deterioration of the tissues in the system,
or some given organ or sets of organs by
which the natural cellular activities and
vital forces are more or less depressed.
*Rea(l before the North Carolina Medical Society, at
Tarboro, N. C, May, 1900.
THE CHARLOTTE MEDICAL JOURNAL.
573
3rd. The destructive action of the bacil-
lus of tuberculosis and the complicating
germs by their presence and their biologic
and chemic actions.
It stands to reason then, that with such a
complicated pathology as must result from
this combination of bases and causes, the
physician needs to study each tuberculous
patient closely to decipher the kind and
nature of involvement present , and to real-
ize the extent and sort of lesions existing.
In this field, and with the view of inducing
a conception for tiie proper kinds of reme-
dial measures in given cases of pulmonary
tuberculosis, the writer has carried on some
bacteriological investigations and made nu-
merous observations in the last ten years.
As this paper contemplates only the expla-
nation of mixed infections as a basis for
proper remedies, I will be brief.
In the first place, I divide my tuberculous
patients as to the origin of the disease into
two classes :
(a) Those born of tuberculous parents —
usually slow types with comparative low
fever. These present usually feeble, spare,
emaciated, bony, slim physiques.
(b) The purely accidental class, among
which we find a majority having had a more
or less robust constitution.
Then I sub-divide these into five classes,
to-wit :
(c) The cases in which the expectoration
is slight or almost nil, and in which the
secretion and excretion contains various
matters, chiefly mucus, some with grayish
pigment, varied germs, but no bacilli of
tuberculosis.
(d) The class in which the bacilli of tu-
berculosis are alone or are found prepon-
derate, and the other germs are in exceed-
ingly small numbers — harmless numbers, I
am tempted to say.
(e) Those in which both the bacilli of
tuberculosis and other infectious germs are
present in numbers to produce each or com-
bined some degree of toxemia and slight
fever.
(f) Those in which the harmful compli-
cating germs preponderate in quantity and
quality, usually attended with more or less
pronounced toxemia with characteristic
fever.
And then again another sub-division is
finally made from the nature of the lesions,
to-wit :
(g) The class known as miliary tuber-
culosis, in which the desseminated invasion
of one or more lung is more or less exten-
sive, by the bacilli, in a rapid manner and
with the formation of few or no tubercle.
(h) The class with congestion, with or
without hemorrhages.
(i) The class with cavities more or less
pronounced, producing, or failing to pro-
duce, hemoptysis by destruction of vessel
walls.
(j) The class known as fibrosis, which
mea'ns an effort of nature to heal lesions by
the formation of fibrous tissue.
By this method of division and sub-divi-
sions, based on historical facts, physical
examination, bacteriologic and microscopic
analyses, I come to conclusions upon which
guess work is eliminated in the application
of remedial measures, and the danger of
falling into the too common and often fatal
error of riding a hobby is removed. In-
deed, exclusive hobbies in the treatment of
such a complicated disease as pulmonary
tuberculosis are, at this stage of our expe-
rience and knowledge, so frequently a
crime that one is not justified in neglecting
any of the essential inquiries in each case
to gain the best data obtainable for a pro-
per and sufficient diagnostic judgment.
Failure in this respect results in more or
less guess work, and guess work is the
foundation of misleading and the exclusive
medical mania which sometimes end in des.
truction of life or loss of opportunities to
cure.
By systematic studies, as I have men-
tioned, I find, first, the need to consider the
history of each case, and the physical,
mental, digestive, and other factors; se-
cond, the need to consider the lesions apart
from the germs connected therewith ; third,
the need to consider, not only the bacillus
of tuberculosis, but every other kind of
germ, their special individual eflFects, and
the pathologic phenomena to which they
contribute in union with the bacillus of tu-
berculosis, or separately, or by virtue of
their proliferation in tissues in good health
or already diseased, or perhaps, by possi-
ble, if not probable, biologic evolution of
harmless and semi-harmless germs into viru-
lent factors under certain conditions, and
the chemic transformations or combinations
that may take place between the products
of various germs growing together.
In this paper, however, I must leave out
of consideration the lesions themselves,
although each of them demands most care-
ful notice at the hands of the practitioner.
A hemorrhagic centre from congestion, for
instance, needs a different treatment than a
hemorrhagic centre from the destruction of
a blood vessel by microbes. A consolida-
tion Dy infiltration needs different attention
from a consolidation from hemorrhage.
And both kinds of solidification must be
considered apart from a consolidation by
fibrosis. And in each of these varieties,
and all other varieties, besides the necessity
574
THE CHARLOTTE MEDICAL JOURHAL.
of deciphering and realizing the lesion or
lesions existing, we must decipher and real-
ize the kind of germs developing in con-
nection with them.
In cases of tubercular involvement prior
to the specific germs appearance into the
sputum, we are left to be guided chiefly by
physical data, though the expert find im-
portant deductions in various analytical
tests.
In pure tuberculosis the bacilli of tuber-
culosis predominate ; the other germs are
too few in number to be of immediate dan-
ger ; still, the possibility of their rapid de-
velopment under numerous circumstances
warn us to act on the defensive. In cases
where the complicating germs play an im-
portant factor, as in the classes E and F, the
physician need know of their presence and
influence and act accordingly. The chief
complicating germs which are usually found
in connection with tubercular infections of
the respiratory organs are : the staphylo-
cocci, the streptococci, the diplococci, the
tetrageni. The first three are known to
have, individually or collectively, more or
less deleterious effects, by their power to
soften tissues, poison the cells, intoxicate
the nervous system, and reduce the vital
powers of the blood, thereby aiding the ba-
cillus of tuberculosis in its destructive work.
The tetragenus is uncertain in its effects.
In some cases these germs, or some of them,
precede the appearance of the germs of tu-
berculosis, and possibly prepare the field
for the growth of the latter.
Besides these germs, one often meets with
numerous air germs of indefinite properties,
and not uncommonly the pneumonia bacil-
lus and the grippe bacillus, in both of which
instances we usually find lesions or witness
symptoms of pneumonia or grippe.
With this exposition of the basis upon
which the careful and conscientious physi-
cian should institute his treatments, I yield
to the essayist who will follow me, and sug-
gest remedies for the affliction in the pure
and complicated conditions ; in so doing
feeling that I might be debarred of sufficient
time to discuss treatments, I wish it dis-
tinctly understood that, after many years of
experimental and clinical work, I cannot
agree to any of the many exclusive thera-
peutic measures vaunted by their authors,
and feel justified in warning the practitioner
that it is as unwise for him, and dangerous
and unjust to tuberculous patients, to treat
them in a way to depend wholly on a spe-
cific remedy and neglect accessory means
which experience and science have demon-
strated as useful. I was first in experimen-
ting and suggesting and using serum for
tuberculosis in America, and first to intro-
duce serum from immunized horses in any
country. Yet considering the bacteriology
and pathology of the disease as above ex-
plained, I use antitubercle serum only in
such cases as experience has taught me its
merit, and they constitute a vast majority.
I neglect nothing else that might be useful,
such as inhalations, medicated air, ozone,
tracheal injections of antiseptics, climate,
dietetics, hydrotherapy, electricity, etc., etc.
I apply such measures as appear right after
taking cognizance in every case of the vari-
ous germs and lesions that play a part in
the phenomena of tuberculosis. In this
statement, which in a measure anticipates
the paper of my associate in the symposium,
I feel it incumbent to apologize to him for
intruding in his territory. As I said, my
excuse is that I may be unable to make the
statement in discussion.
Symposium on the Biology, Pathology and
Treatment of Tuberculosis.*
By C. V. Reynolds, M.D., Asheville, N.C.
I hesitated for some time before selecting
the above as my subject, but when we see
the cry for help depicted upon the pale,
anemic, forlorn and emaciated faces of the
poor, unfortunate tubercular patient, and
with the death rate ot i6 per cent, of
all humanity fast ebbing away by this
dreaded monster, can you wonder that the
pages of medical journals are filled with
thoughts and suggestions in their behalf,
with the hope of adding something to lesson
this alarming death rate?
It is a proven and unquestioned fact that
a systematic bacteriological report of exam-
inations of sputum is of paramount impor-
tance in the management of tuberculosis.
It would be an imposition upon you gentle-
men, and merely a waste of time, to des-
cribe the technique of examining sputa, but
will say the method of estimating the num-
ber of bacilli proposed by Nuttall, which
consists essentially in rendering sputum
fluid by adding a solution of caustic potash
and making several mounts and counts of
same specimen, thereby estimating number
expectorated in 24 hours, is of great value
in prognosis and treatment, but as it is the
nature of this bacillus to hug the connective
tissue surrounding the infected area, and
especially in the incipient stage, where there
is not much breaking down and pus, we
often fail in our examinations entirely;
then upon the second examination we may
find our field studded with pus cells, strep.,
*Read before the North Carolina Medical Society at
Tarboro, N, C, May, 1900.
THE CHARLOTTE MEDICAL JOURNAL.
575
staph. , dip. , and everything that would sug-
gest tuberculosis ; upon the third examina-
tion our efforts may be successful, and tu-
bercle bacilli will be found.
I agree with Nuttall as to the great im-
portance of the examination of sputum for
diagnosis, but with an experience of about
3,000 specimens examined, and noticing
how greatly the mounts from the same sam-
ple vary, and realizing how difficult it is
even when every other symptom indicates
improvement to cause complete disappear-
ance of the bacilli, for I hi.ve noticed bacilli
in abundance when there has been an in-
crease of respiratory expansion, diminished
infiltration, etc. After such an observation
I cannot attach as much importance as to
prognosis or treatment, but nothing is of
greater importance as a means of diagnosis.
Second to the above merely in diagnosis,
and first to give us knowledge as to our pa-
tient's improving or succumbing to this
disease, we get by a systematic examination
of the blood, which gives us the key where-
by we can see at a glance the constitutional
effects of our treatment. Dr. Holmes, of
Denver, speaks very highly of the examin-
ation of blood as a means of diagnosis in
the early stages of phthisis by means of the
degenerative changes within the leucocytes.
This I am not prepared to ratify or deny,
but merely bring it before you for discus-
sion.
Dr. M, L. Stevens, of Concord, who is
now in Asheville. has partially completed
a series of examinations of blood in tuber-
cular patients, and so far has reached the
following conclusions :
"A blood count only gives a small part
of the information needful in these cases.
Thorough examination of stained specimens
is also necessary. Degenerative changes in
the leucocytes are present in all cases of ad-
vanced tuberculosis.
Arrested or perverted development of red
cells is present in all advance,d cases.
The changes produced by treatment in
both red and white cells approach toward
the normal or retrogression therefrom con-
stitute our most reliable data on which to
base the ultimate prognosis of the case."
My observation has been that the blood
iv most of the cases, especially after the
incipient stage, and when there is some
mixed infection, is profoundly altered and
devitalized. Nearly all inflammatory and
infectious diseases are characterized, as you
know, by leucocytosis, phthisis being an
exception, there being a diminished amount
of leucocytes in quality, if not in number,
J. H. Burch, in a paper read before the
Syracuse Academy of Medicine, cites a very
interesting case in which the patient was
supposed to have had typhoid fever, but
failing to get a reaction from any of the
typhoid tests, a blood examination was
made, and there was found present red
blood corpuscles normal, leucocytes dimin-
ished, those predominant, being the large
uninuclear lymphocites, and now and then
a myelocyte. This suggested acute tuber-
culosis, which was confirmed several days
later when a specimen of sputum could be
obtained.
I have examined several cases of blood of
tubercular patients, and found as a rule red
blood corpuscles greatly diminished in num-
ber and in a degenerated condition, with
leucocytes, sometimes large, sometimes
small, there seeming to be in some no cell
wall, nuclei fragmented, and frequently
just an irregular mass of broken down
matter.
Upon the second or third examination, if
your patient is doing well upon your treat-
ment, you can see these blood cells take on
a healthy appearance, increase in number,
and witness with your patient the grand
results of your labor.
Not so in the examination of sputum.
Each month both you and your patient are
disappointed by finding your examination
unsatisfactory, which casts a gloom upon
him, and at least an interrogation point as
to your treatment.
Now, gentlemen, the leucocytes are na-
ture's army, and it is by their chicanery and
fortitude we expect to a great extent our
result in the treatment of this disease. So
it seems to me that in the future, if not in
past, we should watch closely after their
condition, and see, if possible, that nature's
"antitoxine" can't be kept at par.
Koch, since 1897, had extracted from tu-
bercle bacilli by allowing it to stand three
days with temperature of room, with i-io
normal soda solution, after which the fluid
was filtered, but the filtrate was never free
from bacilli, although dead, and when used,
periodical chills, fever and abscesses were
produced. To remove this objection this
precipitate was filtered through porcelain,
and the bacilli was found to be absent, and
no abscess was formed.
The use of this tuberculin upon the hu-
man being should give no ill effects in a
non-tubercular subject, but it has a selective
action, and localizes itself at the seat of in-
fection, producing a hyperemic congestion
which may cause resolution, or add kindling
to the fire causing it to flare up, and death re-
sult, which otherwise would have rested
quietly in its latent state. I think Dr.Paqain,
who has made experimental tests, will bear
me out in my assertion of the above state-
ment. As it is in cattle, so in man it may
576
THE CHARLOTTE MEDICAL JOURNAL.
be of great value in distinguishing a tuber-
cular from a non-tubercular subject, but
you kill the infected cow, and under the
same penalty, how would you like to be the
man? This tuberculin is the specific chem-
ical poison of the bacillus of tuberculosis,
and great Iionor should be to Koch for
his untiring energy and research in solving
this great mystery, and thereby adding so
much to medical science, but the use of a
toxine for diagnostic purposes, which may
cause a waking up of a slumbering disease,
which may result in death, is a question
indeed,
Koch, Fisch, Behring, for a long while
doubted as to which toxin was best to util-
ize in preparing the antitoxine from which
they might get best results, until proven
by Behring's researches that it was essen-
tially the same, whether old tuberculine,
T A, T O, T R, or any other modification,
were used, the practical difference being in
the degree of toxicity and the intensity of
the antitoxine.
Behring maintains the principle whicli
Paquin has held from the time he introduced
serotherapy in tuberculosis, merely that the
only way to immunize an animal or man
against tuberculosis is to use a tuberculin
containing all the active principles or poi-
sons found in the germ and its products in
cultures. As Maragliano and Paquin were
the first to introduce serotherapy in tuber-
culosis in the world, and as Behring is
master in that line of investigation, we are
warranted in adjudicating their position as
substantiated by science.
Say then an animal treated with tuber-
culine, from which an anti-tubercular serum
is secured, their serum acquires the property
of neutralizing the poison produced by the
toxin of the tubercle bacilli. Suppose this
to be the fact, and we have the toxin in the
system neutralized, a question naturally
arises, what destroys the bacillus itself? It
seems to me to simply destroy the toxic
effect of a poison and not get directly at the
manufacturer of the toxin itself, would
merely keep the trouble under control and
never eradicate the disease?
I cannot understand this unless it aids
us, and at last we are compelled to return
to our old friends — Nature's germicide, the
leucocyte, to destroy the intruding and un-
welcome visitor, the tubercle bacillus.
Inanition Fever of Infancy.
By R. C. Ellis, M. D., Shelby, N. C.
Ancient mythology teaches us that Pro-
metheus, the pon of Japetus, was the first
to make men out of clay and to bring fire
from heaven in a reed, and showed them
how to keep it wrapped in ashes. For this
offense Vulcan, by the order of Jupiter,
fastened him with iron nails to a rock, an
eagle being placed near him which gnawed
at his heart. In subsequent time, Hercules
pierced the eagle with arrows, and thus
liberated Prometheus.
The application of this fable to my sub-
ject is, that the fire from heaven represent
that spark of life which exhibits itself in
the new-born infant. Keeping it wrapped
in ashes, is the efforts we may put forth to
retain its vitality. Fastened by nails to a
rock, indicates the complete helplessness of
the little one. The eagle gnawing at its
heart, hunger — that distressing craving and
unfulfilled demand of Nature, dreaded by
man and beast, and evoking the sympathy
of the civilized world. Ample provisions
are made all over our land for the imbecile,
the pauper, the maniac, in the way of
homes and asylums of different kinds, that
none of their inmates may feel the pangs of
hunger. Will not mercy and medical
science raise their hands in horror at the
sight of a little sinless being, fallen a victim
to that dread monster, starvation, with no
one to rescue and no one to save ? A weep-
ing mother, still feeble from the shock and
agonies of parturition, sees, perhaps, her
first-boin withering away hour by hour like
a tender plant beneath the rays of a tropical
sun, and she looks to no other source for
aid than the family physician ; and should
he not bestir himself, and awake his powers
with the energy of a Hercules, and give
this subject his inost profound . thought,
study and attention !
By the term inanition fever, it is my pur-
pose to express as well as emphasize a very
close connection which exists between the
rise of temperature and the condition of
inanition or starvation in the new-born.
In the above heading are included cases
seen during the first five days of life —
usually from the second to the fourth day —
in which there is an elevation of tempera-
ture seemingly due to the fact that the in-
fant obtains very little, ofttimes nothing,
from the breast at which it is nursed. An-
other characteristic of these cases is a sud-
den decline in the temperature when milk
is secreted in abundance, the infant put
upon a full breast, artificial feeding is be-
gun, or even water is given freely. A
failure to observe these precautions at the
proper time, has doubtless contributed much
to increase the table of infant mortality,
*Read before the North Cai-olina Medical Society at
Tarboro, N. C, May, 1900.
THE CHARLOTTE MEDICAL JOURNAL,
hence my reason for selecting this seeming-
ly trivial but important subject.
It is to be greatly regretted that so little
literature has been published by writers on
pedriatric medicines concerning the subject
of this paper, but future authors will no
doubt continue their investigations and thus
give to the world such information as ith
importance demands.
From a careful study of the literature it
seems that Dr. McLean, of New York,
(1S90) was the first to call the attention of
the profession to this condition, he having
reported to one of the medical societies an
extraordinary hyperpyrexia in the new-born
child. The infant w\s found on the sixth
day with a temperature of 106 deg. F., near
which point it remained for three davs.
The breast from which it nursed being ab-
solutely dry. A wet-nurse was procured,
the temperature fell to normal in a few
hours, and the child, which, when first seen
was apparently in a hopeless condition, was
soon perfectly well.
Holt relates the following typical case of
the more severe form : The patient was the
second child, the first having died at the
age of ten days, from no disease, it was
said, but simply from exhaustion. At birth
the infant, a boy, weighed S^ pounds, and
was apparently vigorous. During the first
forty-eight hours his loss in weight was 5^
ounces and his condition good. Was seen
on the evening of the third day. In the
preceding twenty-four hours he had lost
eight ounces in weight, and the tempera-
ture had gradually risen until at the time of
my visit it was 102. 5-10 deg. F. The body
was limp, the child making no resistance to
examination. He cried with a feeble whine,
the restlessness of the early part of the day
having given place to complete apathy.
The lips and skin were very dry, the fon-
tanel sunken, the pulse weak. As the
father, a physician, expressed it, "he had
been wilting through the day like a flower
in the sun." Although put to the breast
regularly the child had gotten very little.
It was, in fact, impossible to squeeze milk
from the mother's breast. Water was given
freely and a wet-nurse secured in a few
hours. The first milk was taken from the
wet-nurse at 11 p. m., and the temperature,
which fell gradually during the night, was
normal the next morning and did not rise
again. During the succeeding four days
the child gained eighteen ounces in weight,
and at the end of a week was as well as an
average infant of his age,
The uniformity of symptoms and charac-
teristic features of these cases of fever en-
title them to a class of themselves. Pyo-
genic infection, which rarely begins before
the sixth day, can hardly be confounded
with this fever. In the treatment of these
cases, water should be given regularly in
quantities from a half to one ounce every
tw-o hours if required by the thirst of the
child, This should be done in every case
where the temperature reaches loi deg. F.
Where the temperature does not begin to
fall at once, the infant should be placed
upon another breast, or artificial feeding
promptly resorted to. The breast from
which the child has been nursing will, on
examination, usually reveal the fact that
the secretion of milk is very scanty and
often entirely absent.
In conclusion I will say, that very much
to my regret, owing to the hurried prepar-
ation of this paper, while 1, perhaps, have
not edified those to whom it has been read,
I shall feel deeply grateful for the task, if I
have succeeded in calling the attention to,
and eliciting the interest of so learned a
body of physicians as compose the North
Carolina Medical Society in a subject, the
management of which, to some extent, af-
fects the population of our great Common-