tuberculosis in the Tuebingen Clinic and found 40 
cases, 21 of which seemed genuine. They were all of the adult 
female breast. 
The writer of this compilation has a case of mammary tuber- 
culosis to report in a woman 34 years of age, of 5 years' standing. 
Limited excision and other treatments having failed and the nip- 
ple having become involved, the mamma was extirpated. Diag- 
nosis by microscope. 
Reerink (59) reports in addition to the work of Mandry a 
case from the Freiberg surgical clinic of tuberculosis of the fe- 
male breast in a patient 32 years old, with no hereditary taint. 
The probable diagnosis was made immediately after operation 
from the histologic picture and made positive by discovery of 
tubercle bacilli. In connection with this observation Reerink 
takes up the question of the manner in which the disease arises, 
with especial reference as to what extent a primary tuberculosis 
of the mamma can be considered possible. A priori, three pos- 
sibilities are conceivable as causes of the disease: 
1st. A direct infection from without along the excretory ducts. 
By this path the disease could certainly gain entrance very 
rarely. 
2d. A direct extension by continuity from a neighboring tu- 
berculous affection. This class of cases is to be regarded as sec- 
ondary. Primary tuberculosis of the mamma can only be con- 
sidered where each and every tuberculous disease in the vicinity 
has been excluded or where proof is adduced that any such condi- 20 
tion has followed an already .existing disease in the mamma. 
There remains only the 
3d method: When the disease comes through the circula- 
tory channels,-hematogenous. We must also constantly bear 
in mind not only hereditary predisposition but also latent tuber- 
cular disease in the case in question. Extirpation is recom- 
mended with excision of axillary glands. 
Sabrazes and Binaud (60), in addition to our present 
knowledge of mammary tuberculosis, report very thoroughly 
upon their own observations with exact investigations. Aside 
from those cases in which the tuberculosis is a direct extension 
from a neighboring tuberculous ulcer or rib caries, they believe 
that the leucocytes are responsible for this rare infection of the 
mamma and that an accidental cause is necessary to start it, 
which is, in the cases described, generally a trauma. In the por- 
tion of the mamma so damaged numerous leucocytes laden with 
bacilli and tuberculous poison are deposited and thus originates 
the tuberculous abscess. That the functional activity of the 
breast can produce tuberculous milk from the entrance of tuber- 
cle bacilli from other parts of the body, they consider possible 
but improbable and totally unproven despite the many beliefs in 
this condition. 
Villar (61) believes with Spediacci that not all cases described 
as tuberculosis of the mamma are really this disease. Those 
cases only are certain in which, besides the known histologic 
changes, the presence of tubercle bacilli have been demonstrated 
and those in which experimental inoculation has produced tu- 
berculosis in animals. His cases were subjected to all these prov- 
ings. He recommends amputation. 
Gaudier and Peraire in the Revue de Chirurgie for Septem- 
ber, 1895, add three new cases of mammary tuberculosis to the 
thirty-nine, that they say have so far been reported in medical 
literature. Age seems to have little influence. One of the 
patients was 20 years of age, another 45, etc. They found 
nothing in the histories that would point to the influence of 
trauma in their three cases. 
TUBERCULAR LYMPHADENITIS, PAROTITIS, TONSILITIS, ETC. 
Tubercular lymphadenitis is universally treated by excision 
of all glands and their connecting lymph channels as radically 
as though operating for carcinoma, and the operator should al- 
ways aim to remove these growths in one mass through free 21 
incisions. When some glands of an infected chain have 
become abscesses they should be opened, curetted and iodo- 
formized before proceeding with the incision. 
Cordua (62) was led to try conservative treatment of lym- 
phatic glands in a state of tuberculous suppuration by puncture 
and irrigation followed by pressure dressings for eight or ten 
days. Only the rare cases of course where but a few glands are 
infected and well broken down are adapted to such treatment. 
The knife is the only remedy for the great majority of these in- 
fections. 
Czerny (63) removed from a 15 year-old girl a packet of 
swollen tubercular cervical lymphatic glands and a bean sized 
tumor from under the left upper lid. This tumor was determined 
by Salzer to be the lachrymal gland in a tuberculous condition, 
with beginning caseation although no bacilli were found. He 
believes that this condition of the lachrymal gland is perhaps 
more common than the scanty literature on the subject would 
lead us to believe. 
The unfortunate tendency to recurrence of disease after the 
most thorough excision of cervical tubercular lymphadenitis can 
perhaps find some explanation in the following papers by 
Starck, Kruckmann and others concerning the relations of 
tuberculous disease of this region to.carious teeth and tonsillar 
crypts which harbor the bacilli of tuberculosis and are no doubt 
very often the atria morbi. 
The deduction is plain and imperative that no operation 
for tuberculosis of the lymphatic structures of the neck can be 
considered completed until defective teeth, disease of the gums, 
tonsils and other adenoid tissue of the naso-pharynx have been 
removed or destroyed. 
Starck (109) was able to demonstrate in 41 per cent of his 
cases of tuberculosis of the cervical glands, the existence of cari- 
ous teeth. The glandular disease corresponded in location, in 
time of development and in intensity with the condition of the 
teeth. Caries of the teeth of one or the other side of the jaws 
vas associated with enlargement of the glands of the same side, 
and caries of the front teeth existed in conjunction with enlarge- 
ment of the anterior glands about the angle of the jaw. Previous 
to the development of the glandular enlargement there was fre- 
quentlv a history of toothache or caries. Caries of many teeth 
was usually associated with enlargement of a chain of glands, 
while caries of a single tooth and slight enlargement of the glands 22 
existed together. He reports two cases in which he was able to 
demonstrate positively that carious teeth had been the point of 
entrance of the tuberculous poison. One was that of a boy, aged 
]8 years, the other that of a girl aged 14 years. They had no 
hereditary predisposition to tuberculosis and previously had al- 
ways been healthy. In both cases the glandular enlargement 
ensued subsequent to toothache. In the case of the boy, in two 
molar teeth numerous tubercle bacilli were demonstrated. In 
the case of the girl, between the roots of a molar tooth was seen 
a macroscopic suspicious granulation tissue, which on micro- 
scopic examination, was found to consist of tuberculous nodules 
and giant cells. In this case although operated upon, a recur- 
rence ensued after an interval of a year and a quarter. In three 
other cases such intimate connection between caries of the teeth 
and tuberculosis of the glands could not be proved, though it 
was probable. The carious teeth and the enlarged glands should 
be removed at the same time, whereby the liability of general in- 
fection and local reinfection is reduced to a minimum. 
Concerning the Relations of Tuberculosis of the Cervical 
Lymphatic Glands to Tuberculosis of the Tonsils.-Kriickmann 
(no) confirms the observations of Hanau-Schlenker (m). In 
thirty cases of lung tuberculosis, there was tuberculosis of the 
tonsils twelve times. An apparently primary tuberculosis of the 
cervical glands can also develop from the tonsils, even when the 
clinical examination fails to demonstrate the presence of pulmon- 
ary tuberculosis. In one case there was tuberculosis of the 
tonsils and the mesenteric glands only. This was presumably 
due to ingestion of bacilli with the food, the bacilli becoming 
localized in the organs that especially receive and retain foreign 
elements, while the mucous membranes themselves did not be- 
come infected. 
Pluder and Fischer (112) found five cases of tuberculosis 
among 32 patients with enlargement of the tonsils. In no case 
could the disease be found elsewhere. They are macroscopically 
not to be differentiated from the ordinary hypertrophied tonsil. 
Tussau (113) believes with Schlenker (111) that tuberculosis 
of the tonsils is more frequent and more serious than has here- 
tofore been acknowledged. The first thinks it is a chronic in- 
flammation caused by alcohol and tobacco in the majority of cases 
which prepares the way for the T. B. Tussau gives three short 
clinical histories as examples and mentions in concluding how 
unthankful is the treatment of chronic amygdalitis and tonsil 23 
tuberculosis. The only effective means are cauterization by 
either thermo-cautery or electro-cautery. 
Brueckmann (64) found in sixty-four bodies examined with- 
in six months tuberculous changes in twenty-five of them, 
and in twelve of these the tonsils were involved. In almost all 
of the cases the relation between tonsil and cervical tubercular 
lymphadentitis stood out most clearly, so that in fact the gener- 
alization of the rule or maxim that secondary infection of the 
cervical glands can come from the tonsils seems to be com- 
pletely justified. The infection of the tonsils follows either from 
the sputum of a contemporaneous lung disease or from a primary 
infection independent of any pulmonary lesion. 
Dieulafoy' (65) has turned his attention to hypertrophic ton- 
sils and adenoid vegetations of the naso-pharyngeal cavities, and 
from the first mentioned has inoculated sixty-one guinea pigs 
and from the latter thirty-five pigs, of which animals eight and 
seven respectively became tuberculous. He therefrom concludes 
that tuberculosis of the tonsils is not at all so rare as has been 
long believed in these sufficiently known but uncharacteristic 
hypertrophies. These tonsil tuberculoses often enough remain 
latent and unrecognized and disappear in time (years), but in 
other cases regional infection of the lymph glands occurs in the 
neck from above downwards and pulmonary or general tubercu- 
losis becomes possible at any time. Dieulafoy seems to assume 
that in his cases the tonsilar tuberculosis was a primary infection 
from the mouth, but instances no proof of this. That the tonsils, 
primarily or secondarily, readily become tuberculous and that 
the infection extends easily to the cervical lymphatic glands is 
proved by the investigations of Brueckmann in 1894. 
Stubenrauch (66) reports a chronic parotitis which he proved 
to be tuberculous; he was unable to find any other case of tuber- 
culosis of this gland recorded. 
MUCOUS MEMBRANE AND SKIN TUBERCULOSIS. 
In addition to the four forms under which skin tuberculosis 
is known (lupus, scrofuloderma, miliary tuberculosis and tuber- 
culosis verrucosa cutis), Riehl (67) differentiates several other 
varieties of skin tuberculosis, which appear from their peculiar 
symptoms and history as independent clinical pictures. 
1. A peculiar form of direct infection tuberculosis. 
2. Tumor-growth skin tuberculosis. 
3. Fibroma and tuberculosis. 24 
4. Naevus and tuberculosis. 
Doutrelepont (68) reports two cases of lupus hypertrophicus, 
in one of which the diagnosis cannot be considered positive with- 
out further proofs; the other was a case of infection tuberculosis 
(scrofuloderma). 
Doutrelepont (69) has made a former report on peculiar cases 
of skin tuberculosis and reports here three new observations. 
In a 6 year-old girl the disease appeared in the form of 
numerous round smooth tumors, which rather suggested mycosis 
fungoides or sarcomatosis of the skin. The tuberculin reaction, 
the examination of the tumors and the appearance of characteris- 
tic nodules after extirpation of the tumors established the diagno- 
sis. There could be no question of lupus hypertrophicus. The 
second case, 29 years old, exhibited at the same time on nose, 
upper lip and ear very striking swellings which proved micro- 
scopically to be a mixed lupus and lymphangioma. In the third 
case, 27 year-old man, a serpiginous tuberculous ulcer was en- 
grafted upon the bubo, which healed after extensive destruction 
of tissue. 
Fabry (70) reports with clinical histories and illustrations over 
174 cases of skin tuberculosis which he saw in Dortmund during 
three and a half years. He describes the various forms. The 
work cannot be adapted to a short synopsis. 
Knickenberg (71) and Heller and Hirsch (72) have exhaus- 
tively reviewed the entire subject of tuberculosis verrucosa cutis 
and refer freely to the works on this subject by Riehl and Pal- 
tauf, Doutrelepont, Fox, Fournier, Hallopeau and Leloir. 
After a lapse of four years Liebriech (73) refers again to can- 
tharidin injections as formerly recommended by him. He has 
continually employed it since and considers it to-day, as in 1891, 
an excellent treatment. Liebreich during this time has acquired 
very positive views concerning infectious diseases. Fie believes 
that the primary changes in tuberculosis, as well as in most other 
infectious diseases, originate in lowered vitality and weakening 
of the cells and that the tubercle bacillus finds lodgment later 
and is a "parasite of the disease," a "noso-parasite." Canthari- 
din is of benefit in that it strengthens the cells. Koebner, Zur 
Kritik des Vortrages des Herrn Prof. O. Liebreich; Ueber Lu- 
pusheilung durch Cantharidin und fiber Tuberkulose: von Prof. 
Heinrich Koebner (Sond.-Abdr. aus "Dermatolog. Ztschr." 
1895), opposes Liebreich's position as untenable and seriously 
doubts his diagnosis and results. 25 
NOSE, GINGIVA, PHARYNX AND ESOPHAGUS. 
The esophagus can become tuberculous usually from the per- 
ibronchial and mediastinal glands or from its lumen, often as an 
extension from the pharynx or thirdly directly through mucous 
membrane. Glockner (74) instances examples from the literature 
of all three forms. By far the rarest form is an infection through 
the circulation as a manifestation of general tuberculosis. Glock- 
ner describes a case from the Pathologic Institute in Prague 
which is particularly interesting in that the muscular layers only 
were affected, all other tissues of the organ remaining entirely 
free from the disease. 
Flexner (75) gives a short glance over the literature of eso- 
phageal tuberculosis and instances one case of his own in which 
the lesion broke through, into the lung and the pleura. 
Fraenkel (76) describes a case of disseminated nodular eso- 
phageal tuberculosis unexpectedly found post-mortem with also 
a papillary cervix tuberculosis. 
Koschier (77) gives exact clinical histories of sixteen patients 
with tuberculosis and six cases with lupus of the nose, all from 
the Stork clinic in Vienna. The six lupus cases were invariably 
typical mucous membrane lupus which never extended to carti- 
lage, or bone nor ever formed deep ulcers. Radical removal was 
practiced, the aftertreatment was with lactic acid. The wounds 
never healed, but increased, and recurrences were frequent. 
In Walter's (78) case of lung and larynx tuberculosis, extrac- 
tion of a tooth was followed by a tuberculous ulcer of the gums 
which destroyed soft parts and bone and opened into the antrum. 
At a meeting of the N. Y. Path. Soc. Nov. 11, 1896, Dr. J. S. 
Ely demonstrated the tuberculous nature of an ulcer of the gums 
in a young man otherwise apparently healthy. He found an- 
other case recorded by a Swede in Virchows Jahrsbr. 1884. 
Gottstein (T14) reports 6 cases of primary tuberculosis of 
the pharynx. Gottstein's cases show nothing new concerning 
the manner of infection. He recommends radical removal and 
regards the prognosis as rather favorable. 
Rosenberg (79) reports twenty-two cases of pharyngeal tuber- 
culosis which were observed in 22,000 patients in Berlin, sixteen 
men, six women. It is usually secondary to lung or laryngeal 
tuberculosis; only three cases which could be called primary have 
been seen. Pain is the main symptom. Regional infection and 
fever failed to appear in all cases. Death followed as a rule in 
two to six months after its appearance. 26 
EYE AND EAR. 
Haug (8o) describes the particulars of three new cases of 
focal or nodular tuberculosis of the lobe of the ear, one of which 
was interesting in that it became carcinomatous. Correct diag- 
nosis is possible only by the microscope. Source of infection is 
often local, through piercing of the ears or lesions of the canal 
by the irritation of ear ornaments. 
Haug (81) describes a perichondritis tuberculosa auriculae, 
which usually occurs in tuberculous or hereditarily disposed male 
adults from 15 to 40 years of age. The exciting cause of the 
disease seems to be attributed to some previous often very re- 
mote trauma. Either behind the tragus or in the muscle appears 
a light reddening and swelling sensitive to pressure, tension or 
tickling; the affection gradually progresses with increase of the 
symptoms or with subacute advances and leads to a thickening, 
enlargement and infiltration of the entire muscle. During an 
exacerbation appear at times One or more doughy swellings on 
any part of the ear which open spontaneously showing fungous 
granulations or if opened before contain characteristic tubercu- 
lous contents, but nothing suggesting the synovial like fluid 
which is seen in ordinary perichondritis. 
The perichondrium perishes completely, the cartilage is 
roughened and necrotic in spots. Notwithstanding these serious 
changes the prognosis is favorable, even after considerable time 
has elapsed. (5 months, Haug.) 
. Microscopic and bacteriologic examinations demonstrated tu- 
bercle in all its degenerations and the presence of tubercle ba- 
cilli. The neighboring glands often suffer from regional infec- 
tion. Radical excision is advised, together with removal of in- 
fected glands, followed by after-treatment with iodoform by in- 
jection, if necessary, or balsam Peru. 
MIDDLE EAR. 
Tuberculous middle ear disease has been recently written 
upon by Guanowski, Koch, Cohnstaedt, Koerner, Haug, Knapp 
and others. 
Of especial interest in Guanowski's (82) report on Otitis Me- 
dia Tuberculosa is the following: 
Tuberculosis of the breast, peritoneum, different joints, the 
skin and the kidneys in one case showed also a right sided 
chronic middle ear suppuration, with numerous polypoid 
growths of the mucous membrane of the tympanum, including 27 
a necrotic hammer and incus consisting partially of pure tuber- 
culous tissue and partially of angiomatous tissue with a few tu- 
bercles; necrosis of the inner wall of the tympanic cavity; exfo- 
liation of the stirrup. 
In two cases of Guanowski's and also in one case each, ob- 
served by Koch (83) and Cohnstaedt (84), the suppuration had 
extended to the mastoid cells, causing more or less extensive de- 
struction; chiseling was resorted to, which was followed by local 
improvement, although the cases eventually resulted fatally from 
tuberculous pachy and leptomeningitis. In Cohnstaedt's (84) 
case the labyrinth was involved and totally destroyed in addition 
to caseous suppuration and destruction of the inner tympanic 
wall. 
In one case of Koerner's (85) in which a lung infection suc- 
ceeded to the ear lesion, the post-mortem showed a very unusual 
appearance, in that the tuberculous process had extended di- 
rectly through the tegmen tympani to the dura mater and the 
brain. Covering the bone defect in the roof of the tympanum 
was a greatly thickened dura bedecked externally with volumi- 
nous and robust granulations in which were found imbedded 
numerous bony fragments; on its inner surface the dura was 
firmly adherent to the adjacent brain, and both were studded with 
hempseed to pea-sized partially caseated nodes. Besides this was 
found: miliary tuberculosis of the pia mater, a conversion of the 
mastoid, auditory canals and tympanic cavity into one large cav- 
ity filled with granulations and bone fragments into which opened 
freely the facial canal, the cochlea, one part of the semicircular 
canals, the fossa jugularis and the lateral wall of the carotid canal; 
complete destruction of the sigmoid fossa, of the sulcus trans- 
versus, suppurative phlebitis of the sinus transversus, and of the 
vena jugularis; this last vein was completely destroyed to the 
middle of the neck and was lost in an abscess the size of a hen's 
<gg- 
Primary tuberculosis of the mastoid has been observed by 
Haug (86) and Knapp (87). Haug's case was a woman with 
double sclerosis of the tympanic' mucous membrane and severe 
pain deep in the right mastoid process. This was apparently nor- 
mal except that the overlying small glands were swollen. These 
were excised, proved to be tuberculous, and were united to the 
bone by lymphatic vessels. As this procedure was not followed 
by relief from pain the mastoid was chiseled open; it was scle- 
rosed and at a depth of 15-16 mm. the bone became suddenly 28 
soft and opened into a bean-sized cavity, which, without a trace 
of pus, was found filled with a reddish brown pulpy mass. Micro- 
scope showed tubercle and tubercle bacilli. Operation was fol- 
lowed by immediate relief. Haug believed it to be a case of pri- 
mary mastoid tuberculosis and is disposed to attach great weight 
to swollen superficial glands in such cases. 
EYE. 
Denig (88) has collected all the cases known of tuberculosis 
of the eye, and has tabulated them according as the eye was af- 
fected alone or later or at the same time other parts of the body 
were involved, besides the clinical histories and ophthalmoscopic 
findings of five cases. 
Denig insists that primary tuberculosis of the eye must be 
admitted. For diagnosis the clinical picture is decisive, for the 
tubercle as well as the bacilli and the inoculation as well can 
be lacking for the diagnosis of tuberculosis. The older the case 
the better the prognosis. The eye, of course, offers a fine field 
for observing all stages of the infection. 
CONTUSION TUBERCULOSIS OR THE RELATIONS OF TRAUMA TO SUB- 
SEQUENT TUBERCULOSIS. 
It has long been known that tuberculosis of bones and joints 
is prone to follow injuries, particularly slight injuries, and Tie 
surgeon is now not infrequently called to testify in accident and 
negligence cases to the possibility of this or other infectious dis- 
eases following a trauma. The courts have decided that patho- 
genic germs in the blood cannot be held to be the proximate 
cause of a disease, but that what medical men term the exciting 
cause, or injury, shall be considered the cause which set in motion 
the active agents of the disease, by preparing suitable conditions 
in the tissues for their growth, reproduction and consequent 
manifestation of their peculiar pathogenic properties. 
Since the time of Koenig and Mueller's beautiful experiments 
of producing tubercular infarctions in bone, since supplemented 
by Watson-Cheyne, Schuller and Krause, the subject of the 
relation of traumas to the tubercular process has received much 
attention and has become of great importance from a diagnostic 
standpoint, as well as from the medico-legal point of view. 
Becker (89) and Kaufmann exhaustively discuss the relations 
between injuries and tuberculosis with citation of examples. 
These relations have acquired especial importance on account 
of accident insurance law, whereby it is to be considered, that 29 
the patient has also a claim for indemnity, if the accident 
occasions the outbreak of a concealed or threatened tuberculo- 
sis or hastens it. 
Spengler's (15) paper on ankle and tarsal tuberculosis showed 
that in about half of the 136 cases there was a history of 
antecedent trauma. This paper is here already referred to under 
Bone and Joint Tuberculosis. 
Sabrazes and Binaud (60) believe that aside from these 
cases in which a tuberculosis of the mamma is a direct exten- 
sion from a neighboring tuberculous ulcer or rib caries, that 
the leucocytes are responsible for the rare affection of the 
mammary gland and that an accidental cause is necessary to 
start it, which is in the cases described generally a trauma. 
In the portion of the mamma so damaged numerous leucocytes 
laden with bacilli and tuberculous poison are deposited and 
thus originates the tuberculous abscess. 
Perichondritis tuberculosa auriculae, as described by Haug 
(81), he thinks can often be traced to a remote trauma. 
Jaccoud (90) in 1896 also reports four cases in his paper 
on hospital tuberculosis, which belong to traumatic phthisis. 
Three patients, who were previously healthy men, suffered 
injuries to the chest for which they entered the hospital and there 
became tuberculous. In two cases Jaccoud could trace tuber- 
culosis to a traumatic pneumonia. The post-mortem examina- 
tions showed no traces of old tuberculous deposits, so that the 
assumption that they were hospital infections can not be denied. 
This report points to rather inefficient prophylaxis for these times 
in French hospitals. 
Schilling (Munch. Med. Woch. No. 40. 1895) reports the case 
of a boy 8 years of age who showed brain symptoms eleven days 
after a severe fall. Fracture of the inner table, with irritation by 
fragments of bone, was suspected, but before operation could be 
made the patient died. Autopsy showed tuberculous meningitis 
and cheesy softening of the bronchial glands. It would seem 
most probable that the bacilli in the glands, where they were en- 
capsulated and latent, becoming mobilized and set free in the 
circulation found at the seat of injury the favorable conditions for 
their lodgment and reproduction. 
A patient of Wagner's (92) injured his elbow in 1886, which 
joint became tuberculous and later the lungs were attacked. 
Wagner traced in a comprehensive manner the phthisis in 1895 
back to the accident in 1886. 30 
A patient of Schaeffer (93), 34 years old, no hereditary taint, 
fell from a carriage upon the left side of the body. The result 
was symptoms of chronic inflammation of the membranes of the 
cord in the dorsal region. Five years later an exudative pleuritic 
occurred, and nine years after the accident death from pulmo- 
nary tuberculosis followed. Schaeffer thinks it probable that it 
was tuberculous meningitis which later attacked lung and pleura. 
Tuberculosis of the urethra although very rare as a primarv 
disease, when it occurs it takes place in a part of the urethral 
mucous membrane prepared for the reception and growth of the 
bacillus by some antecedent injury or disease.-Senn. 
The predisposing causes of tubercular epididymis, given by 
the same author are: Inherited soil, antecedent or coexisting 
disease of the testicle and trauma. As exciting causes of tubercu- 
losis of the testicle which is often secondary to the disease in the 
epididymis most authors enumerate traumatism and chronic gon- 
orrheal inflammation in the posterior portion of the urethra and 
in the epididymis. 
Crytorchism is mentioned by Nepveau & Kocher as one of 
the most potent of exciting causes. Tuberculosis of these organs 
is noted for its insidiousness and chronicity although in rare cases 
Barling (Double Acute Tubercular Disease of the Testis. London 
Lancet, April 9, '92) says: "I can readily understand that in the 
event tuberculosis develops in a testicle or epididymis, the seat 
of an injury or antecedent inflammatory disease, that it might in 
rare cases pursue an acute course." 
Dr. J. G. Mumford, of Boston, in an article on the treatment 
of sprains by massage (Bost. Med. & Surg. Journal), states that 
he has seen a number of cases of ankle sprains that resulted in 
severe chronic tuberculosis. 
W. V. Konig's (17) report on tuberculosis in the shoulder 
joint showed that it cases followed trauma. 
Further information on this subject can be found in the recent 
papers by Prof. Fuerbringer (94) and Dr. Paul Guder (95). 
RELATIONS OF MALIGNANT LYMPHOMA, LYMPHOSARCOMA, CARCINOMA 
AND PSEUDOLEUCEMIA TO TUBERCULOSIS. 
On the basis of several observations in Brunn's Clinic, Diet- 
rich (96) discusses the relations of malignant lymphoma to tu- 
berculosis. His conclusions can be summarized about as follows: 
1. There does exist a combination of malignant lymphoma 
with tuberculosis in the glands themselves or in other organs; 31 
yet an etiologic connection between the two cannot be acknowl- 
edged. 
2. There are, not infrequently, cases of multiple lymphoma 
which clinically can hardly be differentiated from tuberculosis; 
there is indeed a rare form of tubercular adenitis which runs a 
course quite similar to malignant lymphoma, without softening 
or breaking down, and which can not be distinguished micro- 
scopically post-mortem. 
3. Necrosis and softening do not suffice for a decision in 
favor of tuberculosis, as they are observed also in cases of posi- 
tive malignant lymphoma; the cause is unknown and cannot al- 
ways be attributed to the effect of injection treatment. 
4. The diagnosis of malignant lymphoma must depend upon 
histologic examination of an excised piece. 
5. The appearance of eosinophilous cells is perhaps of some 
diagnostic value; they are abundant in lymphoma and scarce in 
tuberculous adenitis. 
Mueller (97) describes one case, which according to his belief 
is another proof of the tuberculous nature of multiple lymphosar- 
coma, or pseudoleucemia. Up to this time the literature contains 
but three cases worthy of record. One case each by Askanazi, 
("Tuberkuldse Lymphome unter dem Bilde der febrilen Pseudo- 
leukamie verlaufend." Beitr. zur pathol. Anat. u. allgem. Pathol. 
Jena, 1888); Waetzoldt, ("Pseudoleukaemie oder chronische Mil- 
iartuberkulose?" Centr.-Bl. f. klin. Med. Nr. 45, 1890; and Cor- 
dua (Arbeiten aus dem pathol. Institut zu Goettingen, 1893.) 
These cases offered the pathologic-anatomic picture of lym- 
phosarcoma, the soft form predominating, with undoubted tuber- 
culous processes closely associated. Of especial interest in all 
three cases was the insignificant regressive tuberculous changes to 
the enormous enlargement of single glands. 
The dissertation is a very extensive and exhaustive work. 
CARCINOMA AND TUBERCULOSIS BY PROF. RIBBERT. 
Ribbert's (98) original article in 1894 on Carcinoma and Tu- 
berculosis deals in extenso with the entire subject. He begins his 
paper with the statement that carcinoma and tuberculosis do not 
often occupy the same part of the body at the same time, except 
on the skin. He closes with saying that it seems to him probable 
from known facts that tuberculosis in one region of a case can be 
the exciting cause of carcinoma, and which he has described as a 
subepithelial connective tissue proliferation originating the carci- 
noma. In other cases other inflammatory causes are responsible. 32 
This communication concerns Ribbert's (9S) ne;. cancer the- 
ory, in that it points to the combination of local tuberculosis with 
carcinoma as a not at all rare occurrence. In all cases Ribbert 
could demonstrate in beginning carcinomas actual tubercle nod- 
ules or at least giant cells, these cases exclude those described by 
him as connective tissue •''-oliferation. The giant c Ils were re- 
garded as evidence of local tuberculosis, as they neither showed 
the foreign body giant cells, around epithelia, nor could be set 
aside as another kind of giant cells, as Ribbert found in two cases 
of carcinoma of the eyelids, which occupied the glandular spaces 
and were probably caused by obstruction of the secretions. Bacilli 
as far as can be discovered, are not demonstrable in the giant cells. 
He could not determine with certainty whether in these eleven 
cases the tuberculosis or the carcinoma was primary. Ribbert in- 
clines to the former, because in two cases of benignant epithelial 
hyperplasia, tuberculosis was present at the same time in the con- 
nective tissue. In this circumstance of the priority, Ribbert per- 
ceives a further support of his theory of carcinoma, as it would 
thereby be made clear that the connective tissue through the 
tuberculosis must first become in an inflammatory condition, be- 
fore it proliferates into the epithelium, which is torn apart and 
thereby excited to malignant growth. 
SKIAGRAPHY IN TUBERCULOSIS. 
Tuberculous changes in bones and joints under the Roentgen 
rays (105) have excited much interest. The usual sharp contours 
of the bones are blurred and shadowy clouds mark the place of 
disease. The same appearance is caused by malignant or other 
growths. In primary osseous tuberculosis in the neighborhood 
of joints, skiagraphy can be of immense value, if the osseous 
disease can be thereby diagnosed and located before it has 
invaded the joint. After one such case skiagraphy should need 
no better argument to establish its claim to a place in every 
first-class surgical clinic and practice. 
PROGNOSIS. 
The last two years have added but little to our knowledge ex- 
cept that conservative treatment is even more firmly established 
by the clinical results and that the principles of prophylaxis 
are more generally observed. 
On May 1st, 1895, Cornet (99) read a paper, already referred 
to, before the Medical Society of Berlin on the prevention of tu- 
berculosis, which entirely corroborated his former work in this 33 
direction. "We must regard siputum and particularly dried sputum 
as the almost only cause for the spreading of lung tuberculosis." 
Whereupon Cornet reiterates his prophylactic demands; keep- 
ing moist and rendering inert the expectoration. Although little 
as yet has been conscientiously done in this direction, Cornet be- 
lieves that material results have been established. He recalls to 
mind the decided reduction of mortality from tuberculosis in the 
Prussian prisons, and estimates that as the result of careful treat- 
ment of sputa in Prussia between the years 1887 and 1893, that 
about 7,000 people less died from tuberculosis than would have 
been expected from the average of previous years. 
Plicque (100) thinks the influence of heredity in tuberculosis 
is greatly overestimated. The possibility of overcoming the ten- 
dency is not sufficiently considered, and children need not neces- 
sarily suffer the ills that have afflicted the parents. It is far more 
profitable to employ means to the improvement of the general 
health and to combat exposure and infection than to dwell on 
heredity. 
Squire (101) also thinks that children of tuberculous parents 
present nothing in particular; they are only weakly in a general 
way, and inclined to disease, taking and become infected by tuber- 
culosis so often, about 9 to 100 oftener than untainted, because 
they have the best chances of being infected by their own parents. 
Beck (102) in the Berlin Institute for Infectious Diseases has 
repeated the investigations of Ehrlich concerning the significance 
of Diaz-reaction in the urine, and is convinced that its prognostic 
value is very considerable. The appearance of Diaz-reaction ren- 
ders the prognosis unfavorable, and when it persists any length of 
time it indicates speedy death. 
Charles L. Greene, of Minnesota, has published a very 
complete article on "The Diagnostic Value of Ehrlich's Diazo 
Reaction," in the Journal of the American Medical Associa- 
tion, February 24th, p. 256, 1894. 
A peculiar mode of infection was discovered by Dewerre (103), 
who examined the swarms of bedbugs in a bed occupied by one 
brother after another who became tuberculous and found that 60 
per cent of the brutes contained numerous tubercle bacilli. The 
bacilli were found by the microscope, in cultures and by inocu- 
lation experiments. 
Smokers will be relieved to hear that the investigations of Ke- 
rez (104) at the Hygienic Institute of Zurich, concerning the ex- 
istence of tubercle bacilli in cigars, have resulted satisfactorily. 34 
That diseased workmen introduce tubercle bacilli to cigars, 
through the sputum, is beyond question; but these germs live at 
longest ten days and are all dead long before the cigars leave the 
drying room and are put upon the market. 
References to articles quoted are appended for those who 
may wish to consult the original writings. 
REFERENCES. 
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New Yorker Med. Mon. Schr. January, 1892. 
2. Ueber die Ausfiihrung der Guajakol-Jodoform-Injektionen bie tuberku- 
Ibsen Lokalerkrankungen, von Prof. Max Schuller. Sond.-Abdr. aus d. 
Ztschr. f. arztl. Landpraxis. IL, 7, 1893. 
3. Die antituberkulose Wirkung des Guajakol-Jodoforms, von Dr. Ferdi- 
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9a. Ueber die Bildungsweise der Reiskbrperschen in tuberkulbs erkrankten 
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75. Tuberculosis of the Esophagus, by Simon Flexner. Bull, of the Johns 
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76. Ueber seltenere Lokalisationen der Tuberkulose, von Dr. Eug. Fraen- 
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77. Ueber Nasentuberkulose, von Dr. Hans Koschier. Wien. klin. Wochn. 
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78. Seltener Verlauf eines tuberkulbsen Gaumengeschwurs, von Dr. 
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79. Quelques remarques sur la tuberculose pharyngee, par le Dr. Rosen- 
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80. Haug. Archiv. f. Ohrenhkde. XXXVI., 3, p. 177. 1894 und Sond. 
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81. Erkrankungen des Gehbrorgans bei Tuberkulose, Haug. Sond.-Abdr. 
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82. Guanowski. Mon.-Schr. f. Ohrenhkde, u. s. w. XXVIII., 12. 1894. 
83. Koch. Berl. Klin. Woch. XXX., 45, p. 1095. 1893. 
84. Cohnstadt. Mon.-Schr. f. Ohrenhkde, u. s. w., XXVI., 5. 1892. 
85. Kbrner. Mon.-Schr. f. Ohrenhkde, u. s. w. XXVIII., 9. 1894. 
86. Haug. Archiv. f. Ohrenhkde. XXXIII., 3 u. 4, p. 164. 1892. 
87. Knapp. Ztschr. f. Ohrenhkde. XXVI., 2 u. 3, p. 152. 1894. 
88. Ueber die Haufigkeit der Localtuberkulose des Auges, die Bezieh- 
ungen der Tuberkulose des Auges zur Tuberkulose der ubrigen-Organe, nebst 38 
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89. Ueber Contusionstuberkulose, von Dr. Gg. Becker in Grunstadt. Ver.- 
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90. Sur 1' origine hospitaliere de la phthisie pulmonaire, par Jaccoud. 
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91. Ueber die Beziehungen der Meningitis Tuberculosa zu Traumen des 
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92. Ein fall von Lungenschwindsucht, dessen Entstehung ursachlich mit 
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93. Trauma und Tuberkulose, von Dr. E. Schaffer in Darmstadt. Eben- 
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94. Zur Cauistik der traumatischen Knochentuberkulosen, Fiirbringer. 
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95. Ueber den Zusammenhang zwischen Trauma und Tuberkulose, von 
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96. Ueber die Beziehungen der malignen Lymphone zur Tuberkulose. 
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97. Ein Beitrag zur Aetiologie des Lympho-Sarcoms, von A. Muller. 
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98. Carcinom und Tuberkulose, von Prof. Ribbert in Zurich. Munch, 
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99. Die Prophylaxis der Tuberkulose und ihre Resultate, von Prof. G. 
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100. L' heredite dans la tuberculose, par le Dr. A. F. Plicque. Gaz. des 
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101. The Influence of Heredity in Phthisis, by J. Edward Squire. Med, 
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102. Ueber die prognostische Bedeutung der Diazreaktion bei Phthisikern. 
von Dr. Max Beck. Charite-Annalen. XIX., p. 583. 1894. 
103. Note sur la transmissiblite de la tuberculose par la punaise des lits. 
par le Dr. Dew&rre. Revue de Med. XII., 4, p. 291. 1892. 
104. Ueber den Einfluss des Tabaks auf den Tubercle-Bacillus, von Dr. 
H. Kerez. Centr. Bl. f. Bacteriol. u. Parasitenkde. XV., 2 u. 3. 1894. 
105. Ueber der Verwerthbarkeit Roentgen'scher Strahlen fur medicinisch- 
chirurgische Zwecke. Schmidt's Jahrbb. CCL., 11, p. 71. 
106. Zirmatzky, Revue de Chir., No. 8. 1896. 
107. Hadra, Semaine Med., Oct. 7, 1896. Addison's disease cured by 
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108. Oesterreich in the Ztsch. f. klin. Med., No. 2. Bulletin Med., Nov. 15, 
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109. Starck, Munch Med. Woch. 1896, 
110. Kriickmann, Virchow's Archiv. Bd. 138, p. 534. 
111. Beitrage zur Lehre von der menschlichen Tuberkulose; von Emil 
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CXXXIV, 2. p. 2479. 1893.) 39 
112. Ueber primare latente Tuberkulose der Rachenmandel hyperplasie; 
von Dr. F. Pluder und Dr. W. Fischer. Archiv. f. Laryngol, IV., p. 372. 1896. 
113. De 1'etiologie de la tuberculose des amygdales et de son traitement; 
par le Dr. Tussau. (Lyon med. XXVI. 16. p. 541. 1894. 
114. Pharynx und Gaumentonsille, primare Eingangspforten der Tuber- 
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Correction. 
Page 197 in article of October, 1895, the third paragraph from bottom of 
page concerning Wartmann's statistics is by Dott. S. Ercole (Rif. Med. IX. 
p. 249, 1893.) Contribute alia chirurgica della ossa e delle artculazione degli 
arti. 
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