to work at once and put them to the practical test of clinical experience. Patient and diligent inquiries into the family histories of many consumptives, induce the writer to make the following strong statement: "Only a small proportion of phthisical patients can be found who do not possess a family history which either demonstrates a directly inherited tendency, or a directly (Section 1 and 2) or indirectly (Section 3) acquired disposition toward the development of the disease." A most interesting and valuable contribution to this important subject is given in Dr. Brehmer's recent publication (Mittheilungen aus Dr. Brehmer's, Heilanstalt, Wiesbaden, 1889; p. 2, c. c.), investigating the previous history of those who visited his sanitarium in Goerbersdorf, during the year 1888, and the following is a short digest of it. Five hundred and fifty-six patients visited the sanitarium during 1888, 4 patients suffered from other diseases than phthisis, 46 patients failed to give a satisfactory history; of the remaining 506 cases as many as 184, or 360 per cent., were offsprings of consumptive parents or grandparents, viz.: 65 times from father's side, 76 from mother's side, 14 times from both parents, 16 times from the father's parents, 12 times from the mother's parents, and twice from the grandparents of both father and mother. These figures demonstrate that in many instances (16 per cent.) phthisis is developed in subjects whose parents were apparently healthy, but were the offspring of phthisical parentage. Of the remaining 322 cases, as many as 109 belonged to families with many children, none of them, however, being higher in the scale than the sixth, and 38 cases belonged to families where the mother had children rapidly, mostly in intervals of one year. This group of "acquired disposition" embraces 147 cases (29 per cent.), only 7 per cent. less than that of "inherited disposition." Of the whole number of 506 cases, 175 remained unaccounted for, but 153 of them have it in common that the patient's parents have been born under conditions described in Section 1, but have themselves escaped the development of phthisis to the date of writing; in 77 cases the indirectly acquired disposition was derived from the father, who was at least the sixth child in 63 instances, and who was born only one year after the preceding child in 17 instances. The mother was the source of acquisition 65 times (respectively 54 and 11 times). Finally, there were 11 cases where both parents belonged to subjects classified in Section 1. This leaves 22 cases out of 506, and of those 15 had it in common that either one of the patient's parents or grandparents was suffering from epilepsy or was insane. Seven cases out of 506 did not present any conditions which would indicate a disposition to the development of pulmonary consumption. The writer's own statistical notes do not -cover so much material, and he found considerable difficulty in obtain ing any reliable information about the patients' grandparents; but, generally speaking, Dr. Brehmer's researches have been verified by the writer's experience. With such proofs before us is it not our duty to teach those depending upon us for advice how offspring of healthy families are made to become predisposed to develop consumption, and that marriage of consumptives is to be strongly discouraged? It is important to know what can be done to protect those with an inherited or acquired unfavorable disposition from becoming victims of the tubercular bacilli, and it is unfortunate that this important subject has been seriously neglected by those otherwise interested in the field of preventive medicine. We know that not all offspring of healthy parents, with large families after the sixth child, become consumptives, nor do all those born in close intervals with the other children, nor even those of consumptive parents, die of tuberculosis. There are, however, certain functional and structural changes which, when found existing in young subjects, indicate serious danger of future tubercular infection. In line of their importance these deranged conditions of the human system are: 1. Those anatomical changes in the formation of the chest which help to present what is known as the phthisical habitus. 2. The fact that the subject is and always has been a small feeder. 3. The fact that, during the age of puberty, the patient has suffered from palpitation of the heart. 4. The fact that, at the same time, and frequently for years afterward, the patient has been suffering from epistaxis (nose bleeding). If these abnormal conditions, or part of them, are found in subjects whose family histories raise the sign of danger, it is necessary to use such means as will diminish the danger of future infection. Medication is of no value, but a transfer of the threatened subject to a proper climate will do much to prevent the future development of pulmonary consumption. The writer is thoroughly convinced that certain elevated regions enjoy comparative immunity from phthisis, and that a removal of those cases which warrant an unfavorable prognosis regarding the development of consumption to such parts, would save many lives. The establishment of a high school for both sexes at Davos Platz is a step in the right direction. The selection of a calling for such subjects deserves the most careful consideration, and the prospect of living an out-door life should have great weight in deciding the question. Many instances are known to the writer, where subjects who presented all the indications for becoming consumptives, are enjoying good health, living in certain. elevated regions and pursuing an out-door life. The time allowed for this paper prevents anything like a thorough discussion of this highly interesting subject, but it is to be hoped that these notes will help to arouse the interest of this Association in this vital branch of preventive medicine. PREDISPOSITION TO PULMONARY PHTHISIS, AND THE PROPHYLACTIC VALUE OF PULMONARY GYMNASTICS. BY GEORGE A. EVANS, M. D. Read before the Medical Society of the County of Kings, March 18th, 1890. It is the consentient opinion of those who have given the subject careful study, that pulmonary phthisis requires for its development two concurrent etiological influences-predisposition, and the tuberclebacillus neither of which in the absence of the other is competent to give rise to the disease. Certain animals have a natural predisposition for tuberculosis, while others are almost invulnerable to its influence. In man, however, we have not only various degrees of predisposition in different individuals, as determined by heredity, but we have also varying degrees of predisposition as determined by such circumstances. as may casually operate to influence constitutional vigor, or to modify that power of resistance to pathogenic principles normal lungs are known to possess. Rhindfleisch' calls attention to the remarkable similarity between the predisposition of "certain animals" for tuberculosis, and the occurrence of tuberculosis in a certain group of persons-the scrofulous. The result of inoculations made with bacillus-culture by Koch and many others, with the careful, systematic, and scientific manner in which they were carried out, has been generally accepted as proving the tubercle-bacillus to be the virus per se of tubercle, and therefore the exciting cause of pulmonary phthisis. If we regard predisposition as fertilization, and tubercle-bacilli as seed, we will fully appreciate the important relation of the former to the latter, and at the same time be led to inquire: Which of the two factors offers the greater degree of vulnerability to our armamentarium? I think it may be affirmed without fear of contradiction, that the tubercle-bacillus is an ubiquitous micro-organism. 1 Rhindfleisch, in Ziemssen's Cyclopædia, etc. 2 No one familiar with the subject would care to risk a contention with Hirsch when he says: "Like typhoid fever, phthisis dogs the steps of man wherever he may be found." Böllinger has shown that a cubic centimetre of phthisical sputum contains from 810,000 to 960,000 tubercle-bacilli. The average consumptive, therefore, expectorates between thirty and forty millions of these parasites in a day, eight hundred, however, are necessary to inoculate a rabbit or guinea pig with tuberculosis. Miguel, as quoted by Bell, Dennison and many others, found 55,000 germs, embracing many varieties, in the floating dust of ten cubic metres of the air of the rue de Rivoli, Paris. Careful observers have demonstrated that tubercle-bacilli enter the body not only through. the respiratory organs, which possess, as we have been informed, a superficial area of two thousand square feet, but even to a greater extent through the digestive tract, and recent investigations, notably those of Villemin, Weigert, and Ernst, have shown uncooked animal food, particularly cow's milk, to be a very frequent source of infec⚫tion. If we accept, therefore, as a settled fact that this micro-organism exists everywhere among the habitations of man, familiar as we are with its life-history, it must be admitted we have little reason to hope ever to be able to influence its career at large, although we may find it possible, through good management, to lessen the liability of individual cases of phthisis to inoculate others. Many efforts have been made to discover a bacillicide competent to destroy tubercle-bacilli in the lungs of the phthisical without injury to their tissue. These efforts have all been notoriously unsuccessful, and I am perfectly willing to put on record the statement, that no such bacillicide will ever be found; and, further, that if this contention is ever shown to be wrong, it will be of no advantage to the phthisical; for were it possible to destroy all the bacilli in a given consumptive's lungs, they would soon be replaced in his tissues from the atmosphere, which the investigations of Miguel, Cornet, Flick and others force us to believe, contains them in the form of floating dust. In a paper on "The Influence of the Microbe Theory on the Treatment of Phthisis," that was read before the New York Academy of Medicine, May 16, 1889, Dr. W. H. Thomson said: "He had never expected any specific treatment to be of permanent value in phthisis on account of the organic nature of the tubercle-bacillus. "He did not know of anything that the farmer could use that would kill weeds but not the potatoes in his field; and in like manner we 2 Handbook of Historical and Geographical Pathology. could not expect to find an agent that would kill the tubercle-bacillus in the body and yet not do injury." Looking at the matter from this standpoint, we are persuaded to abandon the contest and turn our attention to the remaining etiological factor-predisposition-to determine if it is possible to dissipate its co-operating influence for the production of phthisis, or so to modify its power where the disease already exists, as to render the local conditions unfavorable to bacillus cultivation. Koch's discovery of the tubercle-bacillus, in 1882, made an era in medical science. It proved the presence of this pathogenic organism in the sputa of consumptives, thereby giving us a valuable diagnostic sign, and at the same time pointed out the true etiological and pathological relation the parasite bears to pulmonary phthisis; and yet it remains to be shown that this important discovery has lessened the prevalence of the disease, lowered its mortality, or improved our ability to cope with it; and it is an open question to my mind if Koch's discovery has not operated, for a time at least, in a direction contrary to the best interests of the phthisical by securing for the one eltiological agent we cannot overcome so much attention as to lead almost to the forgetfulness of the other-predisposition, which clinical experience has shown to be amenable in a great measure to proper management. 3 Dr. I. H. Platt, writing on this subject, says: "I do not doubt the value of the light thrown upon the etiology and pathology of disease by bacteriology, but what I deprecate is the tendency to neglect as valueless the results of the painstaking investigations of years, because a new etiological factor is found which it is immediately assumed accounts for everything." Even Koch' was compelled to admit that "certain pathological changes are, if not necessary, at least highly favorable to the reception of the germ ;" and states in his consideration of the subject of predisposition, that "Although a good many of the phenomena classed under the head of 'predisposition' may be referred to simple and easily-explained conditions, some facts remain difficult. or impossible to interpret, compelling us for the present to accept the view of a varying liability." He speaks of the "undeniable predisposition to tuberculosis that exists in some families," and of a tendency to catarrhal affections of the air-passages and imperfect development of the thorax as constituting predisposition. Speaking of varying liability, he says: "Individual cases of the disease have often shown that a person is not at all times an equally favorable subject for the development of the parasites; for it not in 3 Brooklyn Medical Journal, October, 1888. 4 Investigations of Pathogenic Organisms. |