the healthy tissues have thrown around the colony a wall of protective granulation tissue. Nevertheless this cordon is constantly invaded and destroyed by the bacilli within.

If now the bone is examined the whole epiphysis will be found rarified, more vascular and more fatty than before. The focus itself will be soft detritis, surrounded by granulation tissue, with perhaps a grain of dead bone at the centre. This little piece of bone was destroyed when the embolus occurred. The rest of the bone, which originally filled the focus, was taken up by the protective inflammation in advance of the destructive invasion of the bacilli. This focus is usually circular, reaches the articular cartilages only after a long time (Fig. 2. F2 F2), and is called a granulation focus.

2

When the embolus occurs in a large terminal arteriole a large mass of bone quickly undergoes infarct necrosis, and then becomes surrounded by tuberculous granulations. It has the conical form of an infarct, with the base of the cone on the articular cartilage. (Fig. 2. F1). In time the cartilage is perforated and the tuberculous detritis is forced into the joint, producing a secondary synovial tuberculosis. The same thing happens in a neglected granulation focus. It takes several weeks or months for a focus to break through the articular cartilage. The cartilage dies en masse. It becomes yellowish white, instead of bluish white. The perforation occurs at a point between the dead and the live cartilage by a process of vascularization.

HISTORY.

Tuberculosis of knee of unknown etiology. Slowgrowing osteal foci. Immobilization for five years. Evidement of three tuberculous foci. Absolute recovery and restoration of function of joint in one year. Complete flexion and extension of joint with no deformity of bones found in radiograph after fifteen years of unconscious use.

Our patient, Miss H., was an echomomic pen and ink artist, sixteen years old, when her trouble began. For several months she had such pain in her knee that she could not sleep at night. She continued to She continued to walk on it, however, and took medicine for rheumatism and also capsules to produce sleep.

In the summer of 1893 I found that she had been sick four years and that she had gone through the cane and crutch stage and had taken to the wheelchair. She was at work at this time in the World's Fair grounds, and went to her work in the early morning and stayed in the grounds until late at night. Her sick knee was distinctly larger than the well one, and all the natural configuration of the joint was lost. The calf and thigh of the sick leg were smaller than the opposite side. The patella on the sick knee did not float, and the subcrural bursa, though palpable, did not contain fluid. There were three sharply defined spots, two on the median and one on the lateral condyles of the femur and tibia, that appeared to be tender and certainly were edematous. The periosteum over the supposed location of the osteal foci was thick and

edematous. It dented under the pressure of the end of the thumb. Elsewhere there was no such periosteal edema. After many examinations, the leg was put in a "Bavarian splint," made of plaster of paris. This was removed at night and the leg was washed or examined and the cast put on again for the night. After this partial immobilization with massage the leg became more comfortable, and the location of the two foci in the epiphysis of the femur and the one in the epiphysis of the tibia became very distinct and indubitable.

I persuaded the patient to go into the hospital in the winter of 1893-4 and submit to the operation which I shall describe:

The most careful antiseptic precautions were taken to prepare the field of operation and render

it sterile. The location of each focus was marked

previously with nitrate of silver. My mental conception of the condition is represented by the diagram, Fig. 2. Chloroform was used as an anesthetic. An Esmarch band rendered the leg bloodless. The first focus attacked was approached by a longitudinal incision through the skin about two inches long. The fibers of the joint capsule were then separated with a dull instrument and the synovial sac of the joint pushed away, as is done with the peritoneum when approaching the urinary bladder for a suprapubic cystostomy By bending the knee the condyle was laid bare over the focus. With a sharp spoon the epiphysis, which had already become softened by osteoporosis from the long continued inflammation, was dug out so as to approach the premised focus. It was carefully

scraped out.

The same procedure was followed for the other foci.

The tunnels, which were just large enough to admit the little finger, were filled with iodoform and the joint capsule and skin kept from closing over the opening in the bone by iodoform gauze tampons.

The joint capsule was opened in one place to allow inspection of the synovia. It was quickly closed with catgut sutures. Otherwise the joint was not opened and no perforations were made in the articular cartilage.

The dressings were large and extended to the groin and the ball of the foot. A light cast covered all. The operation was expeditious and took less than an hour.

The patient was sick after the anesthetic, but ate on the second day, and was out of bed after the third day and about in a wheel-chair.

The cast was removed and the first dressing done at the end of three weeks. The tampons were removed. The patient walked with crutches after this.

At the end of five weeks the cast was permanently removed and massage began, with passive flexion of the knee to 20°. The patient still walked with crutches.

At the end of three months the crutches were laid aside and the patient walked nearly a mile, four times a day, to her work.

From that time on she lived a very active life, married, did most of her housework and had several children. She was never lame or sick.

Recently an X-ray photograph was made of the knee, which shows no deformity of bone, and is so normal a picture that reproduction is not worth while. The motions of this knee are as easy, painless and extensive as those of the other knee. In all these years she has never had the slightest complaint from the joint.

I have operated on a few other cases of tuberculous osteal gonitis in the same manner and with good results. In one case the operation was performed on both knees with an interval of a year between the operations. In every case the patient In every case the patient was under my daily observation for some weeks before the diagnosis was considered sufficiently

exact to warrant evidement.

Although in the latterly observed cases I have had radiographs made, they have not influenced me much and their negative evidence has not deterred me from attacking the focus when the results of my physical examination and the clinical history have seemed to be positive. None of my operations have been followed by pyogenic infection of the synovial cavity, though in nearly all cases I have opened the joint to exclude synovial tuberculosis.

I have not used the Bier's treatment after the operation, though it had been tried on several cases before operation.

All the patients have had a winter of outdoor life and careful feeding before I have operated.

There are many other considerations relative to the early evidement of osteal foci about the knee and other accessible bones which will occur to every physician.

TUBERCULOSIS AND ITS PREVALENCE IN CINCINNATI.

TH

BY B. F. LYLE, M.D.,

CINCINNATI,

PAPER I.

HE tuberculosis problem is undoubtedly the most important one with which the civilized world is confronted. The disease is so ubiquitous that all animal life must pay its tribute; so deeply entrenched that a revolution in social and economic conditions will be necessary before mankind can be released from its bondage. As much of knowledge and subsequent progress is the result of comparison, it will be necessary to look beyond the municipal confines in order to appreciate our local conditions.

It is estimated that the annual loss from tuberculosis throughout the world is 1,000,000; in the United States 150,000; in Ohio 9,000, and in Cincinnati 900. In the cities the death-rate from consumption, which comprises 90 per cent. of all deaths from tuberculosis, is 204.8 per 100,000, while in the rural regions it is 134.1 per 100,000 persons annually. The death-rate among the colored (490.6) is

nearly three times that of the whites (173.5), while the rates among foreign and native whites are 231.1 and 155.4, respectively. The death-rates among males are: White 188.3, colored 527.3; among white females 158.8, colored 455.1

While we recognize the rôle played by the tubercle bacillus in the causation of the disease, other factors are equally important in its continuance. The disease is now so evident throughout the world that no locality is exempt from its presence. There is, however, a marked difference in the total and relative mortality in different regions. Not only is this difference shown in various parts of our country, but a like diversity is seen in various limited areas, as will be shown when we study its distribution in Cincinnati, dependent upon conditions that influence the physical welfare of the people. These conditions are largely the result of social and ecomonic customs, the outcome of which is "the survival of the fittest."

Success in the prevention of the disease, or its limitation to a more or less manifest morbidity, are not so much due to inherent invulnerability as to a constant avoidance of conditions that cause physical depreciation. While the mortality from the disease is enormous, it in no degree corresponds to the number of individuals infected. Philip, of Edinburgh, estimates from personal observation that there are twenty infected individuals to every death from tuberculosis. His views are a corroboration of the German adage, "Everyone in the end has a little tuberculosis," the truth of which has been shown by post-mortem findings. That infection is not equivalent to death, and that the vast majority of infected individuals recover, are facts that encourage efforts to prevent and cure the disease.

The general perturbation which followed the announcement of the discovery of the germ of tuberculosis has led largely to a concentration of effort in an attempt to destroy the bacillus, while the susceptible soil has received but little consideration. This sensitive state is a result of physical depreciation, sometimes inherited, usually acquired. Age, sex, color, habits, place of residence, occupation, earning capacity-are all to be considered in the study of the disease.

The relative mortality varies greatly in various portions of the United States. This is given in the accompanying map, showing the division of the country according to physical and topographic lines, which is manifestly of more value than a political separation. The map shows the relative mortality from consumption and pneumonia.

This table indicates the highest death-rate from consumption in the Pacific Coast region, the Ohio River belt ranking fourth. When the death-rate by States is computed, it is found California ranks first, with rate of 154.6 per 100,000; Tennessee 145.6; Kentucky 144.5; South Dakota 137.6; West Virginia 132. 8; Indiana 126; Colorado 111.7, and Ohio 108.5. Ohio's rank is eighteenth. In this

State the death-rate from tuberculosis is greater in the southern than in the northern part. The deathrate from pneumonia is higher, however, in the latter.

When we glance along the columns of the deathrate from consumption, we are struck by the fact that without exception the death-rate is greater among females in rural regions than among males. This is no doubt due to the greater danger of infection, as the women of the household are usually the nurses; to their ignorance of methods of avoiding infection, to the poor sanitary arrangements, and, possibly, most of all to the fact that in the rural regions more than elsewhere the old saying that

"woman's work is never done" applies with greatest force. In the Delineator for June of this year is an article by William Atherton DuPuy on "The Useless Tragedy of the Farmer's Wife." It is so valuable in showing the influence of overwork and exhaustion as a factor in the premature mortality among the six million farmers' wives of this country that I shall quote it somewhat fully.

"But this typical farm woman! Let us take a look at her as though she were a creature seen for the first time. We catch the dark hair combed straight back and knotted, the blue calico dress falling un

broken in one piece and tied about with a check apron. Such a slim and gaunt figure, we think; though but thirty-three, she looks the woman past the prime of life and broken. Her thinness is appalling; not an ounce of flesh shows on her stooped and wiry frame. There are no signs of feminine tendencies to adorn the person, nor is there a vestige left of the soft qualities that go to make up the appeal of woman to man. There is one characteristic, that of action, for she is intensely busy.

"This woman is not an individual, but a type. There is a lot to be found out about the woman, and it is vital to know of her. It is she who bears the brunt of feeding the multitude, for which the farmer receives so much praise. It is she who gives birth, before her vitality is sapped, to the men who make history. It is she who is martyred even in times of peace and plenty. It is a useless martyrdom, for it is easily preventable.

"You will be told it is all bosh about unfavorable conditions on the farm; there are hundreds of conveniently arranged and ideal homes on the farms. They should be provided on all farms. Probably 10 per cent. of the farmers have them. Strange to say, with the vast majority of them has come a worse condition with the development of the farm. and the advent of prosperity. The practical. men of the Department of Agriculture state this condition as a fact. The tale of the way the wife got the worst of it is the simple tale of the development of the farm. At first her task was lighter than her husband's. As prosperity increased, the crops covered a larger acreage and the harvest brought more money. A larger house was built, and its care required more labor; increased hired labor was needed on the farm and more stock. Hers was the burden of caring for the children, keeping the house in order. Additional burdens had come so insidiously that there could be no realization of their increase. Anyway, there was no hired help to be had, for there were no women to hire. Of course, it was not man's work, and the farmer draws the line very closely in these matters. The woman's lot is better when there is less prosperity, and quite simple when there is poverty; but the increase in the production of the farm-in its size, in its wealth-tends to make the burdens heavier on the woman.

"This matter of work-toilsome, tedious, monotonous, never-ending work-is the down-crushing burden of the woman on the farm. Her tasks must be performed three hundred and sixty-five days in the year. There is no variety in the work, as there is in that of the men on the outside, with the change of the seasons. It is the same endless monotony. Even the boasted health opportunities of the country are denied her. There is no running water in the house, and no sanitation. The refuse decays on or near the premises, and the wife lives always among its odors.

"A current mistake about farm life is that it is healthier than that in the city. It is healthy in proportion to the number of hours spent in the fields away from the house. The farm-house is a breeder. of disease. Dr. Ihlis, of the Public Health and Marine Hospital Service, after an exhaustive study of rural conditions in the South, reports there are five million of farm people in that section who are

physical wrecks from disease caused by a lack of sanitation.

"As a rule, there are no women who can be employed in farm service. Who ever heard of a farmer. who would give more than three dollars a week? Then there is a sentiment back of it which the women hold, and which militates against them. They feel their tasks are sacred to them, and they resent the presence of a hired woman in the house. There are some hundreds of thousands of farmers in the United States who are working their wives in their graves before their time. An investigator, for instance, went out from St. Louis into the region of the dairy farms. There is a high degree of cleanliness which falls upon the women. The investigator travelled for fifteen miles along a road lined with dairy farms, stopping at every farm and talking to the people. He did not find a single house in which there was not a stepmother. The conclusion he drew was that one generation had been worked to death. The husbands are offering up their wives on the altar of avarice. They are ignorant of what they do, but there is no excuse for their ignorance. If every farmer could be gotten by the ears and made to look his wife over as he does his horses and cows, there would be the greatest revolution in conditions that the country has ever known.

“Any organization that will teach women their due and men their duty, will be beneficial. Any enthusiast who is burning with zeal to do good to humanity may go among the farm people and show them a better living, and find a 'better field for missionary work than in savage lands. The consolidated rural school is the nearest present approach to the need, and offers the most obvious ultimate relief."

When we view the statistics of the death-rate from tuberculosis among the women in the rural regions throughout the United States by the light given us by Mr. DuPuy, we can comprehend more fully and intelligently the duty of the medical man, the true missionary, as he wends his way into the homes of the high and low throughout the country. Physical depreciation spells tuberculosis, and the proper way to combat it is not through efforts to cure, but to prevent.

[The second paper of this series of articles on tuberculosis, with especial reference to its prevalence in Cincinnati, will appear next week.-ED.]

pigment contained in almost all of the plants of the vegetable kingdom. Chlorophyl, however, is not entirely confined to the vegetable kingdom, for certain worms and celenterates, such as Hydra viridis, are directly dependent upon the presence of chlorophyl for their existence. Nor is the life of all plants without dependence upon the animal kingdom for their direct existence, and indirectly dependent, therefore, upon hemoglobin, for certain highly organized parasitic plants, belonging to the phanerogams, are chlorophyl-free. The dependence of all existence, both plant and animal, upon the presence of chlorophyl or chlorophyllaceous cells, is without denial. It cannot be said we are wasting time, therefore, when attempting to compare hemoglobin and chlorophyl.

Chlorophyl is found to be present in all the green portions of plants, and most abundantly in the leaves and those parts of the darkest green color. The cells containing it are special cells called chloroplasts. These chloroplasts are the carriers of the green color or chlorophyl, capable of increasing in number by division and developing the green color under certain conditions, and acting as special organs of the plant-cell proper. In certain chloroplasts green granules or drops are visible, distinct from the colorless ground substance. This colorless ground substance is the proteid corpuscle, which corresponds to the proteid substance of the red corpuscle, and, like them, are of various shapes and sizes in different species. In some green protophytes, however, there are no chlorophyl bodies, the green coloring matter being diffused throughout the unmodified protoplasm, which is probably also the case with hemoglobin low down in the scale of the animal kingdom. Hemoglobin is much like chlorophyl in this respect, being contained in special cells, the red corpuscles, which are the carriers of the red color or hemoglobin, and capable of increasing in number under certain conditions. They also act in a measure as special organs for the animal cells, but are not, like the chloroplasts, contained fixed within the cells proper. There is this distinction between chloroplasts and red corpuscles. Chloroplasts may be developed without the formation of chlorophyl, while red corpuscles, so far as known, are never developed without the presence of hemoglobin. We can already begin to see that while chlorophyl and hemoglobin are alike in a broad and general way, they differ a great deal in a close comparison. This will be more apparent further along.

Chlorophyl may be extracted by means of alcohol. This crude alcoholic solution is characterized, from a physical point of view, by its absorption spectrum. By transmitted light the solution is a beautiful green, but deep red by reflected light. However, this fluorescence appears only in the solution, and never in the chloroplasts. From this it is concluded that the chlorophyl occurs in the chloroplast in a state of combination. Also, a solitary

chloroplast or a leaf presents an absorption spectrum in all respects similar to that given by the solution, save the bands, as a whole, are displaced somewhat nearer to the red end. The conclusion here is that the coloring matter is dissolved in the chloroplasts in a dense medium, or is in a combined state. We are, therefore, no more certain in this than we are with the manner in which hemoglobin is contained within the red corpuscle, the hemoglobin being assumed to be present in a peculiar amorphous form.

The spectrum of a solution of chlorophyl is characterized by six absorption bands, three in the more refrangible part before the F line, and three in the less refrangible part. The spectrum of a solution of hemoglobin shows but one absorption band, which lies between the lines D and E. Evidently, then, these two substances are entirely different chemical compounds. However, there still exists certain relationships between them.

Hemoglobin is a very complex substance, belonging to the group of combined proteins, and may be broken up with the formation of a simple protein, globin, and a pigment, hematin. The composition of the molecule is found to vary somewhat in different animals, but all are closely related in chemical and physiological properties, and agree in showing that the molecule is of enormous size. Iron has long been known to exist in hemoglobin in a small quantity. It is a very essential factor, since the important property of combining with oxygen seems to be connected with its presence. Of the chemistry of chlorophyl very little is known, It is, like hemoglobin, a very complex substance, in composition of which lecithins and perhaps also proteid compounds take part. While it can be proven that chlorophyl will not develop in a plant by omitting iron from the nutritive supply, the chlorophyl molecule contains no iron. This is directly opposite to hemoglobin, whose molecule is perhaps entirely dependent upon its one atom of iron.

One of the by-products of chlorophyl is a substance, phylloporphyrin. This substance, occurring in the form of dark-red-violet crystals, has a great likeness to hematoporphyrin, a by-product of hemoglobin. This likeness is demonstrated by comparison of the absorption spectra of the two bodies. Hematoporphyrin may be obtained in a clear redviolet solution, which shows, when examined with the spectroscope, two very beautiful and characteristic absorption bands-a narrow band in the orange and a broader one in the yellow and green. The broad band is especially characteristic in that it consists of two parts, a less intense part towards the narrow band and a deep-black part on the other side. Sometimes the less intense part of the broad band shows an edge towards the red which is marked by stronger absorption, so that we may also speak of three absorption bands in the spectrum. This spectrum is identical with that of