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ular immobility causes deficiency of moral sentiment and consequent faint appreciation of right and wrong.
Quick molecular vibration in those centers causes increase of moral sentiment, and consequent appreciation of right and wrong. So the high-strung nervous persons suffer more from remorse than the phlegmatic or immobile. Crime in the former results from passion, in the latter from lack of moral tone.
INCIPIENT PULMONARY TUBERCULOSIS.*
BY G. W. PENN, M.D.
Tuberculosis, in some one of its varied forms, is responsible for more deaths than any other disease; indeed, one-seventh of the world's deaths are estimated to be due to the ravages of this king of scourges. It may well be called the arch-enemy of the human race. It is not for the purpose of adding anything original to our knowledge of the disease, but to lay stress upon some of the more vital points that I select this important subject for discussion. Tuberculosis may well be considered a common meeting ground for medical men, since every specialist in the ranks, as well as the general surgeon and practitioner of medicine, is brought in daily contact with it, making it a subject of intense interest.
I am convinced that too many physicians are not enough impressed with the fact that consumption, especially in its incipiency, is a curable disease, and not until we familiarize ourselves with the modern teachings of the natural history of the disease will we be in a position to successfully check its
Inestimable as are the benefits of modern bacteriologic research to scientific medicine, none contains the possibilities of as far-reaching utility as does the great work of Koch in re ference to tuberculosis. Two decades ago little more was k nown of tubercular processes than was known in the days *Read before West Tenn. Med. and Surg. Association, Jackson, May 25, 1899.
of Laennec. Heredity was thought to be the chief etiologic factor, and a man born of a consumptive parent was thought to be almost without hope. If he escaped the disease it was a matter of luck, or a good constitution; and while the latter factor is an important one, we know that a hygienic life in the broadest sense of the term, especially if passed in the high altitudes of Colorado or New Mexico, will prevent the development in a considerable per cent. of cases, and a vigorous course of open air and nutrient treatment will cure in almost as many more.
It is not always possible to get a bacteriologic examination, and if it were, the results in early cases are often negative, unless quite a number of examinations are made, but a careful consideration of the clinical picture will, in most instances, furnish sufficient working evidence, and at the first note of alarm the battle should commence, and it should not be desultory Spanish-guerrilla warfare, but a Dewey annihilation, for much depends on the early and rapid increase of vital resistance and improvement of impoverished blood, for by these means phagocytic action is materially augmented, and destruction of the invading army of bacilli accomplished.
Every case presenting symptoms of bronchitis or laryngitis should be most thoroughly examined, especially should there be evidence of depraved or impaired metabolism. Cases of "cold," with dry, hacking cough, dullness over apex, and weak or feeble respiratory murmur over corresponding area, or sometimes a harsh bronchial breathing, are symptoms in which the microscope will corroborate a diagnosis of tubercular disease in the majority of cases. Of course the physician may not be called until the case is much further advanced than the above, but even when there are small vomicæ and slight ulceration or destruction of lung tissue, it is possible, in many instances, for recovery to occur. I have seen complete recovery in no inconsiderable number of cases of clearcut phthisis, and I am sure that the best observers and clinicians of today corroborate this statement.
I believe there should be an organized, systematic effort, under the auspices of some body of physicians, such as the State Medical Society or the State Examining Board, for the
dissemination of knowledge relative to tubercular, as well as all other infectious diseases. It is well known to medical men that the ignorance of even the most enlightened laymen concerning things medical is alarming. Surgeon-General Sternberg, in his presidential address at the Denver meeting of the American Medical Association, suggested some very pertinent points along this line. It is obvious that such an effort would necessarily have to be by and of a committee or board of physicians under the surveillance of the representative organization of the State, so that the necessary instruction could be imparted to the public without bringing into prominence individual members of the profession, which would afford opportunity for personal advertising.
The march of progress of the healing art has been truly wonderful. The great flood of light thrown on the etiology of disease by the microscope, making simple problems of pathology and morbid anatomy hitherto shrouded in the misty halls of theory and speculation, and thereby furnishing rational basis for treatment, is a fitting medical capstone for a century remarkable for scientific advance in all lines. But, after all, the great mass of humanity are about as much interested in the question so intensely interesting to physicians as they are about the population of Sirius or deep sea geology. Hence the superstition and gullibility of the masses. It is no wonder that half the business of every drugstore is in patent nostrums and well-advertised cure-alls. But before there can be a successful warfare against consumption there must be coöperation of the people, who themselves are the fallow ground for the growth of pathogenic bacteria. And right here I wish to deprecate the lack of wisdom recently shown by our Legislature in lowering the standard of medical excellence required in Tennessee, and incidentally fostering charlatanism and quackery.
I know the fact that medicine, not being an exact science, is in a great measure responsible for the broadcast lack of faith shown by the community in the prophylactic and remedial agencies applied in a great many diseases, but without the support of an intelligent clientele the great task of attaining anything like an altruistic state of affairs medical will be only a dream.
Since tuberculosis is preeminently a wasting disease, characterized by ulceration or cell necrosis, the bacilli not exerting a toxemic effect on the central nervous system, as is the case with most diseases of microbic origin, it is evident that the reparative process will be best obtained by that line of treatment which most favors individual cell life. Darwin's law was never more true than of the struggle for supremacy between the bacillus tuberculosis and the pulmonary tissue cells.
There is no remedy which has a specific influence on the course of tubercular processes. Serum therapy, which has revolutionized the treatment of a few diseases, notably diphtheria, has so far given negative results, except in lupus exedens, and while it is almost certain in the near future to give us a panacea for this most relentless malady, we must at present rely on other remedies.
I believe the best results will be obtained by the establishment of sanatoria, as is being done in Germany, and, to some extent, in this country. Not only will this plan place in the most favorable position for cure those already infected, but as a preventive against the spread of the disease it is the best if not the only method at all practicable.
A radical change in public sentiment will be necessary, as suggested above, as well as legislative aid, before the isolation of phthisical patients in sanatoria can be carried out on a scale of sufficient magnitude to be of much real benefit, except to the few who avail themselves of the superior advantages to be had in these institutions. For instance, if intra-thoracic surgery is ever to revolutionize the treatment of diseases of the pleural cavity, as laparotomy has the peritoneum (which I very much doubt), it will be better done in hospitals than in private practice, for the following reason: The dangers of surgical pneumothorax are to a great extent unavoidable, and while the results of atelactasis of one lung are not by any means fatal, the resulting inertia of the unfilled lung, as suggested by Rodet and Pourrat, suppresses the stimulation which the sensory fibers receive from the air in the lung, and which they think necessary to the respiratory reflex, with, of course, an immediately fatal result.
It is true, as Dr. Rudolph Matas has so admirably pointed
out in the April Annals of Surgery, that the Fell-O'Dwyer apparatus for maintaining artificial respiration will greatly simplify operations on the chest, but, as Matas says, "Until the risk of seriously interfering with respiratory functions by inducing acute collapse of the lung is clearly eliminated, or is reduced to a safe minimum, its analogy between the pleura and peritoneum from the surgical point of view will never exist." This being true, we of the general practice, without the paraphernalia of the hospital, cannot hope to so successfully invade the pleural as we do the abdominal cavity.
I do not believe the good results obtained by Murphy by compression and bronchial drainage with nitrogen, and other operations, like those of Krause, Tuffier, Bazy and others, warrant a too sanguine expectation from the surgical treatment of pulmonary consumption. Judging from the amount of expectoration in these cases, it seems to me that one of the most important ends aimed at by these measures, drainage, is effectually done per vias naturales, and one of the benefits of residence in high altitudes is destroyed by compression, viz. : the increased exercise of the lung, brought about by respiration of rarified air. I know that physiologic rest is a basic principle in the treatment of inflammation, but the increased impetus given the pulmonic circulation by deep inspiration must surely oppose exudation and stasis, and by flushing the capillaries sweep out the products of infiltration and favor resolution. The benefits of oxygenation by any part of lung tissue still functionating are also obvious.
I would not for a moment place myself on record as opposing or denying the benefits of the great work of Dr. Murphy or others, but I cannot see in surgery the final solution of the question of the therapy of pulmonary consumption so fondly expressed by some, and which I believe will come to us in serum at no distant day.
We are now chiefly interested in means more readily available to the great majority of patients presenting themselves for treatment. I will briefly outline a course of treatment, which has proven of considerable value in my hands. There is nothing distinctive about it, and one of the leading thoughts I wish to impress is, persistency of treatment. First, the bene