fissure of Rolando. Motions of the face and tongue originate in the lower third of the area; motions of the arm in the middle third, and motions of the leg in the upper third. Spasms in a sin gle group of muscles, or paralysis of a single group of muscles, may indicate disease of its motor area. Extensive spasms or paralysis may indicate a large area of disease in this area, but if more marked in a single group of muscles than in others it may indicate a small focus of disease in the motor area of that group, affecting other motor areas indirectly and coincidently. Paralysis following spasm in one group of museles is a characteristic symptom of disease in the central region.

"Fifth. Disturbance of the power of speech indicates disease in the con

volutions about the fissure of Sylvius

on the left side in right-handed persons, on the right side in left-handed persons. If the patient can understand a question and can recall the words needed for a reply, but is unable to initiate the necessary motions involved in speaking, the disease is probably in the third frontal, convolution, and in the adjacent portion of the anterior central. If the patient cannot recognize spoken language, but can repeat words after another, or can use exclamations on being initiated, the disease is probably in the first temporal convolution. If the patient can understand and talk, but replaces a word desired by one that is unexpected, the disease is probably situated deep within the Sylvian fissure, or in the white substance of the brain, and involves the association fibres which join the convoIntion just named.

separate clearly lesions of the cortex from those of the various white tracts within the substance of the brain."

I would like to detail the surgical procedures of the operation for abscess or tumor, for they are similar, and detail some of the cases carried to a successful issue, but I have already attempted too much for the limits of a single paper.

PROGNOSIS IN PULMONARY TUBERCULOSIS.

A Paper read before the Mississippi Valley Medical Association, Fifteenth Annual Meeting, at Evansville, Ind,, September 10th, 1889.

BY W. C. CHAPMAN, M. D,,

Professor of Diseases of Throat and Nose and Physical Diagnosis, Northwestern Ohio Medical College, Toledo, ().

TWO questions are asked by every

patient: what is my disease, and can I be cured? Having answered the first, it is not so easy to satisfactorily answer the latter. Many factors combine to render this the most difficult of all the problems to be solved by the physician; and yet it is the one of greatest importance to the patient. On the answer given hangs his own destiny and that of those dependent upon him. Prognosis should be, therefore, the result of careful deliberation after exhaustive examination with a full appreciation of intervening possibilities which tend to modify results.

I shall devote this paper to a consideration of the question of prognosis with reference to pulmonary tuberculosis. I do this for the reason that during these latter years there has been much inquiry into the whole question of the etiology and treatment of this disease, and I fear many of us, especially the laity, are building false hopes when considering

look upon, were supposed to be a distinctive sign of developing phthisis. Conjoined with these characteristics is often seen the contracted thorax, the inwardly and forwardly rotated shoulders, and the stooping gate. In such cases the skin is excessively thin and the mucous membranes thin and easily destroyed, and susceptible to other pathological changes. Hemorrhages occur without apparent cause and frequently, and the nervous organism is very sensitive, in the female leading to hysteria, and in the male to irascib.lity. Such are the marks of inherited temperament, which will easily succumb to disease if exposed to specific cause. When patients present themselves for treatment with these peculiarities they do so because there has been made apparent to themselves or friends a lack of muscular power or nervous energy, with consequent loss of appetite and body weight. Possibly an irritating, hacking cough may be a pronounced source of discomfort. No expectoration nor night sweats nor diarrhea have added complications, but it is said as of old "there is fear that the patient is going into a decline, as did the father or mother before."

From neglected cases pictured above spring the numberless fatal results which the world deplores. The soil is preparing so that when the seed is sown, fruitful will the harvest be. In a paper read before the Ohio State Medical Society last year, I endeavored to show that a faulty method of respiration due to inherited or acquired peculiarities was the prime factor that allowed of the lodg ment and development of the tubercular germ. Prognosis at this stage I certainly believe is most favorable, if the patient is seen early and the directions of the advisor are carefully and fully

carried out. A large percentage of such may be prevented from passing into the worse condition I shall speak of hereafter, and I believe that a majority may be permanently cured.

Without taking your time to present my reasons for concluding that faulty respiration with consequent insufficient expansion of the lungs leads to stasis, and that this is the forerunner of coagulative necrosis, leading finally to caseation, I assert my belief that this condition is present in the greater number of those who are considered as suffering from incipient tuberculosis.

Granting that the views of a majority of clinicians and pathologists are correct in ascribing the development of phthisis to an implantation of the germs of certain micro-organisms, the only point which has been difficult of explanation is the accounting for the fact that, whilst it is known that such parasitical bodies abound almost everywhere, and that vast numbers of them are daily taken into the human organism in water, food and air, yet in the majority of instances they die and pass away, whilst in others they take root and flourish to full fruition. Future study will, in all probability, demonstrate that the diathesis briefly stated in this paper is the agency whereby is supplied the proper soil, in a condition to be appropriated, into which they implant themselves, and, as do all parasites, develop and multiply at the expense of the tissues, or of the food supply intended for the sustenance of those tissues. "So long as the tissues of a higher animal are healthy and well nourished, the common forms of septic bacteria cannot thrive in immediate contact with it. They can only exist in the intestines, etc., because they find accumulations of lifeless fluids which offer them

a suitable nidus. Active living tissues may be said to have antiseptic power, i. e., are able to destroy septic bacteria; and it is only owing to this bactericide power of our textures that we can, with immunity, breathe into our lungs the atmospheric air often crowded with these organisms, and swallow multitudes of them with our food. But for it every wound would become putrid, every breath might admit deadly germs to our blood." (Yeo, "Manual of Physiology," page 90.) Granting that this is always true in non-pathogenetic bacteria, is it not also true when the so-called pathogenous bacteria invade certain structures? It has been constantly claimed that the bacillus of tuberculosis can of itself, in healthy tissue, implant itself, and so generate disease. This assumed fact is here denied. No healthy lung tissue can be susceptible to the invasion of the organism unless previously there has been a local necrosis forming suitable environment for the life of the parasite. "Clinical experience would seem to indicate that the tubercle bacillus is no ordinary bacterium such as may enter and affect any organism without distinction. It would seem rather as if infection occurred only when a definite predisposition exists, or where a considerable quantity of virus is introduced. This predisposition may be local as well as general. The loca! predisposition may perhaps depend mainly on inflammatory change. Koch finds that the bacilli grow very slowly, and after inoculation proceed to develop and multiply only when they reach a spot where they are not subject to much mechanical disturbance or displacement. From this we may understand how it happens that many persons, though again and again exposed to the invasion

* * *

of tubercle bacilli, yet remain uninfected. It is, moreover, conceivable that individuals, in whose tissues inflammatory changes have already occurred, are those who are most disposed to tuberculous_infection.” (Ziegler, Text Book of Pathological Anatomy," pages 180-181.) It is, therefore, plain to be seen that, although the tubercle bacillus is classed as a pathogenetic bacterium, there must be a preparation necessary in the locality more commonly selected for the development before such development can occur. "All that is neces

sary is that the bacterium should reach a spot that affords the conditions for its development. If this occurs, it multiplies and forms colonies and swarms.” (Ziegler, page 289.)

In order that a favorable prognosis may be verified, what steps should be taken to sterilize or remove the soil which has been preparing for germ implantation? We come back now to the old, old treatment, and say everything must be in the way of nutrition. Koch's discovery or pathological study has revealed nothing new as relates to therapy. Nutrition must come as a physiological necessity; over-work, over-breathing and over-feeding must be avoided. By work is meant exercise, mental or physical, mountain climbing, walking and horseback riding-all good in their way, but easily overdone. Beefsteak and milk and oysters are nutritious when given in proper quantity and well prepared. Enough for one person may not be enough for another. Judgment must always dictate the sufficient quantity. To place enormous work upon an enervated lung is worse than dangerous; over-breathing easily results from a desire to be too radical and hasty. Take time for cure; be careful not to tire the

lungs. Mental activity and rest must assist nature in curing the patient. Surroundings must be pleasant; the consumptive's hospital must be ignored. Consultation between patients similarly affected must be interdicted. The in cipient tubercular patient is not as yet sick; your desire is to prevent him get ting so. A removal from home permanently does not as a rule assist to cure. I know the climatic treatment is considered favorable to, and even curative of, consumption. I believe more injury is done to the cases we have been considering, by the feeling of exile and the absence of home comforts and nursing, than can be offset by any so-called advantages of climate. If the patient's home is one of great discomfort and insalubriety, then a change may be necessary; otherwise occasional change of scene and atmosphere may be most potent for good. Daily expansion of lung, either within or without the pneumatic cabinet, conjoined with healthful food and exercise, will render a prognosis favorable in a majority of cases belonging to the class we have been considering.

In cases of the second class, where implantation and growth of the tubercular bacilli have taken place, and physical examination develops solidification in a portion of the lung, there is a much graver condition, in which the prognosis must be more unfavorable. A majority of cases will not recover, no matter what treatment may be instituted. After the discovery of the causative agent of the disease it was believed that remedies might be employed which would destroy it before destruction had resulted from its presence. All who have experimented clinically have been disappointed, and it is safe to say with Beaumetz that

we are reduced to alimentation and respiration of pure air in this disease.” Thus we have swung around the circle in attempts to use medicine or procedures supposed to be microbicide in action, coming back to pure air, freely inhaled, and proper nutritious food, so long the stand-byes of the profession. Gas, hot air, and chemicals, though found destructive to microscopic germs in the laboratory, clinically are worthless. We are, however, on a higher plane; experience has shown that all treatment must be followed persistently and judiciously under the eye of one who for the time must govern both mind and body of the patient, with the knowledge that healthcan only be secured by a return of vital force able to overcome and finally destroy the invading micro-organisms. We more intelligently pursue our treatment because we have arrived at a true causation; and whether the theory of the contending armies of the healthrestoring phagocytes and their pathogenetic enemies can be demonstrated. we know that as vital energy is restored so will a more favorable prognosis be possible.

Supposing a case comes in the last stages, when cavities have formed and degeneration of tissue has progressed to great extent, can any hope be offered that death may be averted? There is nothing more difficult to say to a patient than that there is no hope." Nor do I believe we are justified in giving up all hope even in these advanced cases, because many instances have been cited where the first knowledge that the person had ever been afflicted with consumption had been gained by the reve lation of an autopsy showing cicatrices the result of extensive destruction of lung tissue. Do not be effusive in en