tissues were found thickened; the articulating cartilages were intact in a few joints, but in most showed small erosions, and there was an acute osteomyelitis at the head of the left tibia. The author reviews the literature of the subject, and discusses the etiology, pathology (showing that it is distinct from tuberculosis), symptoms, diagnosis, and treatment. For the internal treatment, sodium salicylate, arsenic, tincture of iodin, colchicum, and antipyrin are recommended; for the external treatment, baths, electricity, massage, and salicylic ointments may be used.

F. E. Batten, in studying the relationship between rheumatism and chorea, followed up 115 cases of chorea seen in hospital practice, and found that after 5 years, without rheumatism previous to the chorea, 20% developed rheumatism.

I. M. Snow 2 believes that some cases of cholera infantum are rather cases of heat-stroke, and reports 2 cases at 6 and 7 months, one recovering after a temperature of 107.6° F.; the other having a constantly recurring hyperpyrexia, which resulted fatally.

3

Firbas reports on 300 cases of goiter in children, most of whom were girls; the enlargement of the gland present at birth lessened on a milk-diet, but returned to its original size when a mixed diet was begun. Raw thyroids and tablets or powders of desiccated glands were given once or twice weekly to 27 cases, and a reduction in the size of the goiter was obtained, without any intoxication-symptoms; the raw gland gave the best results.

5

4

E. Shields reports the case of a girl developing normally until 10 months of age, when an attack of acute thyroiditis occurred, without suppuration, lasting one week, and being followed by atrophy of the gland; growth then ceased, and the child, now 7 years old, is a typical cretin. J. Comby reports an interesting case of congenital myxedema in a female infant, 16 months old; at this age, the child was about as large as a normal child at birth, could neither walk nor talk, had coarse hair, a large tongue, and ventral hernia; constipation and subnormal temperature were also present. In spite of the administration of thyroiodin, the condition grew worse, asphyxia from spasm of the glottis necessitated tracheotomy, and death followed, the autopsy revealing complete absence of both thyroid and thymus glands.

E. Schlesinger contributes a comprehensive article on the changes in the thymus gland in hereditary syphilis; the lesions found are a diffuse interstitial inflammation, gumma, large hemorrhages, and the socalled abscess. The interstitial form can only be recognized microscopically, and is therefore often overlooked; the abscess is not a true abscess, but a necrotic change in the concentric bodies; 24 cases are tabulated, and references given to 9 more. The article is a valuable addition to the pathology of the thymus gland.

Gillespie of Edinburgh has used with much success in children presenting enlargement of the thyroid and tachycardia, with or without exophthalmos, 10 gr. of the iodid and 5 gr. of the bromid of strontium,

1 Lancet, Nov. 5, 1898.

3 Jahrb. f. Kinderh., Band 41.

5 Arch. de Méd. des Enfants, vol. i., No. 9.

6 Arch. f. Kinderh., Band 26, Hefte 3 u. 4.

7 Rev. mens. des Mal. de l'Enfance, July, 1899.

2 Arch. of Pediatrics, Oct., 1898.

N. Y. Med. Jour., Oct. 1, 1898.

3 times a day, without producing symptoms of iodism or bromism, but with a disappearance of the rapid pulse, goiter, protrusion of eyeballs, and dyspnea.

1

C. W. Townsend reports 5 cases of diabetes mellitus in children under 10 years of age, all of which terminated fatally.

A. Roth reports a case of progressive multiple ossifying myositis in a girl, 4 years old; the muscles were firmly contracted and the seat of numerous bony deposits, which had some connection with the skeleton; and their formation is attributed to increased activity of the periosteum. In 1 section only were marked changes seen in the intermuscular connective tissue, the process, as a rule, not being a true inflammation, the term myositis, therefore, being somewhat inappropriate. The prognosis as regards life is good, the internal organs being undisturbed. Treatment has accomplished nothing; but it is suggested that a diet with a deficiency of the bone-forming salts, such as calcium, magnesium, and the phosphates, might lead to an absorption of the salts in the depos its, and so improve the condition. Morian3 reports a case in a boy, 4} years old, with a history of pneumonia, dropsy, measles, and traumatism; the great toes were relatively small congenitally, this curious condition having been observed in 69% of all cases of myositis ossificans examined with reference to it. A case is also reported in a boy, 6 years old, by R. Crawfurd and H. Lockwood.*

Lead-poisoning in a child, 4 weeks old, is reported by F. W. M. Stephenson, the origin being the accidental dusting of the neck with powdered white lead; the diagnosis was based on the etiology and the presence of a blue line on the gums, and colic.

Lancereaux reports a case of akromegaly in a child of 12 years; much improvement followed the administration of hypophysin.

Boston M. and S. Jour., May 11, 1899.

* Ibid., Feb. 19, 1899.

5 Ibid., Dec. 6, 1898.

? Münch. med. Woch., Sept. 27, 1898.

Lancet, Apr. 15, 1899.

Sem. Méd., Nov. 23, 1898.

PATHOLOGY.

BY DAVID RIESMAN, M. D.,

OF PHILADELPHIA.

BACTERIOLOGY.

TUBERCULOSIS.

The Hereditary Transmission of Tuberculosis.-G. Hauser1 has made a careful study of the literature bearing on this question, reviewing critically: (1) The cases of tuberculosis in the newborn and in fetuses; (2) cases of tuberculosis in calves and fetal calves from tuberculous cows; (3) the studies on the occurrence of tubercle-bacilli in the testicle and semen of men, and (4) of oxen; (5) the studies on the occurrence of tubercle-bacilli in human and animal ovaries; (6) experimental tuberculosis in animal fetuses, (a) in cases of tuberculosis in the mother, (b) in cases of testicular tuberculosis of the male; (7) the experimental studies on the offspring concerning the transmission of tuberculosis. After judiciously sifting the material, he concludes as follows: 1. There is undoubtedly an hereditary transmission of tuberculosis, both in man and animals, on the part of the mother, the transmission occurring through the placental circulation. 2. Not a single indubitable case of transmission of tuberclebacilli through the father is recorded, albeit it is demonstrated that in grave general tuberculosis bacilli are often excreted with the semen. 3. In the cases of congenital or hereditary transmitted human and animal tuberculosis, the mother suffered almost without exception from the most severe and generally fatal tuberculosis, just as up to the present bacilli have been found in the semen only in case of extensive general tuberculosis or tuberculous disease of the testicle. 4. The hereditary transmission through the mother seems, in grave general tuberculosis (miliary tuberculosis excepted), to occur only in about 10% of the offspring.

The facts just cited cannot explain the heredity of tuberculosis. The bacillary heredity exclusively through the mother is in strong contrast with the undoubted fact that a tuberculous father entails upon the offspring the same liability to tuberculosis as a tuberculous mother. Furthermore, bacillary heredity involves usually the liver and the portal lymphglands, organs which are rarely primary seats of tuberculosis. Studies in the heredity of tuberculosis should be made on those cases in which the disease in the parents is limited; for it is well known that the descendants may suffer from severe tuberculosis when that of the parents was mild; indeed, the disease may apparently skip a generation. Hauser made a series of experiments of his own, using first rabbits, and later guineapigs, in which he produced a localized tuberculous lesion. Not a single 1 Deutsch. Arch. f. klin. Med., Band 61, Hefte 3 u. 4; Univ. Med. Mag., 1898.

positive result was obtained; i. e., none of the offspring of the infected animals was born tuberculous ; the young animals developed naturally, as did also the second generation. From all of the foregoing, the conclusion is drawn that the theory of bacillary heredity of tuberculosis lacks all foundation, and cannot explain the family tendency to the disease, which the author admits. How is this tendency to be explained? It is due to a predisposition, a sort of idiosyncrasy, comparable to other idiosyncrasies that run in families-as those to certain drugs, to certain articles of food, etc. Tuberculosis is maintained, then, not through congenital transmission of the specific virus, but always through renewed infection with bacilli from the environment; this infection is facilitated by the existence of a specific individual susceptibility to the virus of the disease.

The Seat and the Development of Primary Pulmonary Tuberculosis.-Birch-Hirschfeld presents an epoch-making contribution to the pathology of pulmonary tuberculosis. After a brief review of the historic development of the subject, he postulates his opinion regarding the primary development of the disease in the sentence: "Pulmonary tuberculosis in its first stage is, as a rule, a mucous-membrane tuberculosis located in a medium-sized apical bronchus." In proof of this theorem many data are given. The anatomy of the bronchial tree is first discussed, as the thought suggested itself that the preference of the tuberculous infection for the bronchi of the apices might be based upon anatomic grounds. Birch-Hirschfeld succeeded in making some very beautiful bronchial casts, and adopts a new scheme of classifying the bronchi, which it is not necessary to reproduce here. The primary lesions are found especially in the branches of the third to the fifth

order.

The Pathologic Anatomy of Primary Bronchial Tuberculosis. In 3067 autopsies, 41.86% presented tuberculous lung-lesions ; in 11.97% the lesions were cicatrized. Of 826 cases of sudden death from acute disease or accident, tuberculous lesions were found in 171. In 105 of these the lesions were fibrous; in 31 a rather extensive pulmonary tuberculosis, and in 35 beginning tuberculous foci were found. The primary bronchial focus may readily be overlooked. It is often fairly large (the size of a hazelnut), but is situated beneath the surface. The deep situation is explained on the ground that the medium-sized bronchus is the seat of the first changes. The bronchial lesions primarily cause no change on the surface of the lung; the visceral pleura remains smooth and without adhesions. In this stage, the incipient phthisis may readily be overlooked. The discovery of these lesions succeeds best when one forms the habit of palpating the lung in all its parts before incising it. If in this way a circumscribed firm area is found, the attempt should be made to introduce the director into the afferent branch, and to incise this afterward. With this method of examination, 32 cases of beginning tuberculosis were studied. Of these, 28 were alike in having the tuberculous lesion in the wall of a medium-sized bronchus. In a few cases this was the only lesion. More frequently new tuberculous foci had formed; but these left no doubt that the bronchial focus was the primary one. As against these 28 cases of initial bronchial tuberculosis, the author found only 3 in which the primary lesions seemed to have been an interstitial

Lancet, Oct. 1, 1898.

development of miliary tubercles. The possibility of a primary hematogenic tuberculosis must be admitted; but it is certainly rare. In view of the generally accepted doctrine concerning the beginning of pulmonary phthisis in the form of a caseous bronchial pneumonia, it is interesting to know that the author in no instance was able to demonstrate such a beginning. Numerous cases are cited proving his contention. A few words are said concerning the initial hemoptysis of pulmonary tuberculosis. It can, of course, no longer be maintained that the initial hemorrhage is the cause of phthisis (the phthisis ab hæmoptysi of the old writers); but its true origin has not been satisfactorily explained. BirchHirschfeld' attributes it to the rupture of venous branches in the wall of a bronchus or in the peribronchial tissue. This hemorrhage is much more benign than that occurring during the course of phthisis. That a hemorrhage may favor the extension of a tuberculous process cannot be doubted. It probably does so by carrying infectious material to parts of the lung previously healthy. But even when the hemorrhage occurs from a latent tuberculous focus in the bronchus, a favorable termination of the tuberculosis is possible. When once the tuberculous focus has broken down and communication is established with the air-passages, the opportunity for the dissemination of tuberculous material is given, and secondary tuberculous bronchopneumonias are apt to result. In this way a latent pulmonary tuberculosis is transformed into a manifest phthisis. It is a fact that even somewhat extensive apical foci may be arrested. This is generally brought about by obliteration of the affected bronchus and the fibrous transformation of the diseased area beyond. A similar favorable course may be taken by that form of primary tuberculosis having its beginning in the interstitial tissue. The residues of this form present themselves generally as anthracotic Schwielen, with caseous or calcified nuclei, which frequently are subpleural, cause puckering of the surface of the lung, and bear no relation to the bronchi.

The Pathogenesis of Primary Bronchial Tuberculosis.— Two points should be considered: the disposition of the apices to primary tuberculosis, and the perforation of the tuberculous lesion into the bronchial lumen. Regarding the seat of latent bronchial tuberculosis, Birch-Hirschfeld found that in 34 cases the right upper lobe was involved 24 times, the tuberculous focus being situated 22 times in the apical bronchus and only twice in the lower part of the upper lobe. Of 21 lesions situated high up in the lobe, 12 affected the apex itself, and 10 were situated from 5 to 7 cm. below the apex proper. It is noteworthy that both the apical and the subapical nodules seemed to prefer the posterior half of the lobe. It appears from this that the bronchial tree in the posterior part of the lung-apex constitutes a favorable soil for the deposition of inhaled tubercle-bacilli. In 15 cases the left upper lobe was affected, all the areas being situated in the apical territory of the bronchus. It is scarcely proper, from these small figures, to draw any conclusion as to whether the left or the right lobe is the more often affected, although they bear out Laennec's assertion that the right lobe is the preferential seat. More important than this point is the question why the apices are so much more frequently affected than other parts of the lung. This has been the problem since the days of Laennec and Louis.

Deutsch. Arch. f. klin. Med., Band 64.