CHAPTER V.

EVIDENCE SHOWING THE COMMUNICABILITY OF CONSUMPTION.

THE evidence on which this grave issue hangs is chiefly twofold-first, experimental evidence; second, a record of cases taken from the practice, both public and private, of trustworthy observers.

With regard to experimental evidence, it is completely given by Koch himself in the paper to which reference has already so frequently been made. The résumé of it in Chapter II. is, I hope, sufficient to give a clear idea of this part of the evidence. With the exception of Dr. Cornet, not one of the many workers who have followed the teaching of Koch on tuberculosis has, so far as I know, added any very important fact to his discoveries. Their work, it is hardly necessary to say, is most valuable, because it has all helped materially to strengthen Koch's results by confirming them.

And now, as to the records of published cases, which bear with considerable weight upon the subject. The following case is recorded in the Annales de Dermatologie et de Syphiligraphie, vol. v., 1884, pp. 362, 363, 364. A man seventy years old, with neither personal nor hereditary tendency to tubercle, had a whitlow on his left thumb. The abscess was opened with a bistoury. Later on, ulceration set in

a little above the left wrist, on its radial side. The ulceration measured 11 centimètres in length, and 1 to 4 centimètres in breadth. M. Hanot detected the tubercle bacillus in pus taken from the ulceration. One year later this man showed signs of pulmonary tubercle. He died, and post-mortem examination showed the presence of tubercle in his lungs. The axillary glands were sound. It is surely not unreasonable to suppose that this man's whitlow was either itself the result of tuberculous inoculation, or was opened by a knife which carried that infection. It seems also reasonable to believe, that his lung tubercle was caused by infection from the site of the whitlow.

In vol. vi. of the same Annales, p. 668, Dr. Tscherning, of Copenhagen, reports the case of a woman, twenty-four years old, in good health, robust, without hereditary predisposition to tubercle, and showing no evidence of herself having tubercular disease, who was cook in the house of Professor H. He died in 1884 of pulmonary consumption, which had lasted about six months. During the last days of his illness, his expectoration was a

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pure cultivation of tubercle bacilli." A few days before his death, the glass vessel into which he used to spit was broken, and this woman pricked her finger with one of the fragments. Fourteen days afterwards, she consulted Dr. Tscherning, for the first time. She then showed symptoms of whitlow of the injured finger. finger. Carbolic acid applications relieved her symptoms. Eight days afterwards there was no trace of suppuration, but there was felt, in the subcutaneous cellular tissue, a little hard lump

about the size of a pea. It was painful, and surrounded with a zone of oedema. About one month afterwards, Dr. Tscherning cut out this nodule, and found it composed of granulation tissue. It lay between the skin and the tendon. The wound rapidly healed, under a dressing of iodoform and perchloride of mercury. A little more than a month later, the patient again presented herself with a considerable swelling affecting the same finger, but now encroaching upon the palm of her hand, and interfering with the movements of flexion. The disease got worse. About ten weeks after the first operation, through the oedematous skin, a thickening in the sheath of the tendon could be easily felt. At this time two swollen glands in the forearm, and two others in the axilla, were noticed. In other respects the woman was in perfect health, and the lungs were sound. About eleven weeks after the incision of the nodule, Prof. Studsgaard cut out the axillary and forearm glands, and removed the finger at the metacarpo-phalangeal articulation. At the same time, through an incision in the palm of the hand, Prof. Studsgaard removed, up to that joint, the tendon and its sheath. He also scraped away all subcutaneous granulations. eleven days the wounds healed completely, beneath an antiseptic dressing. Under the microscope, the diseased tissues were found studded with typical tubercles, that is to say, tubercles with caseous centres, and giant cells. In these giant cells, and around the caseous material, and more frequently in isolated positions, tubercle bacilli were found, and they were also present in the swollen glands. The

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patient was in good health when seen about two months after the operation.

Dr. Karg, in the Centralblatt für Chirurgie, August 8, 1885, records the following case:

A hospital dead-room porter, aged thirty-eight, had followed that employment during six years, and was often occupied in opening dead bodies. He was married, the father of two healthy children, and had no symptom of tubercular disease. For several years he had had upon his left thumb, close to the metacarpo-phalangeal articulation, a nodule which, treated in various ways, sometimes was enlarged, sometimes diminished in size, but never disappeared altogether. One day this nodule began to swell. It became red and painful, and a little later some small nodules were noticed in the forearm. When Dr. Karg saw the patient, there were five abscesses upon the forearm, in the course of the lymphatics running from the thumb. The largest of these abscesses was about as big as a cherry. In front of the elbow were two hard nodules, about the size of peas, moving freely under the skin. In the axilla, was a single, swollen, but painless gland. Dr. Karg, suspecting that the case was one of tubercular disease, laid open the abscesses, and removed all the diseased tissues. Under the microscope, sections of the nodules, of the sides of the abscesses, and of the swollen lymphatic glands, were seen to contain tubercle bacilli.

Dr. Axel Holst, of the Christiania Hospital, relates a case, in the Semaine Médicale, of a hospital nurse who, while attending consumptive patients, had pain and swelling of the right thumb, which opened of itself, and resulted in a sore which refused

to heal. Similar symptoms showed themselves in the right index, and left ring fingers. Later, a glandular swelling was noticed in the right axilla. The open sores were scraped before Dr. Holst saw the case, and, therefore, he did not there search for tubercle bacilli; but in the axillary glands, which were excised, he found that organism in large numbers.

Dr. Paul Raymond, in the France Médicale, 1886, Nos. 99, 100, and 101, reports certain cases, of which the following is one :-A man, aged sixty-two years, without any symptoms of tubercular disease, but whose two sisters and wife died of tubercle, pricked himself with a thorn. At that time this man slept with his consumptive wife, who died three weeks afterwards. He cleaned out the vessels she used as spittoons, and rubbed with his hands the handkerchiefs into which she used to spit, in order not to send them in quite such a soiled state to the laundry. After fifteen days the little sore made by the prick of the thorn, began to get larger, and, four weeks later, little abscesses formed around the ulceration and opened into it. When he was admitted to the hospital, the sore was of the size of a five-franc piece. There were two enlarged and slightly painful glands over the inner condyle of the humerus. The lungs were sound. The sore healed after having been scraped, and under an antiseptic dressing. In three preparations made from the diseased tissues, tubercle bacilli were found.

In the France Médicale, of July 1887, Dr. Cartaz relates that he has collected seventeen cases from various authors, besides a case of his own, in which