T^C^w Ololumbta lltttuprHitg in tl|p (Ettg of Npuj f nrk S^fj^r^nr^ IGtbrarg ^^x Digitized by tine Internet Archive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/tuberculosistreOOkleb TUBERCULOSIS TUBERCULOSIS A TREATISE BY AMERICAN AUTHORS aV ITS ETIOLOGY, PATHOLOGY, FREQUENCY SEMEIOLOGY, DIAGNOSIS, PROGNOSIS PREVENTION, AND TREATMENT EDITED BY ARNOLD C. KLEES, M.D. WITH THREE COLORED PLATES AND TWO HUNDRED AND FORTY-THREE ILLUSTRATIONS IN TEXT NEW YORK AND LONDON D. APPLETON AND COMPANY 1909 Copyright, 1909, by D. APPLETON AND COMPANY )0- PRINTED AT THK APPLKTON PRESS NEW YORK, U. S. A. EDITOK'S PREFACE A CONTINUOUS and systematic discussion of the whole subject of tuberculosis in all those phases of interest and value to the practitioner by a single author has become an impossibility. In view of the enor- mous literature — nearly three tliousand pul)lications of 1908 alone have been collected in the editor's office — the task of sifting the important from the unimportant can only be undertaken by those who can devote much time exclusively to one distinct phase. The study of tuberculosis thus necessitates a specialization within the range of a special subject. Every chapter in this book deals with a distinct phase of the subject, and is treated by authors whose particular familiarity with it is well recognized — in several instances even far beyond the boundaries of this country. It has been the endeavor of the editor to bring the articles into proper juxtaposition by personal intercourse and extensive corre- spondence with the contributors, so that the principal theme is treated in a uniform manner, and does not merely represent a collection of articles, but a consistent whole to fill the requirements of the man in busy practice and without the* " cold neutrality " of a mere work of reference. Altliough the fullest attention has been paid to the funda- mental work done in other countries, it is but natural that in this Ameri- can treatise a full consideration is given to the work done here, the value of which will undoubtedly become more and more generally ap- preciated. Thus it may be hoped that the international cooperation auspiciously inaugurated at the Washington Congress may also be fur- thered by this work for the benefit of all concerned. The guiding consideration of the needs of the practitioner has neces- sitated a shorter discussion of certain subjects which have received con- siderable space in other works. An often bewildering completeness has thereby been avoided. A carefully selected bibliography, however, ar- ranged by names of authors and subjects as well, should prove of assist- vi EDITOR'S PREFACE ance to those who wish to inform themselves about special questions not extensively discussed in the text. But it may be confidently asserted that the practitioner will find in the following pages a lucid discussion of the great problem of tuberculosis, based upon the most recent con- ceptions of the international army of busy workers, sufficiently full to aid him in the solution of the ever-recurring puzzles which this disease presents to him as a physician and citizen as well. The admirable X-ray plates we^e kindly furnished by Dr. Lewis Gregory Cole, of New York. They are remarkable for their clearness and jDcrfection of detail. It must be borne in mind, however, that these were taken with the patient recumbent, which accounts for the oblique position of the clavicles and certain other minor differences from the pic- ture as seen on the fluoroscope, which is usually used with the patient erect and with the clavicles therefore more nearly horizontal. Arnold C. Klebs. CONTKIBUTORS Edward R. Baldwin, Saranac, jST. Y. Resistance, Predisposition, and Immunity. Individual Prophylaxis. Jaevis Barlow, Los Angeles, Cal. Clim atic Th crape u tics. Hermaxn M. Biggs, New York City. Intruduction to Prophylaxis. Lawrason Brown, Saranac^. K. Y. Specific Treatment. Thomas D. Coleman, Augusta, Ga. Tuberculosis Among the Dark-shinned Paces of America. Home Treatment by Sanatorium Methods. Leonard Freeman, Denver, Col. Tuberculosis of the Lymph Glands. Primary Tuberculosis of Muscles and Fascice. Tuberculous Ischiorectal Abscess and Aual Fistula. Tuberculosis of the Gcnito-Urinary System. LuDwiG Hektoen, Chicago, 111. Tubercle and Morbid Anatomy. Eichard H. Hutchings, Ogdensburg, N. Y. Frequency of Tuberculosis in Insane Asylums. Arxold C. Klebs, Chicago, 111. Frequency of Tuberculosis. The Sanatorium, its Construction and Management. VlU CONTRIBUTORS S. Adolphus Knopf, Nbav York City. Public Measures in the Prophylaxis of Tuberculosis. L. L. McArthur, Chicago, 111. Tuberculosis of Bones and Joints. Tuberculosis of the Brain and its Membranes. Intestinal Tuberculosis. Tuberculosis of the Peritoneum. Charles L. Minor, Asheville, N. C. Symptomatology of Pulmonary Tuberculosis. Physical Examination. Diagnosis. William Osler, Oxford, England. Historical Introduction. Clemons von Pirquet, Baltimore, Md. Tuberculosis in Childhood. Mazyck p. Pavenel, Madison, Wis. Etiology — The Tubercle Bacillus. Henry Sewall, Denver, Col. The Physiology of Climate. Edward L. Trudeau, Saranae, N. Y. Introduclion to Treatment. Gerald B. Webb, Colorado Springs, Col. Specific Therapeutics of Mixed and Concomitant Infections. CONTENTS INTRODUCTION PAGE Historical Sketch 3 Semeiological 3 Anatomical 5 Etiological 5 Prevention 7 American Work on Tuberculosis g PART I ETIOLOGY AND MORBID ANATOMY CHAPTER I ETIOLOGY— THE TUBERCLE BACILLUS History 13 Types of Tubercle Bacillus 13 Morphology of the Tubercle Bacillus 15 Staining 15 Other Acid-fast Bacilli — Pseudo-Tubercle Bacilli 19 Diagnosis of Tuberculosis by Microscopic Examination 20 Cultivation of the Tubercle Bacillus 20 Biology of Tubercle Bacillus . . * 23 Chemical Composition of the Tubercle Bacillus 26 Poisons of the Tubercle Bacillus 2S Preparation of Tuberculin * 30 Modes of Invasion 33 Addenda 46 CHAPTER II TUBERCLE AND MORBID ANATOMY Histogenesis and Fate .... Origin of Tubercle .... Tuberculous Granulation Tissue Tuberculous Exudative Inflammation Caseation Healing Points of Entrance and Primary Localization of Tubercle Bacilli Dissemination of Tuberculosis within the Infected Body 52 52 55 56 56 5!t (50 62 X CONTENTS Acute General Miliary Tuberculosis The Morbid Anatomy of Pulmonary Tuberculosis .... Acute General Hematogenous Tuberculosis of the Lungs Partial Disseminated Hematogenous Tuberculosis of the Lungs Localized Pulmonary Tuberculosis Ulcerative Tuberculosis of the Lungs ...... Mixed Infection in Pulmonary Tuberculosis Fibroid, Quiescent, and Healed Tuberculosis of the Lungs 64 69 70 70 71 74 77 78 CHAPTER III RESISTANCE, PREDISPOSITION, AND IMMUNITY Resistance 80 Animals in General 80 Man 80 Individual Resistance 80 Normal Physiologic Resistance 81 Influence of Age 81 Influence of Heredity 81 Nature of Physiologic Resistance 82 Subnormal Resistance — Predisposition 82 Influence of Sex 83 Inherited Predisposition 83 Inherited Structural Defects ■ . 84 Local Predisposition 86 Acquired Predisposition 87 Specific Susceptibility from Previous Tuberculous Infection .... 87 Lymphatic 87 Pulmonary 88 Nonspecific Susceptibility 89 Infectious Diseases 89 Diseases of Nutrition 90 Miscellaneous 91 Injuries 91 Increased Resistance 91 Physiologic 91 Occupation 91 Diathetic 92 Diseases 92 Specific Increase of Resistance 92 Immunity 93 Experiments 93 Application 94 Explanation of Mechanism 95 Specific Substances in the Blood 96 Agglutinins and Precipitins 96 Opsonins 96 Antitoxins 96 Summary 97 Addenda 98 CONTENTS XI PART II FREQUENCY AND DISTRIBUTION CHAPTER I FREQUENCY OF TUBERCULOSIS General Considerations Frequency in Autopsies Autopsies in Children Frequency Intra Vitam "Tuberculosis a Children's Disease" Morbidity Statistics .... Mortality Statistics and the Decrease of Tuberculosis Geographic Distribution PAGE 105 105 108 110 112 112 113 116 CHAPTER II TUBERCULOSIS AMONG THE D.\RK-SKINNED RACES OF AMERICA Tuberculosis in the Negro ..." Tuberculosis in the Indian . . . Tuberculosis Among the Japanese and Chinese ... . . . 121 127 129 CHAPTER III FREQUENCY OF TUBERCULOSIS IN INSANE ASYLUMS Tuberculosis in Hospitals for the Insane Diagnosis of Tuberculosis in the Insane Treatment of Tuberculosis in the Insane Individual Treatment 133 134 135 135 PART III SYMPTOMATOLOGY AND DIAGNOSIS INTRODUCTION Tuberculosis in Childhood Portal of Entrance for Infection Other Portals of Entrance Clinical Stages Progression of the Infection Anergy Scrofulosis .... Prophylaxis and Therapy . CHAPTER I SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS Introduction .... Chronic Phthisis . Acute Phthisis Acute Miliary Tuberculosis 142 142 143 143 144 146 147 147 149 150 153 155 Xll CONTENTS PAGE Subjective Symptoms 159 Fever 159 Hoarseness 171 Sweats 171 Languor 172 Emaciation 173 Anorexia 175 Dyspnea 176 Cyano.sis 178 The Circulatory System 17S Digestive System 182 The Liver 188 Urinary System 188 The Bones and Mu.scles 191 The Skin 192 The Hair 193 The Physical C'ondition 193 The Special Senses 196 The Larynx 197 Cough 200 Expectoration 204 Microscopic Examination 207 Hemorrhage 212 Pain 222 Objective Signs 224 Inspection 224 Palpation 232 Mensuration 233 Percussion 237 Auscultation 246 Roentgen Rays 268 Blood 285 Metabolism 292 CHAPTER II PHYSIC.A.L EXAMINATION Physical Examination 297 CHAPTER III DIAGNOSIS Sputum Examination 327 Physical Signs 331 Symptoms and Clinical Course ■ . . . . 335 Other Diagnostic Measures 339 The Tuberculin Test 339 Modifications of the Tuberculin Test 346 Differential Diagnosis 353 On the Recognition of Stages 361 On Recording Findings 374 CONTENTS xiii PAGE Addenda 379 Symptoms . 379 Metabolism . . 380 Diagnosis 380 Diagnostic Value . . . 380 Prognostic Value 3S1 The Cutaneous Reaction 382 Other Diagnostic Methods 334 Sputum Examination 355 Physical Diagnostic Measures 335 Use of X-Rays 335 Prognosis 386 PART IV PR0PHYL.4XIS OF TUBERCULOSIS IXTRODUCTIOX Introduction 392 CHAPTER I INDIVIDUAL PROPHYLAXIS Measures for the Healthy Individual 393 Infancy 393 Childhood 397 Youth 400 Adult 400 Measures for Tuberculous Individuals 393 Closed Tuberculosis 404 Scrofulosis 405 Closed Pulmonarj^ Tuberculosis 405 Open Tuberculosis 405 Duty of Consumptive Individual to Society 408 Duty of Society to Consumptive Individual 408 Marriage 409 Addenda 409 CHAPTER II PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS Historical Review 410 Handbills and Invitations to Lectures 414 Economic Loss to the Commonwealth through Tuberculosis . . .414 Protest Against Patent Medicines and "Sure" Consumption Cures . . 410 Character of Tuberculosis Lecture 416 Unjustified Prejudice against Consumptives 417 Federal Phthisiophobia 418 State Phthisiophobia— Goodsell-Bedell Law 420 Results of Federal and State Phthisiophobia 422 XIV CONTENTS PAGE Law of Mexico as a Contrast to the Goodsell-Bedell Law .... 423 Journals Devoted to the Prevention of Tuberculosis 424 The Public Press and Tuberculosis 424 Tuberculosis Exhibits, etc 425 Tuberculosis Clinic 433 Advice and Care Stations 438 Seaside and Inland Sanatoria for Tuberculous Children 439 Day Camps 440 New York's Ferryboat Day Camp 441 Class Method at Home 441 Special Relief Work of Tuberculosis Committee of the C. (). S., New York . 442 Maternity Sanatoria 444 Medical Mission of the Tuberculosis Sanatorium 445 Social Mission of the Tuberculosis Sanatorium 445 Duty of the Municipality toward the Family of the Consumptive . . . 44(3 Preventatorium 440 Agricultural and Horticultural Colonies 447 Remuneration of Physicians in Public Tuberculosis Institutions . 447 Compulsory Notification of Tuberculosis Cases and the Work of the Health Department in Relation Thereto 447 Compulsory Registration in the United States Considered by a Layman . 458 Care of Tuberculous Federal Employees 463 Care of Tuberculous Insane 463 Care of the Tuberculous in Almshouses, Asylums, and Boarding Schools . 465 Tuberculosis in Prisons and Reformatories 465 Tuberculosis and Domestic Animals 473 Supervision of Slaughter-houses 474 Protection against Infection from Tuberculous Milk 474 Housing of the Masses, Good Tenement-house Laws and their Strict Enforce- ment Essential 477 Parks and Playgrounds 478 Emigration from City to Village 479 Creation of Schools of Forestry and the Preservation of Forests . . 479 Sanitation at Home 481 Window Tent for the Open-air Treatment at Home 482 Dry Air and the Danger from Overheated Dwellings 486 Danger from Dry Sweeping 486 The Common House-fly as a Propagator of Tuberculosis .... 487 Prevention of Tuberculosis in the School Child 488 Sanitation of Workshops, Factories, Sto;-es, etc. 492 Antituberculosis Work Among Factory Workers 492 Insurance against Tuberculosis 493 Addenda 495 Economic Meaning of Tuberculosis 495 Raising of Funds for Tulierculosis Propaganda 495 Special Dispensaries 496 Compulsory Examination of Children 496 Day and Night Camps 497 Administrative Control .... 497 Naval and Military Prophylaxis ... ... 497 Prison Prophylaxis 498 CONTENTS XV PAGE Prostitution 498 Children's School Farms 498 Trained Nurses 499 Public Schools, Colleges, etc 499 Insurance of Workingmen against Sickness 500 Resolutions 500 PART V TREATMExXT INTRODUCTION Introduction 505 CHAPTER I SPECIFIC TREATMENT Historical Introduction 508 Schema for Tuberculins and Tubercle Bacillus Vaccines 511 Varieties of Tuberculin Used Clinically 515 Chemistry of Tuberculin 517 Methods of Administration 518 Intravenous 518 Oral 518 Inhalation 519 Dermin 519 Subcutaneously 519 Dilutions . . 520 Preservation in Dilution 520 Method of Diluting 520 Diluents 521 Estimating Dilutions 521 Preparations for Injections . . _ 523 Cleansing of Skin 523 Needles 523 Accidental Inoculation 523 Site of Injection 523 Dosage and Interval 524 General 524 Beginning Dose 524 Interval 525 Increase of Dose 525 Time of Injection 527 Record of Treatment 527 Typical Reaction 529 Skin Reaction 530 Organ Reactions 531 Localizing Symptoms 531 General Symptoms ... 532 Temperature ... 532 1 XVI CONTENTS PAGE Antipyretic Action 534 Increased Susceptibility 534 Pulse 534 Weight 534 Complications 535 Final Dose 535 Hypersusceptibility 538 Value of Small Doses 538 Schemata 539 Selection of Patients 541 Theory of Action 541 Symptoms and General Condition 543 Elevated Temperatures 543 Complications 544 Physical Signs 544 Duration of Disease 545 Age 545 Prophylactic Use 545 Advice for Inquiring Patients 545 Selection of Tuberculin 545 Duration of Treatment 548 Repeated Courses 549 Tuberculin Test 549 Treatment During the Administration of Tuberculin 550 Sanatorium 550 Rest and Exercise 550 Rise of Temperature 550 Medicinal 550 Vaccines 551 Effects of Repeated Doses 551 Weight 551 Blood 551 Mobilization of Tubercle Bacilli 553 Sputum 553 Urine 554 Elevated Temperature 554 Hemoptysis 555 Physical Signs 555 Complications 555 Pathologic Changes 555 Experimental Results , . . . 556 Results 556 Reports of Tuberculin Treatment 560 Loss of Tubercle Bacilli 564 Antagonistic Bacteria 565 Bacterium Termo 565 Erysipelas 565 Syphilis 565 Yeast 566 "Acid-fast" Bacteria 566 Attenuated Tubercle Bacilli 566 CONTENTS xvii PAGE Vaccination 567 Products of the Tubercle Bacillus 567 Organotherapy 568 Lungs 568 Lymphatic Glands 569 Muscle 570 Blood Cells 570 Hemotherapy 571 Serotherapy 571 Varieties 572 Administration 572 Results • .... 573 Serum Disease 573 Maragliano's Serum 573 Marmorek's Serum 574 Antistreptococcic Serum 575 "False Specifics" 575 Creosote and its Derivatives 576 Arsenic and its Derivatives 577 Alcohol 578 Drugs that Produce Leucocytosis . 579 Ichthyol 581 lodin 581 Silver 582 Lecithin 582 Calcium 582 Strychnin 583 Inhalations 583 Sprays 584 Injections 584 Addenda 585 CHAPTER II SPECIFIC THERAPEUTICS OF MIXED AND CONCOMITANT INFECTIONS Specific Therapeutics of Mixed and Concomitant Infections .... 589 CHAPTER III HYGIENE. DIET AND OPEN AIR IN THE TRE.\TMENT OF TUBERCULOSIS Home Treatment by Sanatorium Methods Food 601 Milk 603 Eggs 603 Meat 604 Prepared Foods ... 604 Alcohol ... 604 Carbohydrates ... 605 Dietaries 605 Air and Environment 608 XVIU CONTENTS Rest and Exercise Clothing Hydrotherapy and Hardening . Symptomatic Treatment Debility and Loss of Appetite and Weight Anemia .... Fever Cough Night Sweats Gastro-intestinal Disturbances Hemorrhage .... Cardiac Weakness and Dyspnea Complications .... Insomnia .... Pain Pleurisy with Effusion Empyema .... Pneumothorax Pityriasis versicolor Ischiorectal Abscess . Tuberculous Laryngitis Diarrhea .... The Sanatorium, its Construction an Requisites of the Sanatorium .... Selection of Sanatorium Site .... Planning and Construction .... The Administration Building .... General Planning of the Sanatorium Building Building Material and Cost .... Management and Sanatorium Regime . D Management PAGE 612 616 617 618 618 620 622 624 628 629 631 634 635 635 636 636 637 637 637 637 638 639 641 643 645 657 658 658 661 CHAPTER IV CLIMATIC TREATMENT The Physiology of Climate Relations of Climate to Physical and Psychical Condition .... 663 Cla.ssification of Climates 666 Effect of Excessive Illumination 670 High Altitudes 671 The Principles of Physiologic Rest 679 Climatic Therapeutics Historical Aspects 680 General Definition of Climatotherapy 682 Is there a Specific Climate for Pulmonary Tuberculosis? .... 682 Principal Types of Climate 684 Ocean Climates 684 Inland Climates 686 General Utilization of Climatic Treatment ........ 690 CONTENTS xix PAGE Open and Closed Resorts 692 The Selection of a Special Climate or Resort 696 Enumeration of Resorts 697 United States Resorts 700 The Adirondack Mountains 701 New Jersey > . . 702 Pennsylvania 703 Blue Ridge Mountains 703 Appalachians 703 Florida • 706 Rocky Mountain Resort Region 707 Colorado ...... 707 New Mexico 710 .Arizona 713 California 714 Foreign Resorts 717 Mexico . 717 Canada 718 Madeira 718 Canary Islands 718 Europe 718 Southern Spain 719 Africa 719 Russia 719 Addenda 720 PART VI SURGICAL TUBERCULOSIS CHAPTER I TUBERCULOSIS OF THE LYMPH GLANDS Tuberculosis of the Lymph Glands Etiology Symptoms and Diagnosis .... Treatment Tuberculosis of the Cerv^ical Lymph Glands Tuberculous Infection of the Lymph Glands of the Groin Tuberculosis of Lymph Nodes in the Axillary Region 723 724 725 726 728 729 730 CHAPTER II TUBERCULOSLS OF BONES AND JOINTS Tuberculosis of Bones .... 731 In the Arterioles 732 In Venous Terminals 732 Treatment 733 XX CONTENTS PAGE Tuberculosis of Special Bones 733 Cranial Vault 733 Ribs -734 Sternum 734 Vertebrae 734 Tuberculosis of Joints 735 Symptoms 735 Prognosis 736 Diagnosis 738 Treatment 739 Tuberculosis of Shoulder Joint 742 Occurrence 742 Symptomatology 742 Differential Diagnosis 743 Prognosis 743 Treatment 743 Tuberculosis of Carpus and Tarsus 743 Tuberculosis of Hip-joint 744 Sequestra 745 Symptoms 746 Diagnosis . * 747 Treatment 747 Tuberculosis of Knee-joint 748 CHAPTER III PRIMARY TUBERCULOSIS OF MUSCLES AND FASCIiE Tuberculosis of Fasciae 750 CHAPTER IV TUBERCULOSIS OF THE BRAIN AND ITS MEMBRANES The Meninges 751 Diagnosis 751 Symptoms 751 Treatment 752 The Brain 754 Tuberculomas 754 CHAPTER V INTESTINAL TUBERCULOSIS General Considerations 756 Frequency 758 Enterogenous 759 Etiology • 761 Ulcerative 761 Hypertrophic Variety 762 Location 764 Treatment 764 CONTENTS xxi CHAPTER VI TUBERCULOUS ISCHIORECTAL ABSCESS AND ANAL FISTULA PAGE Pathology 766 Symptoms and Diagnosis 766 Treatment 768 CHAPTER VII TUBERCULOSIS OF THE PERITONEUM Occurrence 771 Classification 771 Symptomatology 772 Diagnosis 774 Treatment 775 CHAPTER VIII TUBERCULOSIS OF THE GENITO-URINARY SYSTEM General Considerations 777 Tuberculosis of the Testicles 778 Pathology 779 Symptoms 779 Diagnosis 780 Treatment 781 Tuberculosis of the Seminal Vesicles and Prostate 784 Symptoms 785 Treatment 785 Tuberculosis of the Kidney 785 Pathology 786 Symptoms 787 Diagnosis 788 Treatment 788 Tuberculosis of the Suprarenal Gland 791 Tuberculosis of the Bladder 791 Symptoms 791 Diagnosis 792 Treatment 792 Tuberculosis of the Urethra 794 Tuberculosis of the Genital Tract in Women 794 Pathology 794 Symptoms and Diagnosis 794 Treatment " ■ 794 Addenda 795 \ xxii CONTENTS APPENDICES APPENDIX I PAGE The Tuberculo-Opsonic Index 799 APPENDIX II Tuberculosis — A Leaflet for Teachers 804 APPENDIX III Facts a Mother Should Know Concerning Tuberculosis 808 APPENDIX IV An Act . . 811 APPENDIX V Instructions for the Physician's Use in Private Practice . . . 813 APPENDIX VI Formulary for the Symptomatic Treatment of Pulmonary and Laryngeal Tuberculosis 819 APPENDIX VII Devices for the Cure and Prevention of Tulierculosis 832 APPENDIX VIII Diet Lists 852 BIBLIOGRAPHY 861 INDEX 905 LIST OF COLORED PLATES PLATE I FACING PAGE . 198 1. — Tablelike Thickening and Elevation of the Mucous Membrane of the Posterior Commissure. — Small Erosions or Ulcers of Free Border of the Cords, giving the Characteristic " Nibbled-out " Appearance. 3. — Thickening of the Right False Cord which Overlaps and Hides Most of the True Cord. Thickening and Injection of Insertion of Cords and Small Ulcer at the Base. Superficial Erosion of the Upper Surface of the Vocal Cords, Very Typical of Tuberculosis. 6.— Grayish WrinkUng of the Posterior Commissure, not Diagnostic, but Very Suspicious if Combined with Other Symptoms. — Ulceration of the Free Border of the Right Cord, Producing the Ap- pearance of a Reduction of the Cord. — Wartlike Growth, Rising from the Posterior Commissure Near the Insertion of the Cord. PLATE II 1. 592 Shows in the Same FielcJ Pus Cells containing Tubercle Bacilli and Streptococci. 2. — Organisms Similar to (1), but Contained in the Same Pus Cell. 3. — A Large Pus Cell Containing a Tubercle Bacillus and Many Staphy- lococci. 4. — Pus Cells Containing Staphylococci, Pneumococci, and One C'ell Containing a Tubercle Bacillus and Pneumococci. 5. — The Micrococcus Catarrhalis and the Pneumococci and Tubercle Bacilli. 6. — The Influenza Bacillus. PLATE III 1. — Tuberculosis of the Kidney, Showing Cavities and Nodules. 2. — Tuberculosis of Lymph Node, Showing Caseous Nodules. 3. — Tuberculosis of Epididymis, Incision through Normal Body of the Testis. 786 LIST OF ILLUSTRATIONS IN TEXT 1. — Tongue and Tonsils of Swine Infected by Feeding Tubercle Bacilli 36 2. — Lungs of Swine Infected by Feeding 37 3-4. — Tuberculosis of the Intestines and Lungs of Monkey Fed with Tubercle Bacilli 41 5. — Tubercle in Lung Tissue 57 6. — -Tuberculous Pneumonia and Conglomerate Tubercles .... 69 7.— Section through Lung, Showing Caseous Tuberculous Lymph Glands . 73 8. — Tuberculous Pneumonia in a Child Thirteen Months Old .... 74 9. — -Cavity from Breaking Down of Tuberculous Pneumonia .... 74 10. — Tuberculosis of Eleven Years' Standing 76 11. — Normal, Well-developed Upper Thoracic Opening with Good Pronun- ciation of Paravertebral Spaces 99 12.^ — -Typical Stenosed Upper Thoracic Opening with Asymmetry ... 99 13. — Asymmetrical Thoracic Opening with Slight Scoliosis of Cervical and Upper Thoracic Spine 100 14. — Formation of True Joints with Epiphyses and Capsules .... 100 15. — Distribution of Tuberculosis at the Various Age Periods in a Series of 1,400 Autopsies 108 16. — Cutaneous Tuberculin Reaction in 1,407 Children Ill 17. — Cutaneous Tuberculin Reaction in 1,134 Clinically Nontuberculous Children Ill 18. — The Age Distribution of Consumption Mortality 114 19. — Proportions of Deaths from Pneumonia and Consumption at Certain Ages 115 20. — Comparative Mortality from Consumption of Whites and Blacks . . 124 21. — Treatment of the Tuberculous Insane on an Open Porch .... 136 22. — A Cold-proof Sleeping-bag and Method of Adjustment .... 137 23. — Treatment of the Tuberculous Insane in a Solarium 138 24. — Stage I. Tyisicai Moderately Subnormal Temperature (Chart) . . 159 25. — Stage I. Marked Subnormal Temperature in Young Woman of Very Poor Vitality (Chart) 160 26. — Stage 11. Slowly Spreading and with Gradually Rising Fever (Chart) 160 27. — Stage III. Extensive Lesions with Normal Temperature (Chart) . 161 28. — Stage III. Active Spreading Process in Both Lungs and Commencing Cavity Formation (Chart) 162 29-30. — Non-re.solving Tuberculous Pneumonia with Chills, Sweats, Hectic Fever, and Rapid Breaking Down of Lung, with Mixed Infection (Chart) 163 31-32. — Stage III. Inactive, Showing Effect of Overexertion (Railroad Jour- ney) and of an Acute Bronchitis (Chart) 166 XXV xxvi LIST OF ILLUSTRATIONS IN TEXT FIGURE PAGE 33. — Stage II. Showing Effect of Intercurrent Broncho-pneumonia on Fever Curve (Chart) 167 34. — Stage III. Shows Effect of Absohite Rest in Bed on the Fever in a Pa- tient who had been Exercising Freely (Chart) 168 35. — Temperature Chart for Seven Months, Showing Various Incidents in the Course of the Disease, with Final Improvement . . . ,170 36-38 — Rapidly Destructive Process of but Six Weeks' Duration, but Re- sembling an Advanced Chronic Case 225 39-41. — Shows Chest Outlines and Limitations of Resonant Area, Right Shoulder Droop 227 42-43. — Prominent Angle of Louis and Funnel Below It 229 44. — Cyrtometer Tracing of Incipient Case (I) 234 45. — Case in I. Stage (R). Re-expansion after Five Months (Broken Line) . 234 46. — Active Recent Disease on Left Side, Arrest, and Final Cure . . . 234 47. — Marked Shrinkage in Incipient Left-sided Case (I) 234 48. — Fibroid Disease, Continually Improving 235 49.— Stage III. Patient Failing 235 50.— Round Type of Chest 236 51. — "Pigeon Chest," Case in Stage III 236 52.— Flat Type of Chest 237 53. — Bulging Backward on Account of Scoliosis 237 54. — Marked Shrinkage of Left Side, Due to Post-pneumonic Emphysema . 237 55.— -Tuberculosis of Tracheobronchial Lymph Glands in Child Four Months Old 242 56. — Posterior View of the Lungs in an Acute Active Case, Showing Mul- tiple Cavities in the Infiltrated Upper Left Lobe .... 269 57. — Anterior View of an Old Chronip Process 270 58. — Anterior View of an Extensively Involved Left Lung .... 273 59.- — Anterior View of the Lungs in a Case of Early Acute Tuberculosis of the Left Lung 275 60. — Anterior View, Showing Enlargement of the Peribronchial Glands Around the Roots 277 61.^ — ^Anterior View of the Lungs in an Old Case of Nineteen Years' Standing 279 62. — A Posterior View of an Infiltrated Left Apex with Slight Retraction of the Heart to the Left 281 63.— Anterior View 282 64. — Anterior View of the Lungs in a Case of Pleurisy with Effusion at the Right Base 284 65-66. — Proper Position of the Fingers and Wrists 309 67. — To Show the Use of the Little Finger in Delicate Percussion . . 310 68-69.^ — -Fibroid Tuberculosis of Six Years' Duration in a Man of Fifty-six, in which the Fat Hides the Shrinkage of the Chest . . .311 70-71. — To Show the Deforming Effect of Pulmonary Tuberculosis Upon the Thorax 312 72-73.— Tuberculosis of Left Apex 313 74-77. — Typical Case of Fibroid of Left Lung in Case of Four Years' Duration 315 78. — Tuberculin Injection with Negative Result ....... 345 79. — Mild Reaction after Fourth Injection 345 80. — Mild Reaction after Second Injection ........ 345 81. — -Active Reaction after Third Injection 345 82.^ — After First Injection, Pseudo-reaction from Parulis 345 LIST OF ILLUSTRATIONS IN TEXT xxvii FIGURE PAGE 345 83. — Tuberculin Diagnosis in Neurasthenia 84-85. — Suspect Case in Anemic, Slender Youth (Diagrams) . 86-87. — Incipient Case (Diagrams) 88-89. — Incipient Case, Chiefly Posterior, Extent I (Diagrams) 90-91. — Stage I (Diagrams) 92-93. — Stage I (Diagrams) 94-95.— Incipient Bilateral Case (Diagrams) 96-97. — Incipient Case, but with Disseminated Lesions and Laryngeal In volvement 98-99.— Stage II (Diagrams) 100-101. — Stage II. Left Basal Pleurisy and Limited Motion (Diagrams) 102-103. — Stage II. Of Long Duration, with Retrogressions and Exacerba tions (Diagrams) 104-105. — Stage II. Beginning Softening, Later Excavation (Diagrams) 106-107. — Stage II (Possibly III). Beginning Softening (Diagrams) 108-109.— Stage III (Left), I (Right). Fibroid Phthisis (Diagrams) 110-111. — -Stage III. Softening of Consolidated Right Apex (Diagrams) 112-113.— Stage III (R. Ill, L. I). Cavity R. U. A. (Diagrams) 114-115.— Stage III. Cavity (R.) and Fluid at Base (L.) (Diagrams) . 116-117. — Stage III. Rapidly Spreading, Softening (Diagrams) 118-119.— Acute Tuberculous Pneumonia, Stage III, Illness Six Weeks (DiagT-ams) 120-121. — Acute Miliary Tuberculosis (Diagrams) 122. — Playground on Roof of Residence in New York City 123. — Sleeping Balcony 124-125. — Cottage Showing Arrangement for One Sleeping Porch 126-127. — Cottage Showing Arrangement for Two Sleeping Porches 128-130. — Exhibition of International Tuberculosis Congress, 1908 . 426-427 131. — An Effective and Inexpensive Method of Tuberculosis Propaganda . 432 132. — Exterior of Tuberculosis Clinic of New York Health Department . . 435 133. — Floor Plan of Tuberculosis Clinic of New York Health Department . 436 134. — Signboard for Dispensary Waiting Room 437 135. — Open-air Treatment of Surgical Tuberculosis at Sea Breeze, Coney Island 440 136.— B. Frankel's Mouth Mask for the Prevention of Drop Infection . . 469 137.— Window Tent in Use 482 138.— Window Tent Raised, When Not in Use 483 139.— Window Tent 484 140. — Diagram Showing ^^entilation of \yindow Tent 484 141-142.— Woolen Hoods for Outdoor Sleeping 485 143. — First and Second Breathing Exercise 490 144.— Third Breathing Exercise 490 145. — Breathing Exercise with Rolling of Shoulders 491 146. — Exercise for Children in the Habit of Stooping 491 147. — Tnstrumentarium for Tuberculin Injections 521 148. — Conditions on Discharge, Expressed Proportionally, of Patients in the Incipient Stage, Treated with Tuberculin 557 149. — Conditions on Discharge, Expressed Proportionally, of Patients in the Moderately Advanced Stage, Treated with Tuberculin 150.— Proportions of Dead and Living in 1906 of all those Treated with Tuber culin • • 365 365 366 366 367 367 368 368 369 369 370 370 371 371 372 372 373 373 374 401 402 403 404 xxviii LIST OF ILLUSTRATIONS IN TEXT FIGURE PAGE 15L— Showing the Numbers per Thousand Surviving at the End of One, Two, Three, etc.. Years after Leaving the Adirondack Cottage Sani- tariums 558 152. — Grade I. Baskets Holding about Twelve, Eighteen, and Twenty-four Pounds of Mold or Other Material 613 153. — Shovels and Spades Used in Grade 2 and 3 for Digging Earth and Lifting It Into Barrows 614 154. — Forks of Different Weight for Graduated Work in Grade 2 . . . 615 155. — Pickaxes of Various Weights Used in Grade 4 for Breaking Ground, Excavating, etc 616 156. — Dr. Millet's New Modified Shack for One Patient at Brockton, Mass. . 647 157. — Open-air Gallery Joining Two Buildings. Gaylord Farm Sanatorium, Wallingford, Conn 648 158. — Dr. King's Original "Lean-to" for Eight Patients at Loomis Sana- torium, Liberty, Sullivan County, N. Y 648 159. — Two "Lean-tos" of the Loomis Sanatorium 649 160. — -Dr. King's Modified and Enlarged "Lean-to" for Sixteen Patients. Loomis Sanatorium 649 161. — Interior of Sitting Room, Showing Locker, Toilet, and Bathrooms in the Rear in Sixteen-bed "Lean-to." Loomis Sanatorium . . 650 162. — -One of Two Sleeping Galleries of Dr. King's Sixteen-bed "Lean-to" . 651 163. — Open-air Pavilion Connected with Main Building. Maine State Sana- torium 652 164. — -Dr. Holden's Open-air Pavilion, Agnes Memorial Sanatorium, Denver, Colo. . 652 165. — Floor Plans of Dr. Holden's Open-air Pavilion at Agnes Memorial Sanatorium 653 166. — Boston Consumptives' Hospital at Mattapan 654 167. — -Boston Consumptives' Hospital at Mattapan 654 168. — Boston Consumptives' Hospital at Mattapan. Day Camp . . . 655 169. — Boston Consumptives' Hospital at Mattapan 655 170. — Main Building (Floor Plan of First Story) for Sanatorium for 100 Patients 656 171. — Main Building (Floor Plan of Second Story) for Sanatorium for 100 Patients 657 172.— Type of Sixteen-bed "Lean-to," H. M. King 658 173. — Floor Plan of First Floor of Administration and Infirmary Build- ings of Maryland Tuberculosis Sanatorium at Sabillasville, Md. . 659 174. — Bird's-eye View cf Maryland Tuberculosis Sanatorium, Sabillasville, Md. 660 175. — Normal Surface Temperature for the Year in the ITnited States . . 699 176. — -Seasonal Rainfall in American Health Resorts, Compared with Phila- delphia 700 177.— Case of Pott's Disease 734 178. — Characteristic Position of Tuberculous Hip-joint 744 179. — Multiple Fistula Openings of Tuberculous Knee 747 180.— Plaster-of-Paris Splint with Fenestra 748 181. — Indicating how the Urinary Group of Organs is Pathologically Dis- tinct from the Generative Group, with the Bladder as a Central Point 777 LIST OF ILLUSTRATIONS IN TEXT xxix ILLUSTRATIONS IN APPENDICES FIGURE PAGE 1. — The Completed Capsule 799 2. — Aspirating Supernatant Liquid with Suction Curley Pipette Down to Leucocyte Zone 800 3. — Glass Capsule Containing Sterilized Emulsion of Tubercle Bacilli . . 800 4. — The Finished Pipette 801 5. — Beverley Robinson's Zinc Inhaler 820 6. — A Laryngeal Medicator, Devised by Mannheimer and Yankauer . . 828 7-8. — Improved Wooden Box for Sending Specimens of Sputum to the Laboratory for Examination 832 9-11. — Knopf's Pocket Flask, Manageable with One Hand, Showing Method of Use 833 12-17. — Pocket Sputum Flasks . 834 18-20. — Three Different Kinds of Paper Pocket Cuspidors .... 835 21. — Pocket Sputum Case of Paper 835 22. — Pasteboard Sputum Cup for Bedside 835 23. — Aluminum or Porcelain Spit Cup for Bedside 835 24. — Large Hygienic Pasteboard Cuspidor for Use in Factories, Public Buildings, etc 836 25-26.— Pasteboard Filler and Tin Frame Holder of an Individual Cuspidor (Portable) 836 27. — Crematory Basket and Fillers 836 28-30. — Sanitary Cuspidors to be Attached to Wall, Closed, Open, and in Use 837 31.— Wall Cuspidor 837 32-37. — Elevated Cuspidors for Use in Sanatoria or Public Buildings . 838-839 38. — Telephone Fitted with Paper Screen to Prevent Infection . . . 839 39. — Suction Mask for the Treatment of Pulmonary Tuberculosis by Hy- peremia 840 40. — Suction Mask Adjusted to Face 840 41. — Humidifier for Hot-air Registers 840 42. — Hair Hygrometer Registering Directly Relative Humidity . . 840 43. — Reclining Chair of Bamboo, with Patient in Sleeping Sack . . . 841 44.— Reclining Chair of Steel Tubing 841 45-47. — Portable Cot, Occupying Little Space when Folded .... 842 48. — Rest Cure at Home, in a Wicker Chair, Padded on the Inside . . 843 49. — Half-tent with Patient Resting on Metal Reclining Chair . . . 843 50.— Steel Frame for Half-tent Folded Together 844 51. — Portable Tent Cot, Opened and Folded 844 52. — A Simple Inexpensive Tent for Tuberculous Patients .... 845 53. — Various Ventilating Devices of a Tent 846 54.— Portable Cottage 847 55. — Tent on Grounds of Bellevue Hospital, New York 847 56.— Irving Fisher's Tent 848 57.— Dr. Biggs's Adirondack Tent House; It can be Used with Perfect Com- fort During Eight or Nine Months of the Year 848 58. — Elevations and Floor Plan of Dr. Biggs's Adirondack Tent Hou.se . 849 59.— Plan and Section of a Ventilated Tent 850 60.— Details of Roof Ventilator on a Tent 851 61. — Permanent Arrangement for Open-air Treatment in a Country Home . 852 62. — Original Sleeping Balcony in Hanover, Mass 852 INTRODUCTION INTRODUCTIOX Rv WILLIAM OSLER HISTORICAL SKETCH The history of tuberculosis may be read in full detail in several monographs/ Here it will suffice to give a brief sketch of the stages in the development of our knowledge; and perhaps a clearer idea of its evolution may be had by a division into four periods corresponding with the gradual recognition of the great facts in connection with the disease. Wliile these epochs overlap, each represents a special contribution. Better than any other acute infection, tubercidosis illu.strates the methods by whicli we have slowly reached our present knowledge. Dur- ing a prolonged period the objective features of disease alone attracted attention, and the modes in which it could he recognized were system- atized and defined. For centuries diseases presented only this semeio- logical phase and nothing was known of the morbid appearances or of the cause, and consequently no efficient steps could be taken for their prevention. At the beginning of the nineteenth century most of the common infections had not got beyond this stage. Not one illustrates more fruitfully than tuberculosis the slow but sure advance of science and of its practical application /or the benefit of humanity. I. Semeiological. — The title of one of the lost books of Democritus, On Those Who Are Attaclced with a Cough after Illness, probably indi- cates that the pre-Hippocratic writers had practical knowledge of cer- tain features of tuberculosis. In the Hippocratic writings there is much of importance. The disease was recognized as a fever; the association with hemoptysis and with pleurisy was known; an excellent description was given of the phthisical habit and of the general appearance of the chest and of the bulbous fingers. The cause was simple— dropping of the pituita from the head into the lungs produced ulceration and fever. Galen did not get much beyond the Hippocratic standpoint, but he is very specific in a strong recommendation of milk diet and a dry climate in the disease. The clinical picture by Aretaeus is one of the best in literature. Celsus, too, has an admirable account and distinguished pulmonary phthisis from the other species of tabes, namely, atrophy • Waldenburg, Predohl, Johne (see Bibliography). 3 4 INTRODUCTION and cachexia. He rccoiimioiKlcd long sea vo3'ages, cliange of climate, particularly Egypt, and a milk diet. There are indications in the old Greek writers that they knew of the contagiousness of the disease. Not much was added to the symptomatology by the Arabian scliool, which followed slavishly Hippocrates and Galen. Nor did the writers of the Renaissance add much, but Fracastorius recognized very clearly the con- tagious character of the disease, regarding habitual residence with a consumptive as one of the most common sources. He insisted that the germs could remain attached to the clothing and rooms for a year or more. In the seventeenth century tlie disease was much more fully con- sidered, and special monographs liegan to be written. Among these the Phthisiologia of Richard Morton, 1089, is perhaps the most important. He recognized the wide prevalence of tuberculosis of the lungs: " Yea, when I consider with myself, how often in one year there is cause enough ministered for ])ro(lucing these Swellings, even to those that are wont to observe the strictest Rules of Living, I cannot sufficiently admire that anyone, at least after he comes to the Flower of his Youth, can dye without a touch of Consumption." He recog- nized the two types of fever, the acute inflammatory at the beginning and the hectic toward the end. Altogether, the work indicates a wide and accurate knowledge, and the intestinal, the pleural, and the throat symptoms are well described. He had a strong belief in the curability of consumption in its early stages, but warns of its liability to recur. From no seventeenth-century work do we get so interesting a picture of the knowledge of the period, and it is from the hand of a highly educated physician of wide experience. IMorton fully appreciated, too, the contagious nature of the disease and gives some striking illustra- tions. In the writings of Sydenham are to be found many interesting sections on phthisis, but his special contril)ution was the insistence of the value of fresh air and of horseback riding in the treatment of the early stages of the disease. His remark on the latter is worth quoting: " I am sure that if any physician had a remedy for the curing of a phthisis of equal force with this of riding, he might easily get what wealth he pleased." If we except Auenhrugger's invention of the art of percussion, I do not know in the eighteenth century of any single contribution of the first rank to the symptoms or signs of tuberculosis, and in the popular text-books on physic at the latter part of the century, and even in the early part of the nineteenth century, as, for example, Cullen's " First Lines," there is not much beyond the description given by Morton. The modern study of the clinical features of the disease dates from the publication of the immortal work, de l' Auscultation Mediate, 1819. Not only did Laennec describe the disease anatomicallv and recognize the HISTORICAL SKETCH 5 pliysical signs, hut he gave us the first careful study of the healing of tuberculosis, and his article (1819, i, 19) remains to-day one of the best descriptions, clinically and anatomically, of this process. We have here, too, one of the first, as it is to-day one of the best, accounts of the sputa of consumption. Within the next fifty years the careful studies of Andral and Skoda, C. B. J. Williams, Stokes, Austin Flint, and many others, gave clearness and accuracy to our knowledge of the symptoms and physical signs of the disease. II. Anatomical. — Franciscus Sylvius (161-1:-1672) was the first to describe accurately tubercles in the lungs. He attributed them to en- largement of small glands following upon a scrofulous constitution. He knew that they caseated and broke down to form cavities. He regarded phthisis as identical with ulcus puhnonum. Manget, in his edition of the Sepulchretum of Bonetus, 1700, described for the first time miliary tubercles. In an autopsy of a person dead of phthisis granules were found in the lungs, liver, spleen, kidneys, mesenteric glands, and intes- tines, which he compares to semen millii. Morgagni did not add much of importance. He raised the question whether the tubercles were really glands. Stark, Avhose works were published in 1785, fifteen years after his death, gave to miliary tuberculosis its proper pathological and clin- ical position. Thomas Eeid, 1785, insisted that the tubercles were not really glands. Bayle, 1810, is the founder of the modern patholog}' of tul)erculosis. He describes the stages of development and accepts the miliary tubercle as the starting point. At first firm, later they soften and are finally destroyed by suppuration. Such tubercles he describes in nearly all the organs, and. he recognized that in these various parts of the body they were related, genetically and clinically. For him phthisis was a general disease of a specific nature and by no means to be considered the result of inflammation of the glands or of the lym- phatic system. The cheesy substance was a specific material character- istic of the process. He held that inflammation never caused tubercu- losis and that the hemoptysis was the result and not the cause of pulmonary ])hthisis. Laennec agreed with Bayle in regarding the miliary tubercle as the starting point, and held that the miliary granule of Bayle was simply the forerunner of the tubercle, the two bearing to each other the relation of green and ripe fruit. He recognized but one cause of true phthisis, namely, tuberculosis, and he simplified very much Bayle's classification and separated from the disease pulmonary gangrene and carcinoma. The modern view of the unity of phthisis dates from the work of Laennec. Great confusion arose in the middle of tlie nineteenth century by Yirchow's attempt to disprove the spe- cificity of the caseous tubercle in which he saw only one form of tissue necrosis. The term tubercle he restricted to the miliarv granule of 6 INTRODUCTION Bayle and Laennec, and the miliary tubercle he classed with the lym- phomata, developing in preexisting lymphoid tissue. He thought that caseation in the lungs arose from other processes than tuberculosis. This led to the heterodox views of Niemeyer and others, who carried the dualistic view to such an extreme that they believed the worst fate to happen to a consumptive was for him to become tuberculous. In 1857 Buhl showed that acute miliary tuberculosis was a specific infec- tious disease. In twenty-three cases he found in twenty-one cheesy nodules, yellow tubercles, or other tuberculous foci. The specific virus was regarded as coming from these cheesy nodules from which the poison was disseminated throughout the body. This prepared the way for the third and all-important stage in the history, and led to the discovery of the true cause of the disease. III. Etiological. — Cruveilhier, in 1826, undertook systematic inocu- lation experiments, but he thought that tuberculosis resulted from the inoculation of a variety of substances and was not specific. But even before this, in 1789, Kortum attempted inoculation experiments with scrofulous material. In 1843 Klencke stated that tuberculosis was inoculable and made successful experiments in support of this view. A French army surgeon, J. A. Villemin, conclusively demonstrated that tuberculosis was a specific infectious disease. His original paper was read before the Paris Academy of Medicine, December 4, 1865. His epoch-making work. Etudes sur Ja Tuherculose, published in 1868, is one of the most remarkable contributions ever made to scientific medicine. The experiments were conducted with the greatest care and accuracy, and his work everywhere shows the brilliant scientific investi- gator. For the period his conclusions were novel and far-reaching, and it is not surprising that they were received with a great deal of scep- ticism. First, tuberculosis is a specific infection; secondly, it has its origin in an inoculable agent ; thirdly, inoculation from man to rabbits is very successful ; fourthly, tuberculosis belongs, therefore, to the viru- lent diseases and should be classed with small-pox, scarlet fever, syphilis, and more particularly with glanders. In 1877 Cohnheim clinched the question of inoculability by his brill- iant experiments (with Salomonsen) in inoculating tuberculous mate- rial into the anterior chamber of the eye of the rabbit. The sources of error in previous experiments were eliminated and conclusive proof offered of the specificity of tulierculous material. Klebs was the first to undertake feeding experiments with tuberculous material, and he was able to really cultivate a vinis on egg albumen through several generations, and he narrowly missed the detection of the bacillus. The final etiological demonstration was reserved for Koch in 1883, who Toinid a definite bacillus in all forms of tuberculous lesions. He was HISTORICAL SKETCH 7 able to cultivate the organism through many generations, at the end of which it was inoculable. His observations were quickly confirmed, and it is not too much to say that no single discovery in disease has had a more wide-reaching influence. The remarkable tuberculosis campaign, inaugurated in the eighties, derived its inspiration directly from his work. Many minor points in the etiology remain unsettled, but the great fact remains — the enemy is known, its life history is known, the mode of entrance into the system is known, and this has heen followed by the fourth stage in the history of the disease — the period of IV. Prevention. — It was the French who awoke to the fact that in the fight against tuberculosis organization was the first essential, and under the presidency of Chauveau congresses were inaugurated and an attempt made to influence public opinion. The past twenty years has seen one of the most remarkable revolutions ever attempted in sanitation. Throughout the world the most intense interest has been stimulated in the fight against the white scourge. Governments have appointed commissions, local congresses have been held, local societies formed, national associations exist everywhere, and an important international congress meets triemiially, a permanent international bureau exists, and, above all, a universal enthusiasm has been aroused which has enabled the battle to be carried on with an extraordinary measure of success. The three important factors concerned with the effective prevention of the disease are a knowledge of the means of transmission, a recog- nition of the importance of social and personal environments, and a conviction that if taken early and properly treated the disease may be arrested or cured. A knowledge of the sources of infection has been the most potent element in the. institution of sound measures for pre- vention. Hereditary transmission, formerly thought to be one of the most important modes of conveyance, is now believed to play a very minor role. A few cases of congenital tuberculosis occur, but the num- ber reported in man is very small. On the other hand, a constitutional susceptibility may be transmitted — i. e.. a soil favorable to the growth of the bacillus. The study of the statistics of inheritance in tubercu- losis has received a fresh impetus from the work of Karl Pearson, who has applied the new biometric methods to the problem, and his con- clusions conlirm the belief, intensified in the profession of late years, as to the importance of what the French call heredite de terrain. He concludes that the diathesis of pulmonary tuberculosis is undoubtedly inherited and that the intensity of its inheritance is comparable with that found for normal physical characters in man. After the work of Comet the belief became general that tuberculosis was transmitted by dust-I)orne dry sputum, and the chief avenue of infection was through the lungs. Flugge modified this air-borne view by showing that the 8 INTRODUCTION danger was not so much from the dust as from infected droplets of mucus and saliva thrown off from the patient in the acts of coughing, speaking, and sneezing. Infection was also thought to be derived from the milk of tuberculous animals. In 1901 Koch denied the suscepti- bility of human beings to the bovine type of tuberculosis. Commissions in Germany and England have made exhaustive reports, which on the whole are opposed to this view of Koch and show that the bovine form is capable of transmission to the human species. In recent study on the modes of infection von Behring discredits largely the dust-borne infection, and holds that the disease is communicated to the child through the bovine milk. The bacilli readily pass the intestinal mucous membrane and lodge in the lymph glands of the mesentery and of the bronchi, where they remain latent until debilitating circiimstances — an acute infection, for example, such as measles — afford an opportunity for successful attack of the latent germs. The general result of von Behring's work has been to call attention to the frequency of infection through the alimentary tract, particularly in children, and through the tonsils and the glands of the neck. Poverty and tuberculosis are everywhere associated, particularly in the large centers of population. The Vienna figures quoted by Bul- strode (*()8) illustrate this in a striking manner. In District No. 1, the best portion of the city, the death-rate from tul)erculosis was 11 per 10,000 of the population ; the income-tax payers amounted to 25 per cent of the population, and the illegitimate births to 0.8 per thou- sand, whereas in District No. 10, the poorest section of the city, the death-rate from tuberculosis was 67 per 10,000 ; the income-tax payers 9.2 per cent of the population and the illegitimate birtlis 9.2 per thou- sand. This is the case all over the world, and is brought out in a striking manner by the figures collected by Bulstrode in his report. Wherever the population is so crowded that the families live in one or two rooms the tuberculous death-rate is fully doul)le that of districts in which the families live in houses with four rooms and upward. Alcoholism is another factor, the importance of which has been dealt with, particularly by French observers. Neither in England nor in America is the available evidence so striking, but there is no question, I think, that the chronic alcoholic is more prone to succumb to tuber- culosis than the temperate man or the teetotaler. Of course we have to recognize the very widespread prevalence of infection, and only a comparatively few persons reach the age of fifty without a focus somewhere of tuberculosis. Niigeli's estimate of ninety per cent may l)e high for some localities, luit even if we take a moderale percentage of fifty it shows what an enormous number of persons have in them the possibility at least of liecoming seriously diseased. In some AMERICAN WORK ON TUBERCULOSIS 9 il is a siiuill jipical j)U('kerin<:^. llic I'csult of a local infection years before indicated |)erlKi|is al the tiuni by some obscure illness. Another has a small caseous focus iucaj^sulated beneath tiie pleura, a third has the bronchial glands involved, while a fourth has a focus or two of case- ation in the mesenteric glands. Upon the personal hygiene of the indi- vidual depends largely whether or not he becomes consumptive. All debilitating circumstances render the body less able to keep the invader in check. Following directly upon this increased knowledge of the etiology of tuberculosis has come the gratifying recognition of the curability of the disease and of the proper means to be taken for its prevention. We know what the germ is and how it is transmitted. We are able to take measures to prevent its spread in the community, and we know, too, that the nature of the soil is of quite equal importance to the germ. All this has had a direct l)earing upon the measures taken for the treat- ment of the disease. Statistics show very clearly that with the im- provement in general sanitation there has been a remarkable reduction in the death-rate from tuberculosis. The death-rate has fallen steadily in the past sixty years from 38.8 per 10,000 in the quinquennial period 1838-42 to 12.1 per 10.000 in the quinquennial period 1901-1905. This is an extraordinary record and almost justifies the hope that tuber- culosis may ultimately come within the category of such diseases as leprosy, typhus fever, and malaria, which have been practically abolished. The early recognition of the disease is now everywhere regarded as the first essential in the successful cure of a case. At present we are in the sanatorium phase of treatment, and from the work of Brehmer, Dett- weiler, Trudeau, and others we have learned very important lessons in the proper management of cases. But the disease is so widely prevalent that we can never hope to place sanatorium treatment at the disposal of more than a very small percentage of the patients. The brunt of the battle must be borne by the practitioners at large. The better they know the disease, the better equipped, they are to recognize it early, the more intelligently will they appreciate the conditions under which, even in homes, it may be arrested or cured. AMERICAN WORK ON TUBERCULOSIS Some of the 7uore distinguished American students of tuberculosis may here he mentioned. Benjamin Hush, the American Sydenham, was a very careful student of the problem, and several of the first papers on the disease published in America are from his pen. He regarded it as a debility affecting the whole system, and the cough, ulceration, and purulent discharges from the lungs were the effects of the disease. 10 INTRODUCTION He had Sydenham's views of the vahie of open air and exercise in treatment. He doubted very much if it was contagious. Rush was one of the first students of climatology in America. Samuel George Morton, the celebrated craniologist, was a pupil of Laennec, and learned at first hand from the great master the essentials in the pathology and diagnosis of the disease. In 1834 he published a volume on " Pul- monary Consumption" (the first issued in the United States), which contains a great deal of original matter. Among the American pupils of Louis, William W. Gerhard and Henry I. Bowditch became the rec- ognized authorities on tuberculosis in their day. In 1842 the former published a work on the " Diagnosis, Pathologj^ and Treatment of the Diseases of the Chest." He was one of tlie first to contribute a careful study of tuberculous meningitis. Tliroughout a long and active life Bowditch was always interested in consumption. He early introduced aspiration in pleural effusion, and his study of consumption in New England was a very valuable contribution to the disease. By far the ablest and most scientific of American students of the disease was Austin Flint, whose contributions to the physical signs and the symptoms were among the most important of his many clinical studies. His work on " Phthisis " is of value to-day. There were many other students of the subject, but the names I have mentioned are the most important among those who have passed away. In the past two decades the United States and Canada have seen an astonishing revival of interest in the disease, all aspects of which are being studied with the greatest en- thusiasm. PART I ETIOLOGY AND MORBID ANATOMY CHAPTER I ETIOLOUY— THE TUBERCLE BACILLUS By MAZYCK p. RAVENEL History. — In 1865 Villemin, in his first communication to the French Academy of Medicine on the inoculability of tuberculosis, fore- shadowed the nature of the virus in the following words : " Tubercu- losis is the effect of a specific causal agent, of a virus. This morbid agent ought to be found, like its congeners, in the morbid products which it has determined by its direct action on the normal elements of the affected tissues introduced into an organism capable of being affected by it. This agent ought then to reproduce itself, and to repro- duce at the same time the disease of which it is the essential principle and the determining cause." In 1877 Klebs, studying tuberculous products by means of his method of fractional cultures, obtained a growth to which he gave the name " monas tuberculosum," and which he believed capable of repro- ducing the disease when injected intraperitoneally into animals. Schiil- ler ('80) repeated the experiments of Klebs, and obtained like results. In 1881 Toussaint obtained. a growth from tuberculous products, injections of which produced tuberculosis, as proved by the subsequent findings of tubercle bacilli in the tissues of the inoculated animals. In the light of present knowledge it is evident that some true tubercle bacilli must have been carried over from his original material into his cultures. It remained for Robert Koch, in 1882, in a masterly series of studies to demonstrate the true nature of the bacillus of tubercu- losis and to obtain it in pure culture. The immense amount of work which has been done since that time has only served to confirm the accuracy of his discovery and to define certain types of the bacillus found in different species of animals. Types of Tubercle Bacillus. — Soon after the announcement of Koch's discovery, very confusing and contradictory results were obtained by French investigators. Exchange of cultures and further experiments proved that the French were working with cultures obtained froin birds, which showed striking differences in growth and virulence fiotn the mammalian bacillus. 13 14 ETIOLOGY— THE TUBERCLE BACILLUS Ai-iau Tuberculosis. — Tuborculo^is in birds differs markedly from the disease as seen in mammals. It affects almost exclusively the organs of the abdomen, }3rincipally the liver, which is enlarged and packed with tuberculous granules. The spleen is almost always affected, showing small whitish nodules. The intestine is rarely ulcerated, but constantly contains nodules which tend to occupy the serous surface. The most striking peculiarity is, however, that the lungs are practically never in- volved. Lesions of the joints, mouth, pharynx, nose, and eye are met with. Whatever the location or character of the lesion, it contains myriads of bacilli, often so packed together as to obscure the anatomic elements. Bovine Tuberculosis. — In 1896 and 1898 Theobald Smith called attention to certain differences between the tubercle bacilli obtained from human sources and those from cattle. These differences appear in the morphology, cultural characteristics, and staining reactions, though the most marked feature is the vastly greater pathogenic power for prac- tically all experimental animals shown l)y the bovine bacillus. Tuberculosis in cattle presents certain points of difference from the disease as seen in man. Among these may be mentioned the marked tendency of the lesions in cattle to undergo calcification rather than caseation, as seen in man, and the involvement of serous surfaces, such as the pleura>, peritoneum, etc.. with the formation of new growths, beginning as minute, gray, translucent nodules, which increase in size by the proliferation of connective tissue about them and form clusters which assume shapes like bunches of grapes, mulberries, or a cauli- flower, hence the names, " Perlsucht," "grajjc disease." These new growths are frequently very large, even reaching sixty pounds in weight. There is also less tendency to secondary infections, and consequently •the ulcerative type of the disease is not common, though large caseous abscesses are frequently seen in the lungs, as well as in other organs. Tuberculosis is met with in practically every known animal which has come in contact with man. The bacillus isolated from these various animals has always, up to the present time, belonged to one of the two types, human or bovine, and the infection can often be traced to one or the other source. No other species of animal has been found to be affected so constantly with tuberculosis nor to harbor a type of bacillus with such marked characteristics as to warrant a further classification of mamnuilian tubercle bacilli. Other types of tubercle bacillus have been isolated from cold- blooded animals, such as the fish tubercle bacilhis of Dubard, that found in a turtle by Friedmann, and that produced by Moeller by inoculation of a slowworm with a mammalian culture. These cultures approach the acid-fast group in their characteristics, and there is no evidence that they ever produce disease in man. STAINING 15 Morphology of the Tubercle Bacillus. — The morphology of the tubercle bacillus varies according to its origin, the length of time it has been grown on artificial culture media, the composition of the cul- ture media, and the age of the individual culture examined. Two types of bacilli are found in man, the human and the hovine. The human bacillus is a slender rod 0.3 /x in thickness and from 1.5 fx. to o fi long, its length being from about one fourth to one half the diam- eter of a red-blood corpuscle. Longer forms are sometimes met with. The rods are straight or curved and occur singly, in pairs, or in small bundles. In old cultures, filamentous clubbed and branched forms are not infrequently seen. The bacilli often stain unevenly, presenting a beaded appearance, due to unstained areas along the rod with deeply stained portions between them. The bovine ])acillus is shorter than the human organism, seldom being more than 2 ju, in length, and is somewhat thicker. The rods are straight and often spindle-shaped. Very short forms are common, the length being not more than twice the thickness. They take the stain evenly and deeply, beaded forms not being common, though sometimes seen, especially in tissues. The two types are quite tenacious of their characteristics, but tend to approach each other under prolonged cultivation, the bovine bacillus coming to resemble the human more closely. Capsules of Schron. — These are round, oval, or elliptical bodies, from 1 /* in diameter to 5-6 fi long and 2-3 /u, in breadth, the largest exceeding greatly the tubercle bacillus in size. They stain deeply with carboi-fuchsin but decolorize by Gram's method. They are found in tuberculous tissues, especially glands, quite frequently, and are believed to be involution forms of the tubercle bacillus. Walsham states that they are sometimes seen in pure cultures of the tubercle bacillus. Staining. — The tubercle bacillus stains with difficulty, owing to the large amount of fatty or waxy matter it contains (ten to forty per cent), but having once taken the stain, resists decolorization strongly, a characteristic which enables one to distinguish it readily from the vast majority of other bacteria. In the examination of sputum one can usually be safe in depending entirely on this characteristic, but when examining feces and urine or certain tissues, further precautions must be taken which will be spoken of later. Various stains have been proposed for demonstrating the tubercle bacillus, but the great superiority of the Ziehl-Neelsen carboi-fuchsin stain over all others has led to its practically universal adoption. Saturated alcoholic solution of fuclisiii 11 c.c. Solution carbolic acid in water (five per cent). . 100 c.c. 16 ETIOLOGY— THE TUBERCLE BACILLUS In practice a .small portion of the material to be examined — sputum, pus, scraping of tissue, cultures, etc. — is spread evenly and thinly on a cover-glass or slide and dried in the air. Next the glass is passed through an alcohol or Bunsen flame three times with about the speed one waves the hand to a friend, the film side being uppermost. This "fixes"' the material. Sufficient stain is used to entirely cover the film and heat is a|)plied until steam arises. This is ke|)t up for three to live minutes; the preparation is then washed in water and decolor- ized until it becomes a faint pink. In doing this it is alternately put in the decolorizer and washed in clear water. The preparation nuiy then be counterstainod with methylene blue, washed, and examined wet, or else dried and mounted in cedar oil or balsam. The examination is preferably made without a counterstain, especially if the tubercle bacilli are few in number, since the deeply stained rods stand out very clearly in the practically unstained field, and can scarcely escape detection. For decolorization sulphuric and nitric acids are the best, and liave been used in various strengths up to thirty-three per cent, though the stronger solutions are now seldom employed. The most satisfactory solution for decolorization in the writer's experience consists of Nitric acid (concentrated) 5 parts. Alcohol (eighty per cent) 1)5 " A very convenient method for the practitioner is that of Gabbett, in which the decolorizer is combined with the counterstain. The film is stained with carbol-fuchsin, as described above, washed and flooded Avith Gabbett's solution, which should be left on cold for thirty to forty-five seconds, and then washed off in an abundance of water. Gab- bett's solution consists of Methylene blue 3 parts. Sulphuric acid 25 " Water 75 " Ehrlich's anilin-water stain is still preferred for some purposes. Its great disadvantage is that it decomposes rapidly, while the carbol-fuch- sin may be kept indefinitely. It is prepared as follows: To 100 c.c. of water add 5 c.c. anilin oil. shake well, then pass through a moistened filler. To the filtrate add drop by drop a saturated alcoholic solution of ini'lliyl violet, or fuchsin, until a metallic luster a])pears on the sur- face. According to Weigert, 11 c.c. of tlie stain is added to 100 c.c. of the anilin watei'. The tubercle bacillus retains the stain when treated with Gram's iodin solution. STAINING 17 In ccrtaiu lesions, and especially in pus from old abscesses and sputum, it is often impossible to demonstrate tubercle bacilli, though inoculation of these tissues will produce tuberculosis. It has been believed by some that the tubercle bacillus formed spores in the tissues Avhich could not be demonstrated, but accounted for the pathogenicity of these lesions. In lilOO Marniorck demonstrated the fact that young tubercle bacilli lost their stain when treated with acid — in other words, were not acid-fast — tliis characteristic being acquired with age and depend- ing on the formation of fatty material. E. Klebs ("04) published confirmatory and more extensive obser- vations. He describes three stages in the development of the tubercle bacillus seen in cultures on liquid media called " veil," " white layer,"' and " yellow masses." In the two first no rods can be demonstrated by the usual fuchsin-acid method. Stained with methylene blue, fine particles, among which are rods and granules, may be seen. Granules are seen in great numbers in the •' veil," while rods are more numer- ous in the " white layer " and stand closer to the tubercle bacillus. Much ('07) investigated the subject, and by the use of a modi- fication of Gram's stain demonstrated two forms of the tubercle bacillus which are not acid-fast. One resembles the ordinary form morpho- logically, while the other consists of granules which may occur singly, in groups, or connected so as to form little rods. They are usually associated with the rod forms, which appear to be the intermediate stage between the granular and acid-fast rods. ]\Iichaelides has con- firmed these findings, and describes a form of the tubercle bacillus which is negative to Gram as well as to Ziehl-Xeelsen, but takes tbe Loffler-Giemsa stain. Herman has for many years employed the following method for staining the tubercle bacillus in sputum, pus, or in tissues. Stain : Crystal violet, three-per-cent solution in ninety-five per cent alcohol. Mordant : Carbonate of ammonia, one per cent in distilled water. These solutions are kept in separate bottles and mixed just before use in the proportion of one part of the stain to three parts of the mordant. The slide, covered with the stain, is heated on a water bath until vapor rises for one minute. It is then decolorized in nitric acid (ten per cent) for a few seconds, and next in ninety-five per cent alcohol, after which it is well washed in water. Iv)siii (one per cent) makes a good counter- slain if it is wisbcd. Merman showed in ISS!) tlial tubercle bacilli conid be demonstrated in tissues bv Ibis method when otlieis failed, lie lias recently compared it willi Die ]>rocess recommended l)y Much, and believes if distinctly superior. Not only does it reveal a greater num- ber of l)acilli in a utable often to tubercu- losis. By inoculation of guinea pigs Dieulafoy found tuberculosis of the tonsil in 15 of 96 cases. Latham, who was careful to use only tlie interior portions of the tonsil, in 45 consecutive autopsies on children from three months to thirteen years of age, found 7 which were tulxn-- culous. Confirmatory results have been obtained by Baup, Friodniann, and other observers. The tonsils are very frequently tul)erculous in persons who die of phthisis. AValsham found tubercles in 21 of 3-L cases examined ]»ost-mortem, and in several he considered the lesion primary. Tubercle bacilli may be lodged in the tonsillar crypts and remain there a longer or shorter time without producing tuberculosis of the tonsil. The results of Dieulafoy have been severely criticised on this ground, and properly so, since he made no histologic examination of the tissues 36 ETIOLOGY— THE TUBERCLE BACILLUS used for inoculation. The work of Latham, with practically identical results, is not open to a similar objection. The tonsils are composed of lymphoid tissue, and no doubt act, to a certain extent, like lymph glands in fdtering out and retaining invad- ing bacteria. Hence, while they may be overwhelmed, and become avenues of entrance for the tuber- cle l)acilhis, they certainly prevent p^'stemic infection for some time. Their ability to resist tuberculous changes is remarkable. Experimentally, the suscepti- 1)ility of the tonsil in some animals has been shown repeatedly. In a series of experiments at the labora- tory of the State Livestock San- itary Board of Pennsylvania on the comparative virulence of hu- man and bovine tubercle bacilli, swine fed with jnire cultures in every instance developed general- ized tuberculosis with marked in- volvement of the tonsils, which were in most instances necrotic and ulcerated. The inspection of swine for tuberculosis by the United States Government is based on the fact, established by careful observa- tion on many thousand animals, that the lymph glands of the neck show the primary lesion in the vast majority of cases (Figs. 1 and 3). Pharynx, Esophagus. — Tubercu- losis of the pharynx and esophagus is extremely rare under any circum- stances, and as a primary infection is practically unknown. It is probable, however, that the intact mucous membrane of the pharynx does, at times, allow the passage of tubercle bacilli, which first make themselves known by the enlargement of the related lymphatic glands. Experimental evidence of this is very strong, though it is, of course, very difficult to place the exact point of entry. In the case of a monkey to whom the writer fed tubercle bacilli on banana, and who died of pulmonary tuberculosis, the glands of the neck r I Fig, 1. — Tongue and Tonsils op Swine Infected by Feeding Tu- bercle Bacilli. Extensive ne- crosis of tonsils, which apparently served as port of entry. MODES OF INVASION 37 were enlarged and caseous, and no lesion of the tonsil was found, so it appeared certain that invasion had taken place through some part of the mouth or pharynx. The habit monkeys have of storing food in the lateral pockets of the mouth renders them peculiarly liable to infection through the mucous membrane of this region. Cornet has also pro- duced experimental infection through the uninjured mucous membrane of the ])harynx. Fig. 2. — Lungs of Swine Infected by Feeding. The intestinal tract and mesen- teric glands free from lesions. Infection probably through tonsils. See Fig. 1. Stomach. — There is no evidence that infection ever takes place through the stomach. Tuberculous disease of the stomach is one of the rarest forms met with. Tlie cause of this apparent immunity is not evident, but is attributed by some to the hydrochloric acid of the gastric 38 ETIOLOGY— THE TUBERCLE BACILLUS juice. Nvinierous experiments have been made to determine the action of the gastric juice on the tubercle bacillus (Falk, Wesener, Strauss and Wurtz, Frank and Fischer, Cadeac, etc.), both artificial and natural juice having been emi)loyed, by which it has been shown that the tubercle bacillus is able to survive intimate contact with gastric juice for at least as long as the ordinary digestive period. Clinical experience has also proved that infection of the intestine through swallowing sputum con- stantly takes place in phthisis. Further proof of the ability of the tubercle bacillus to resist for some hours the reaction of the gastric juice is found in experiments made to demonstrate the permeability of the intestinal mucosa (Dobroklonski, Nicolas and Descos, Eavenel, Cal- mette, etc.) in phthisis. Intestine. — The frequency of intestinal tuberculosis in phthisis has just been mentioned. The autopsy reports of various pathologists state that it is found in from thirty to ninety per cent of cases. It is certain that in the great majority of these the actual lesion is secondary, and due to the swallowing of sputum laden with bacilli. This does not, however, in any way preclude the possibility that the pulmonary disease was caused in the first place by tubercle bacilli which gained access to the body through the intestine. In other words, the location of the primary lesion, on which so much stress has been laid, does not indicate with certainty the point of entrance of the invading organism. In regard to primary intestinal tuberculosis — that is to say, those cases in which the oldest or primary lesion is found in the intestine itself or in the related glands — the reports from pathologists are con- tradictory. This is probably due, in part, to a difference in methods of examination and interpretation of results, and doubtless also, in part, to a real difference in the incidence of such cases in different communi- ties, brought about by local customs and habits. In all reports a con- siderable number of cases are found in which it has been impossible to determine the site of the primary lesion. It is very difficult to draw entirely correct conclusions from many of the reports, since they have been made to demonstrate certain points, and do not give details as to other important features. In England the pathologists who have studied tuberculosis in chil- dren are practically unanimous in considering that infection frequently takes place through the intestinal tract, since they find in the related glands evidences of the primary lesion. Still, Symes and Fisher, Shen- nan, Guthrie, Carr, Ashby, Batten, Kingsford, report on 1,560 autopsies, in which the primary lesion was found in the intestine 290 times, or 18.6 per cent of all cases. In America, Northrup, Holt, and Bovaird report on 369 cases, all in New York or its environs, with 5 of intestinal origin, a little more MODES OF INVASION 39 than 1 per cent. Holt contributed 119 of these autopsies, in none of which did he consider the intestine the seat of the primary lesion. It is interesting to note, however, that he found the mesenteric glands involved in 35 per cent and the intestine in 37 per cent of these cases. Hand reports from the Children's Hospital of Philadelphia 115 autopsies on tuberculous children, with 10 cases (8.7 per cent) of pri- mary intestinal localization and 1 of tonsillar invasion. In 29 cases the site of invasion could not be determined. In this connection the work of Councilman, Mallory and Pearce is most instructive. They found tuberculosis in 35 of 220 children dead of diphtheria. In 18 of these the mesenteric lymph nodes were tuber- culous, with involvement of the intestine 6 times; and in 7 cases the mesenteric glands were diseased without involvement of any other part of the body. In 13 cases (37.1 per cent) the infection evidently occurred through the digestive tract. Statistics from Germany are most confusing and contradictory. Baginsky, in 5,448 autopsies on children, 1,468 of whom were tubercu- lous, found only 14 cases of primary intestinal involvement. In another series of 806 autopsies, 144 of which were tuberculous, he found only 6 in which he considered the intestinal lesion to be the oldest. A third series of figures by Baginsky, often quoted, gives the results of 933 cases of tuberculosis in children, in which he never found intestinal tuber- culosis without involvement of the lungs and bronchial nodes. These figures are without value, as there is no indication of the site of the primary infection. Biedert found only 16 cases of primary intestinal tuberculosis in 3,104 auto])sies on children. Ganghofner, Koch, Heubner, Benda, von Hansemann, and others agree in regarding primary intestinal tubercu- losis as comparatively infrequent. On the other hand, we have a mass of testimony from equally reliable observers which agrees very closely with the figures from England. Hueppe, without giving statistics, says that "the number of cases (primary intestinal tuberculosis) may fairly be reckoned as between 25 and 35 per cent of all deaths in children from tuberculosis." Hof, in a systematic study of the autopsy records of the Pathological Insti- tute at Kiel, found 2,697 cases of tuberculosis in adults, 159 (5.9 per cent) of which were primary in the intestine, while in 84.9 per cent the respiratory tract was primarily involved. In children there were 936 cases of tuberculosis, 235 (25.1 per cent) of which showed evidences of infection through the intestine, and 527 (56.2 per cent) resjuratory infection. Wagener (Kiel), in 600 autopsies, 76 of which were on chil- dren, found primary intestinal tuberculosis in 16, or 21.1 per cent. Heller, in 714 fatal cases of di])htheria, found tuberculosis 140 times, 40 ETIOLOGY— THE TUBERCLE BACILLUS in 53 (37.8 per cent) of which the origin was ])rimary in tlie intestine. In a later series of 230 autopsies, Heller found intestinal tuberculosis in 12 per cent of adults and 26 per cent of children. Nebelthau, in 26 autopsies on tuberculous children, at the Halle Polyclinic, found that the infection was primary in the intestine in 5 (19.2 per cent), and in the respiratory tract in 9 (34.6 per cent), while in 12 (46.1 per cent) both tracts were infected. Kossel, in 14 children dead of other diseases, found tuberculosis of the bronchial glands 10 times, and of the mesenteric glands 4 times. In 22 children who died of tuberculosis, he found the disease confined to the intestine only once. Lubarsch, in 297 autopsies on children, found tuberculosis in 63, of which 14 (21.2 per cent) were primary in the alimentary tract. Studies on the bodies of children who died of other diseases, such as those reported by Councilman, Mallory and Pearce, Heller, and Kos- sel, are particularly valuable in the determination of the avenue of entry for the tubercle bacillus. It is well known that in children tuber- culosis tends to become generalized rapidly, and at autopsy it is fre- quently impossible to tell by what route the infection took place. When death has come from other causes, the tuberculous lesion is usually localized, and often confined to the glands which are in relation to the point of invasion, hence the portal of entry can be determined with great certainty. In a most masterly study Harbitz gives the following table of his own results obtained from 117 cases: Primary in respiratory tract 48 cases, 41 per cent. Primary in digestive tract 2G " 22.0 " Primary in digestive or respiratory tract. . 24 " 20.5 " General lymph-node tuberculosis 11 " 9.4 " Doubtful, or other primary seats 8 " 6.8 " For the sake of fairness, statistics have been given at some length in order that the reader may know the ground for the conclusions arrived at and be able to judge of their soundness. As stated before, however, the site of the primary lesion does not always indicate the point of entrance of the tubercle bacillus, and this is probably especially true of infection by way of the intestine, though it has been shown by numer- ous experimenters (Cornet, Dobroklonski, Desoubry and Porcher, Nico- las and Descos, Eomer, Eenshaw, Sidney Martin, Eavenel) that the mucous membrane of the various parts of the body can be penetrated by the tubercle bacillus without previous injury and without demonstrable lesion. This opinion is now very widely held by pathologists, owing to the extreme frequency with which various groups of glands are found MODES OF INVASION 41 lo be tuberculous, with no demoustrable lesion of the mucous surface which they drain. In many of the feeding experiments especial care Fig. 3. Fig. 4. Figs. 3 and 4. — Tuberculosis of the Intestines and Lungs of a Monkey Fed WITH Tubercle Bactlli. (Probably pulmonary infection through intestines.) 42 ETIOLOGY— THE TUBERCLE BACILLUS has been taken to avoid injury of the alimentaiy tract, the bacilli hav- ing been mixed witli milk given on baiianas, etc. Tn some experiments a purge of castor cnl was given to fiee the intestine of all rough matter it might have contained, and the animal fed on soft foods for a num- ber of days before the infected meal was given (Figs. 3 and 4). Harbitz considers it perfectly reasonable to believe tiiat tubercle bacilli may pass through one or more groups of lymph nodes before becoming stationary and setting up inflammation, supporting this view by the results of certain feeding experiments, in which the thoracic glands have been found to be tuberculous without corresponding disease of those in the abdomen. Entrance of tubercle bacilli and otlier organisms through the intes- tinal wall without demonstrable lesion has been proven repeatedly, jjegin- ning with the work of Dobroklonski, under Cornil, in 1890, who showed that the tubercle bacillus would quickly penetrate the healthy wall of the intestine in guinea pigs. Desoubry and Porcher, students of Nocard, showed in dogs that during the digestion of fats large numbers of bac- teria were carried through the intestinal wall, and could be detected in the chyle. If food deprived of fat was given, few or even no bacteria were found in the chyle. In feeding experiments conducted at the laboratory of the State Livestock Sanitary Board of Pennsylvania we often observed extensive tuberculosis of the lungs and thoracic glands in animals which showed slight or even no involvement of the intestine. In 1902-3, acting on the suggestion contained in the work of Desoubry and Porcher, the writer introduced into the stomachs of a number of dogs tubercle bacilli suspended in an emulsion of melted butter and warm water, using a stomach tube in oider to avoid possible infection through the trachea. The dogs were killed after three and a half to four hours, during active digestion, and as much chyle as possible collected, together with the mesenteric glands, which were examined microscopically, and also inocu- lated into guinea pigs. Tubercle bacilli were demonstrated in abun- dance in eight out of ten experiments, proving that, during the diges- tion of fat, tubercle bacilli are carried rapidly through the healthy intestinal wall. Romer, with von Behring, has shown that the tubercle bacillus, and even the anthrax bacillus, which is very much larger, passes through the normal intestinal mucosa of young guinea pigs readily. A single feeding with a minute quantity of tubercle bacilli frequently produced tuberculosis. In the infected animals the glands of the neck were always involved, and later there often developed a type of the disease usually regarded as the expression of an inhalation tuberculosis. Von Behring asserts that the origin of epidemiologic pulmonary tuberculosis in man, MODES OF INVASION 43 *and epizootic pulmonary tuberculosis in cattle, is a prinuiry intestinal infection taking place in early infancy. The subject has recently been studied Ijy Caluiette and his fellow- workers at the Pasteur Institute ol' J^ille, (iuerin, Vansteenberghe, and Grysez. In numerous experiments they have found it impossible to produce anthracosis of tlie lungs even when the animals were compelled to breathe an atmosphere saturated with lampblack, provided the esoph- agus was closed. On the other hand, when lampblack was introduced into the stomach by means of a tube, or mixed with food, anthra- cosis of the lungs appeared rapidly. When tubercle bacilli, either dry or moist, were administered l)y inhalation, by intratracheal insufflation, or direct inoculation into the trachea, the bacilli never penetrated far- tlier than the first branches of the bronchi. The introduction of tubercle bacilli into the stomach througli a tulje, in order to avoid all danger of respiratory infection, always produced tuberculosis rajiidly. They confirm the observation that tubercle bacilli readily penetrate the intestinal wall without leaving any lesion. They have traced the bacilli, and found that as soon as they reach the chyle vessels they are taken up by leucocytes, which from this time on act as carriers, and convey them to the related gland, where they are retained for a longer or shorter time, reaching finally the thoracic duct, which, in turn, pours tliem into the pulmonary circulation. They are then arrested in the fine capillaries of the lung. If the leucocyte has taken up many bacilli it soon loses its motility and acts like a toxic foreign body, against which the cells of the vessel wall react, and englobement by one of the cells (endothelial macro- phages) takes place, producing the primitive tuliercle, which is always intravascular. On the other hand, leucocytes which have englobed only one or two bacilli retain for a long time their motility, and when arrested in the capillaries penetrate the vessel walls by diapedesis, reaching the lymphatic channels, which carry them to the bronchial or mediastinal glands. Here they may die, and the contained bacilli produce lesions; or else again reach the thoracic duct and the circulation, by which they are carried to distant parts of the bod}^, being finally killed by the poisons of the bacilli and arrested in the capillaries of some organ or tissue, perhaps the meninges, the kidney, the joints, etc., where a primi- tive tubercle is formed. In young animals the mesenteric glands retain the bacilli and the leucocytes which contain them for some time, and the glands enlarge in proportion to the intensity of the infection, the lungs becoming sec- ondarily involved. In adult animals, on the contrary, the glands do not retain the bacilli nearly so long, and they can be found in the lungs twenty-four hours after their introduction into the stomach. This de- 44 ETIOLOGY— THE TUBERCLE BACILLUS pends oil the niimite anatomy of tlic glands, which arc mucli more permeable in adult than in young animals. Calmette concludes that pulmonary tuberculosis acquired at any age may be due to recent intestinal infection. More recently Schlossmann and Engel have shown that when tubercle bacilli in milk or cream are injected into the stomachs of young guinea pigs through an incision in the abdominal wall they reach the lung in a few hours, as proven by killing the animal and inoculating others with portions of the lung. Eavenel and Eeichel have repeated the work of Schlossmann, and have obtained confirmatory results. Fifty guinea pigs, from sixteen hours to two weeks old, were inoculated directly into the stomach. They were killed from four to twenty-four hours later, and their lungs inoculated into other guinea pigs. The results were positive in 28, or fifty-six per cent, the larger number of these being in the younger animals. Thirty of these pigs were killed after four, five, and six hours, 16 giving posi- tive evidence that in this short time tubercle bacilli had passed from the stomach to the lungs in sufficient numbers to produce tuberculosis in animals inoculated with these organs. Oberwarth and Eabinowitsch have given conclusive evidence on this matter, employing young swane. They established a gastric fistula in these animals, and then closed the esophagus. Tubercle bacilli intro- duced into the stomach were shown to have reached the blood and the lungs within twenty-two hours. Most valuable contributory evidence of the importance of infection through the digestive tract is given in the Second Interim Report of the Royal (British) Commission on Tuberculosis (Part 1, 1!)07). This commission, appointed to study the relation of bovine tuberculosis to the human disease, isolated and examined 60 cultures of tubercle bacillus from human beings. Fourteen cultures proved to be the bovine bacillus — 1 obtained from sputum, 3 from cervical glands removed at operation, and 10 from the lesions of primary intestinal tuberculosis in children. Similar findings have been reported by Ravenel. de Schweinitz, Theobald Smith, the German Commission of the Imperial Health Office, and others. The opportunities for the inhalation of bovine tubercle bacilli by human beings are slight at best, except, perhaps, for persons who habitu- ally care for cattle, and compared to those for ingestion they are insig- nificant. There is almost no possibility, in the case of children, for the inhalation of bovine bacilli, even if we admit that the aspiration of particles of food may occur. We are therefore forced to conclude that in those cases from which the bovine bacillus has been isolated the infection has taken place through the digestive tract. Respiratory Infection. — Experimental demonstration of the possibility of infection through inhalation w^as first given by Tappeiner in 1877, MODES OF INVASION 45 who mado dogs breathe air hideii with dried and pulverized sputum. In later experimcDts by Koch, Cornet, Gebhardt, and others, pure cul- tures of the tubercle bacilli were employed. Many negative results were obtained by other experimenters, such as de Thoma, Celli and Guarnieri, Cadeac and Malet. Cornet believed these failures due to the fact that conditions similar to those of natural infection were not obtained. In 1898 he placed 48 guinea pigs in a large room, at different heights above the floor and in different parts of the room. Dried s])utuni was ])laced on tlie carpet and broken up and distributed by sweeping. Of the 48 guinea pigs, 47 contracted tuberculosis of the bronchial glands and lungs, with partial cavity formation. This work, in common with most inhalation experiments, is o])en to the very grave objection that no attempt was made to close the esophagus, and it is certain that some of the bacillus-laden dust was swallowed. Xenninger has, however, shown that when rabbits are forced to breathe air laden with the Bacillus prodigiosus, cultures can be recov- ered from the finest bronchi. Similar observations have been made by Paul, Fischer, Beitzke, etc. Findel, working with Fliigge, has infected dogs and a calf by blowing a spray of bovine tubercle bacilli into the trachea, which had been previously opened. At autopsy, tuberculosis of the lungs was found, while the tonsils, cervical, retropharyngeal, and mesenteric glands were free from disease, both macroscopic and micro- scopic. Schultze has repeated some of Calmette's experiments, and though after feeding pigment it w'as found only in the lungs, he believes that it reached them through aspiration. He does not consider that the use of a stomach tube excludes the ])ossibility of inhalation. In a rabbit he introduced pigment into th^ stomach through a fistula for two months, and at death was unal)le to find any deposit in the lungs. Spronk also believes that the aspiration of food particles frequently takes place even when a stomach tube is employed. Under his direc- tion Nieuwenh-uyse carried out feeding experiments similar to those of Vansteenberghe and Grysez, but in only one animal was the pigment recovered in the lung, and this was believed to be due to aspiration. In view of the evidence at hand, and which is constantly accumu- lating, it may be said that infection tlirough the alimentary tract is not only possible, but unquestionably occurs in a large proportion of cases. In children, especially, it occupies a position almost, if not quite, as important as respiratory infection. It must not be understood that the source of such infection is always food. Dust which reaches the uj)per air passages and mouth is constantly swallowed with the saliva and nasal secretion. The frequency with which the bovine tubercle bacillus has ])ecn found in children slious, howevei', that food is often respon- sible foi' the infection. 46 ETIOLOGY— THE TUBERCLE BACILLUS ADDENDA Sinnvtari) of Bacteriulogical Work Presented at the International Con- gress, Washington, D. C. Viability of the Tubercle Bacillus. — Dr. M. J. Kosenaii has carried out extensive experiments on the viability of the tubercle bacillus, lie points out the difficulty of telling dead from living tubercle bacilli by inoculation, owing to the production of tubercles by the dead germ, and shows the necessity of making secondary inoculations in all doubt- ful cases. The tubercle bacillus is killed surely by a temperature of 60° C. continued for twenty minutes. Types of the Tubercle Bacillus. — Professor Arloing is a stanch believer in the unity of the tubercle bacillus. All the variations in virulence and morphology are simply changes brought about by envi- ronment. The human bacilli, as obtained from different types of the disease, show marked variation in virulence. This variation is as marked as is the difference usually found between the human bacilli and the bovine bacilli. He has modified both bovine and human bacilli by special methods of culture, showing that it is possible in this way to lower or increase the virulence. He has even produced types closely allied to the avian bacillus. From the standpoint of hygiene his studies emphasize the importance of guarding against all types of the tubercle virus, whatever may be the origin. Investigations into the Eelations between Human and Bovine Tuberculosis. — Profs. J. Fibiger and C. 0. Jensen have made an elabo- rate investigation on tliis point. The authors hold strongly to the unity of the tubercle bacillus, and do not admit a sharp distinction between the bacilli usually spoken of as hunum and bovine. A number of cul- tures show transitional forms having some of the characteristics of the bovine and others of the human type. They believe strongly in the danger to mankind from bovine infection. Dr. Nathan Eaw admits of the differentiation of the tubercle bacillus into two types, the human and the bovine. He holds strongly to the belief that the bovine bacillus is highly virulent for mankind, and produces certain types of tuberculosis as a rule. These are peritonitis, lymphadenitis, acute miliary tubercu- losis, meningitis, arthritis, and lupus. The human type of the tubercle bacillus produces usually pulmonary tuberculosis, ulceration of the in- testines, and laryngitis. He believes that an infection by the human type protects against bovine infection, and vice versa. In his practice he uses the tuberculins in accordance with this view. He has treated about two hundred eases of tuberculosis with the various tuberculins, and is greatly encouraged. ADDENDA 47 Intertransmissibility of Tuberculosis. — Dr. Charles F. Dawson liokls strongly to the danger to mankind of hovine infection. The wide range of pathogenic power of the bovine tubercle bacillus makes it practically certain that it is pathogenic for man also. The infection comes usually from ingesting the products of tuberculous cattle, infec- tion taking place through the alimentary canal. Susceptibility of Cattle to the Surgical Forms of Tubercu- losis. — Susceptibility of cattle to the surgical forms of tuberculosis has been studied by Dr. R. R. Dinwiddie. Intraperitoneal inoculations of material obtained from two cases of glandular tuberculosis, one of arth- ritis, and one of genito-urinary tuberculosis, were made in yearlings without effect. The writer has believed, with Dr. Raw, that certain forms of tuberculosis are of bovine origin, which has not been confirmed by his experiments. Dr. Charles W. Duval has studied the tubercle bacilli isolated directly from the tissues of four human bodies, the disease in each case begin- ning with cervical adenitis, and death occurring in from six to eight weeks after the first symptoms. All cases showed primary lesions in the cervical region and acute general miliary tuljerculosis. Of the four cultures one was human in character and one bovine, the two others representing intermediate forms, one approaching bovine and the other the avian type. Inoculations of animals with these led him to suspect the possible relation between Hodgkin's disease and such bacilli. Drs. J. X. Davalos and J. Cartaya have examined a series of cases in human beings and failed to isolate the bovine bacillus from any of them. Xumber of cases not given. Dr. Hidego Xoguchi has shown that oleate soaps have the power of modifying the virulence of tubercle bacilli. According to the concen- tration used the virulence of the tubercle bacilli is so modified as to infect guinea pigs slightly or not at all. The guinea pigs which failed to develop tuberculous lesions following the inoculation acquired a definite degree of immunity to virulent bacilli. The oleate soaps showed the same effect on tubercle bacilli cultures, very small amounts inhibit- ing the growth or preventing it completely. The bactericidal effect of these soaps is much greater than that of the component parts used separately. He believes that those substances derived by autolysis from organs which are actively bactericidal contain lipoids, and that soaps formed during autolysis are important, if not the chief, factors in this bactericidal action. Drs. N. Jancso and A. Elfcr, from an extensive series of studies made on !)3 tuberculous persons, 11 bovines, 1 pig. and 18 chickens, lind thai all types of bacillus isolated nmy !)(' divided rather sharply inl<» three groups — human, bovine, and avian. Among the cultures derived 48 ETIOLOGY— THE TUBERCLE BACILLUS from Imnian beings, one showed all the characteristics of the avian type, the others all belonging to the human type. The bacillus obtained from the pig belonged to the bovine type. They find, however, that among cultures which can be placed in one category or the other, there are marked differences in many of tlieir characteristics and in virulence. They obtained a number of cultures from human beings which produced death in rabbits, though, as a rule, their human cultures showed ver}' slight virulence for rabbits. Cultures obtained from the different organs of one and the same individual also showed marked variation in impor- tant characteristics. They find that it is relatively easy to modify the characteristics of the various acid-fast organisms isolated, especially their pathogenicity. They have not, however, succeeded in giving them any specific properties, and believe that in nature the more important groups tend to l)ecome more and more clearly differentiated, one from the other. Courmont (J.) and Lesieur show tliat infection may be produced in calves, rabbits, and guinea pigs through the uninjured skin if the culture used is sufficiently virulent. Inoculations with p])utum are not as effec- tive as those made witli jmre cultures. In one third of tlie infections the skin shows no trace of the passage of bacilli, in one third we find sliglit indurations or small scabs, and in one third warty tulx'rcles are found. The skin, therefore, does not form an impossible barrier to the tul>ercle bacillus, even when apparently intact. Abrasions and minor injuries may form portals of entry for distant lesions. The absence of a local lesion does not disprove this mode of infection. In rabbits we may have a pulmonary lesion resulting from percutaneous infection, a marked example of a lesion originating at a point far removed from the point of entry of the bacillus. Carl Frankel also produced infection in guinea pigs through the apparently intact skin. Dr. Isador Spitzstein has performed similar experiments with entirely negative results, and concludes that if per- cutaneous infection is possible at all it is the most unfavorable route for the tubercle bacillus to enter the body. Cultural Characteristics of Tubercle Bacilli. — Dr. Johann von Szaboky finds that agar made from lung tissue forms the best medium for growth of the tubercle l)acillus. The next best media are sputum-agar, sjnitum-lung-agar, and tuberculous lung-agar. The best reaction of media varies with the media. In general feebly acid media seem best. Very moist media, like lung-agar, gave best results, and dry media least good. The tubercle bacillus changes the reaction of the medium during growth. Most media showed first an alkaline reaction, which changed to acid, and again to alkaline. Agar made with soinatose showed changes the exact reverse of this. ADDENDA 49 Ctie:mistry of Tubercle Bacilli. — Dr. X. C. Vaughaii finds that the tubercle bacillus after being freed from substances soluble in ether and alcohol, may be split into two portions by an alcoholic solution of alkali — a poisonous and nonpoisonous. The poisonous portion kills ani- mals after a few months in doses of 75 to 100 mgm. The nonpoisonous portion sensitizes animals to the whole bacillus. It is used in the treat- ment of human tuberculosis, but it is too early to say whether or not it is better for this purpose than old tuberculin. Chamber for Handling Dried Tubercle Bacilli. — Dr. A. P. Kitchens has devised a chamber for handling dried tubercle bacilli with perfect safet}'. It consists essentially of a tight chamber, provided wath a suction pump and a cotton filter for the admission of air. Manijnilation is carried out by means of rubber gauntlets sealed into the wall of the chamber, and the pump is operated during use. After use the pump is cut off and the filter box closed, formalin and lime or permanganate of potash, which were placed in the chamber before use, are mixed, and complete disinfection takes place. It may be used for handling other dry biological products. Action of Diffused Light on Tubercle Bacilli. — John Wein- zirl, Ph.D., finds that direct sunlight kills the tubercle bacillus in from two to ten minutes. Diffused light always killed tubercle bacilli within one Aveek, sometimes in twenty-four hours. He lays stress on the point that no medium which absorbs light shall be placed between the bacilli and the light. Moist cultures were killed sooner than dry ones. It seems certain that light in dwellings, etc., is a valuable germicide. Flies as Agents in Dissemination of Tubercle Bacilli. — Dr. Ch. Andre finds that flies are acfive agents in the spread of tubercle ba- cilli, polluting foodstufi^s with bacilli adhering to feet after contact with sputum. After feeding on tuberculous sputum they evacuate bacilli within six hours, and some may be found in feces as long as five days after. Food thus polluted by flies will infect guinea pigs. Flies caught in hospital wards produce tuberculosis in guinea pigs. It is therefore of prime importance to disinfect sputum and feces promptly and to protect them from flies. Foods must also be protected and flies de- stroyed as far as possible. The transmissibility of bovine tuberculosis to human beings was discussed at a conftn-ence in rainera. The trend of the discussion was put into the hands of Koch, who limited it to two (piestions — first, tlu! frequency of intestinal tuberculosis, and second, the occiirrciicc of I Ik; bovine bacillus in pulmonary consumption. Tn lf)01 Koch said "human tuberculosis differs from bovine and cannot be transmiltcd to cattle," and further tliat " if transmission from cattle to man ever took ]»lare. it was so rare that he did not deem it 50 ETIOLOGY— THE TUBERCLE BACILLUS advisable to take any measures against it." The disproof of the first statement was so easy tliat observers all over the world soon gave numer- ous cases showing its error. Many private workers, as well as a British Eoyal Commission and a German Imperial Commission, soon showed the fallacy of these two statements, as has been pointed out in the body of this book. Koch's ground having been sliown to be untenable, even l)y a com- mission of which lie was a member, he has now shifted, and makes the claim that pulmonary consumption is not caused by the bovine germ. At the conference in question he made the following statement, " I desire to put myself again on record by saying that I have never denied that bovine tuberculosis may occur in human beings," a statement which was repeated more than once. His general conclusion, as given in his paper before the Congress, was that our preventive measures must, therefore, " be directed jjrimarily against the human disease," an opinion which is not by any means original with Koch, but is held all over the world, even l)y those men who believe most firmly in the danger to mankind from cattle tuberculosis. In reply to Koch's demand that cases of pulmonary tuberculosis due to the bovine tuberculosis be brought forward, Professor Arloing at once gave the history of a most typical case. The British Eoyal Com- mission also reported the finding of bovine bacilli in the sputum of a consumptive. It will be remembered also that the German Com- mission found the bovine bacillus in a case of miliary tuberculosis of the lung, though Professor Koch now denies that this case bears on the subject at all — a method of reasoning which cannot be understood by the ordinary mind. In miliary tuberculosis a person usually dies before the tubercles soften and the case becomes an open one, as is well known, but infection of the lung from the intestinal tract is proven by a case of miliary tuberculosis just as much as though the case were one of ordinary consumption. In fact, miliary tuberculosis is believed to be the result of a large number of bacilli entering the blood stream at one time. The evidence then is strong that in such a case the num- ber of bacilli gaining entrance to the system from the intestinal tract is very large. Taking up the second point, in regard to the rare occurrence of pri- mary intestinal tuberculosis, Koch quoted at length from Flligge. He was well answered by Professor Fibiger, of Copenhagen, who, while acknowledging the figures quoted from Orth, Baginsky, and others as having been correct for the year 1901, called attention to the fact that, without exception, these same men had in more recent work found a greatly increased number of such cases. For example, Benda, who in 1903 stated that he had found only 2 or 3 cases during some eighteen ADDENDA 51 iiiontlis, ill liXto said tliat the frequency ol' this form oL" tuljerciilosis was greater tlian he originally thought. Orth, wlio in 1904, during a period of fifteen months, reported 2 eases among 33 children, in 1905 during twenty-two months reported 6 cases among 77 children. Baginsky, who in 1901 had not ohserved a single case of primary intestinal tuberculosis, found 6 cases among 144 children in 1903, and 30 cases among 389 children in 1905. Even these figures do not reach those given by Heller, Hof, von AVagener, Edens, and others. One of two conclusions is obvious, either that these pathologists are finding more intestinal tuberculosis since their attention has been di- rected to it, or else there has been a great increase in this form of disease. Has this been brought about through carelessness in the use of milk from tuberculous cattle, since Koch has publicly announced that there was little or no danger from such use? CHAPTER II TUBERCLE AXD MORBID ANATOMY (General and Pulmonary Tuhercniosis) By LUDVIG HEKTOEN HISTOGENESIS AND FATE Tuberculosis is the result of the activities of the tubercle bacillus, which arouses in the body various reactive changes. Anatomically, tuberculosis manifests itself most characteristically and most commonly by the development of avascular cellular masses or tubercles (Baillie, 1794; Bayle, 1810), but it also may appear in other forms, more par- ticularly as diffuse granulation tissue and as exudative inflammations. The designation " tuberculous " is applicable to all the changes caused by the tubercle Itacillus, no matter whether tubercles are present or not. Origin of Tubercle. — The tubercle is produced primarily by multi- plication of the fixed cells, especially of connective tissue and of capil- lary endothelium at the site of the localization of the microbes. The exact mode of action whereby this cellular proliferation is started has not yet been explained with convincing clearness, but vari- ous interpretations have been offered. Perhaps the most widely accepted explanation is that l)y Weigert, Avho regarded the cellular processes as essentially secondary to " injury " to cells and to intercellular substance by an immediate action of the bacillus. In most tissues the obtainable morphologic indications of such direct injury are not very striking; in tuberculosis of the placenta, however, Warthin ('07) finds unmis- takable evidence of primary chemico-toxic action by the tubercle bacil- lus in the form of minute areas of necrosis, about which typical tuber- cles subsequently develop. As a rule the first definite result of the invasion of many tissues by tubercle bacilli has been found to be (Baumgarten. '8.5) swelling and mitotic division of the fixed cells, which usually arrange themselves in a somewhat radiating manner about the bacilli, some of which soon appear within the cells. Because the cells may present rounded and I)olygonal bodies with vesicular nuclei, and appear to be connected with one another, Virchow designated them as "" epithelial '' cells, and they 52 HISTOGENESIS AND FATE 53 are now commonly ilocribed as rpitheUoid. As tlie epithelioid cells of tubercles in most cases represent proliferative connective-tissue cells and endothelial cells, they correspond in every way to thp fibroblasts in non- tuberculous inflammatory processes. In parenchymatous organs tuhercle formation is commonly asso- ciated with evidences, in the form of mitotic figures, of active multipli- cation of the specific cells of the parenchyma. This is .seen both in the hepatic cells and in the epithelium of the l)ile ducts, in the neighbor- hood of developing tul)ercles in the liver, and in the epithelium of the uriniferous tnl)ules about renal tubercles. It cannot l)e said, however, that it has been satisfactorily estal)lished that the derivatives of such cells regularly become constituent elements of tubercles. When tuber- cles develop in the neighborhood of epithelial cells — i. e., in the skin or mucous membranes — these may also increase in number and volume and undergo other changes, but without entering into the real structure of the tubercle. The occurrence of typical tubercles in the midst of fibrinous exu- dates, without any direct connection with tissues, is urged as proof of the correctness of the view that tubercles develop wholly from emigrated leucocytes which may form both the epithelioid and other cells. It must be acknowledged that many tubercles in exudates can be formed only from cells with spontaneous motion. Young connective-tissue cells possess this faculty, however, and there is no good reason known why they mav not wander out into fibrinous exudate in response to positive chemotaxis, and aggregate about tubercle bacilli at the same time as lymphocytes and leucocytes gather about and perhaps invade the growth. Frequently, but not always, niultinuclear giant cells form a con- spicuous element in tubercles, even at an early stage. Much thought has been given to the explanation of giant cells, and at present two modes of formation are generally accepted. Probably rapid, commonly amitotic nuclear division or fragmentation, unaccompanied with corre- sponding division of the cells, is regarded as the more important. The failure of the cell to divide is ascribed by Baumgarten and Weigert to local necrotic or retrogressive changes in the cell body. It is also be- lieved that giant cells form by the fusion of several adjacent cells ; on account of the large number of nuclei often present, it has been sug- gested that in this case also there may be rapid nuclear division. The typical tuberculous giant cell (Langhans, '68) sends out many branching processes and contains numerous oval, vesicular nuclei which are arranged more or less regularly or semicircularly at the periphery or massed together in one or two places. The anuclear part of the cell commonly shows evidences of necrobiosis, which is ascribed to the action of bacilli taken up by the cell. 54 TUBERCLE AND MORBID ANATOMY A large amount of discussion lias been given to tlie nature and significance of the giant cells of tuberculosis. Baumgarten, Weigert, and others have held that the giant cell is an element that is on its way to destruction from the very first and that it fails to divide because of the necrol)iotic action of the bacilli it usually harbors. Metchnikoff, on the contrary, has championed the view, which now is more generally accepted, namely, that the giant cells of tuberculosis, like multinuclear ])lasmodial masses in general, begin their existence as active pliagocytes. The fact that they are often destroyed has not changed this conception because this fate they suffer in common with all the colls in active and progressive tuberculosis. Among the indications that the giant cells are active phagocytes, at least at first, may be mentioned the occur- rence within them of disintegrating and disintegrated bacilli. Koch was the first to point this out. In certain animals (SpermopJiilus gut- talus, Algerian rat) Metchnikoff, and also Welcker, note calcareous and also ferruginous incrustation of what they regard as bacilli within giant cells in experimental tubercles, and Metchnikoff thinks that cal- cium salts and other substances are laid down by the giant cell itself in the reaction against the bacillus. Calcareous concretions, the exact nature of which is not clear (bacilli, elastic fibers?), also occur in giant cells in human tuberculous lesions. That the giant cells are not merely retrogressive structures is shown by their power under certain condi- tions to subdivide into cells that develop further. True giant cells may be simulated by cross sections of hyaline thrombi in capillaries or minute vessels, with confluence of the endothelial cells. This is not a real giant cell; as a rule it is a circular body with smooth, definite outlines, and the study of serial sections may be necessary in order to determine its real nature and origin. Sooner or later leucocytes in variable numbers gather at the periphery of the newly formed nodule and contribute to its enlargement. These cells are mostly small, mononuclear, round cells (lymphocytes), and correspond to the small round cells in simple inflammatory infiltrations (Maximow's " polyblasts," Marehand's " leukocytoids "). In many cases they may crowd into the tubercle and force the epithelioid cells apart (lymphoid tubercle) ; in other cases they may be present in very small numbers. Later still, especially when degenerative changes occur, polymorphonuclear cells may accumulate, sometimes in such numbers that the tubercles appear surrounded and invaded by purulent infiltra- tion. It seems that the greater the number of bacilli, the more marked the inflammatory changes; whereas the slower the growth, and the fewer the bacilli the more numerous will be the epithelioid and giant cells. At the same time, as there is migration of leucocytes, there is also HISTOGENESIS AND FATE 55 more or less serous exudation into the newly formed nodule. The amount of fibrin in tubercles — coagulable inflammatory exudate — is subject to great variation even in the same organ, and is dependent on the degree of injury to the blood-vessels, which in turn may be determined by the number, relative virulence, and location of the invading bacilli. Tubercles also occur without any demonstrable fibrin. The slower the development of the changes, because of relatively low virulence on the part of the bacilli or because of relatively greater resistance on the part of the tissue, the more marked the proliferative as distinguished from the exudative processes in the tuberculous lesion (Orth). The intercellular fibrillar framework, which is demonstrable in all tubercles but, as a rule, most apparent in the margins, is kno^vn as the reticulum. It is an essential, preformed constituent, and not, as some- times stated, the result of the action of fixing solutions. This reticu- lum is derived, at least in part, from fibrillation and rarefaction of the ground substance of the tissue in which the tubercle forms, the pro- liferating cells forcing the fibers apart until they become drawn out and thin in places, perhaps destroyed. (The elastic fibers in the old tissue disappear.) Then, too, the new cells composing the tubercle often send out long interlacing processes which surround the cells ; this is especially true of the giant cells, the processes of which have been likened to spider's feet. It is worthy of special emphasis that not only are new vessels not formed in tubercles, but also that the preexisting vessels at the site of developing tubercles commonly undergo obliteration. At the height of its progressive development, when the purely pro- liferative changes predominate, the tubercle forms a small, grayish, translucent nodule, the granulation tuherculeuse of Bayle and Laen- nec, the simple tubercle of Virchow and others, and the " granulation- tuberculosis " of von Behring. Commonly likened in size to that of a millet seed, it is in reality smaller (submiliary), as emphasized long ago by Virchow and more recently by von Behring. Sooner or later cer- tain retrogressive changes may occur in conse(|uence of which the tubercle becomes somewhat larger, opaque, whitish, yellowish- white or grayish-wliite (Laennec's miliary tubercle). This is caseation. Tuberculous Granulation Tissue. — In addition to the formation of tubercles, the invasion of tissues by tubercle bacilli may result in the de- velopment of a diffuse, vascular granulation tissue which is distinguished by the presence within it of the specific bacillus, by occasional giant cells and tubercles, and by a tendency to retrogressive changes or caseation. This form of reaction on the part of the tissues occurs mostly when large numbers of bacilli and their products are brought into contact with extensive surfaces, as occurs when numerous bacilli are excreted by the 56 TUBERCLE AND MORBID ANATOMY kidneys or when serous membranes are hatlie^l by exudate ricli in bacilli. Tuberculous Exudative Inflammation. — The tubercle bacillus is capable also, as are its products, of causing diffuse typical inflammation with serous, fibrinous, or purulent exudation. Thus there are certain forms of tuberculous leptomeningitis in which there is a copious sero- purulent or purulofibrinous exudate, without much, if any. tubercle formation. And in the lungs especially pure exudative tuberculous inflammations may occur without the characteristic tuberculous prolif- erations. Laennec was the first to include this form of pneumonia with tuberculosis. (See Pulmonary Tuberculosis.) Tuberculous peritonitis, pleuritis, pericarditis, and synovitis are often marked by the predominance of the exudative processes. In such exudates the predominating cells are mononuclear cells. In many cases there may be a mixed infection. In the so-called tuberculous cold abscess the material in reality is not pus, as ordinarily understood, but rather a debris of necrotic cells and softened caseous material. Un- doubtedly the products of tubercle bacilli can induce true suppuration, because tuberculin, according to Koch, is an excellent agent for the production of suppuration experimentally. The tuberculous process begins with the formation of minute foci which arise either singly or, in case of several foci of infection, in simultaneous crops. As the bacilli multiply new foci may arise. Com- monly the tissue about, even in the case of the typical tubercle, pre- sents more or less inflammatory reaction in the form of congestion, exudation, cellular immigration, and proliferation. In this way de- velop foci, often nodular, especially on flat surfaces, and of varying extent in the congested grayish-red tissue of which the character- istic tubercles are detected more or less readily with the naked eye as minute grayi.sh or grayish-yellow nodules. Now if the infection is arrested promptly almost ideal healing may be accomplished. But if the infection spreads into the adjacent tissue, and this is the more common occurrence, then the original focus enlarges and extends as the reactive phenomena continue; sooner or later caseation takes place, perhaps with softening and the growth of fibrous tissue, and in this way arise chronic tuberculous foci and caseous masses, the morbid anatomy of which is best described in connection with tuberculosis of the different organs. Caseation. — All tuberculous formations — tubercles, diffuse granula- tion tissue, and exudates — sooner or later undergo the peculiar form of necrosis termed caseation. Dead caseous tissue has an appearance quite similar to that of cheese. In caseation the cells lose their outlines, become irregular, refuse to stain, and are finally converted into struc- HISTOGENESIS AND FATE di tureless masses and detritus (Fig. 5). Wells ("07) points out that case- ous matter, like cheese, is a mixture of coagulated proteid and finely divided fat, so that the reasons for the gross resemblance of caseous ma- ■■^::-T giant GO TUBERCLE AND MORBID ANATOMY cells under certain conditions undergo progressive changes — indicates that they are not merely necrobiotic elements doomed to destruction from their inception, as claimed by Baumgarten and others. On the other hand, it lends support to the view, championed by Metclinikoff, that they are active phagocytes. POINTS OF ENTRANCE AND PRIMARY LOCALIZATION OF TUBERCLE BACILLI The determination of the routes of entrance of tuberculosis is of great importance, because of the light thereby thrown on the source and nature of the infection, and the indications thus obtainable as to the best means of prevention. These and allied questions are discussed elsewhere, and at this point suffice it to say that four quite distinct modes of entrance must be recognized, namely: (1) inhalation of bacilli present in dust or minute droplets of sputum; (2) introduction into the digestive tract by means of food contaminated with bacilli and by other means; (3) direct implantation on the skin and exposed mucous surfaces through contact with infectious material; (4) intra-uterine in- fection through the placental circulation. The two last methods of infection are regarded as of relatively small importance, and there now exists considerable difference of opinion among investigators with respect to the comparative significance of the first two modes, but the evident tendency is to assign far greater weight than formerly to primary infection by way of the digestive tract, and more especially in children (Harbitz, '05).^ The assumption by Baumgarten that tuberculosis in the children of tuberculous mothers, even when originating years after birth, is the result of an intra-uterine invasion, the bacilli remaining latent until the conditions, suitable for pathogenic action arise, is not regarded as susceptible of proof. It is true that Harbitz found animal-virulent bacilli latent in the lymph nodes of children, the nodes being, so far as determined, normal in strncture, but the determination of the pos- sible duration of such latency is most difficult, because of the many chances for postnatal invasion. Whatever the primary point of entrance, the original localization of the bacilli, in the majority of the cases, occurs either at the point of entry or in some group of the regional lymph nodes, most frequently the nearest. It is generally accepted that infection of the lymph nodes ' So far as now known, there are no anatomic characteristics that enable one to distinguish between hiunan tuberculosis due to human bacilli and that due to bovine bacilli. POINTS OF ENTRANCE AND PRHIARY LOCALIZATION 61 cau take })lae(^ withoni leaving any recognizahle Iraee at the point of invasion of the tissues. Judging from the frequency of what is regarded as primary localization of tuberculosis, the most suitable organs in the body are the lungs and the lymph nodes. This appar- ent susceptibility may be due. in large measure, however, to the rela- tively great frequency with which these organs are exposed to infection, but the localizations in hematogenous infections also point to the aflfinity of the tubercle ])acillus for these organs. The lymph nodes in question are essentiall}' those connected immediately with the digestive tract (tonsils, cervical, mesenteric, retroperitoneal) and with the respir- atory tract. According to recent investigations, the lymph nodes are by far the most frequent points of primary tuberculous localization in children (under fifteen). Harbitz, who has studied this question minutely, groups his cases as follows : Primary in the respiratory tract 41.0 per cent. Primary in the digestive tract 22.0 '• Primary in the respiratory or digestive tract 20.5 " (Jeneral lymph-node tuberculosis, doubtful cases, etc 10.2 " In the intestinal cases there may be primary intestinal ulcers. On account of the ease with which tuberculosis may spread in the lymph- vascular sy.stem of children, on account of likelihood, in many cases, of hemaiogenous infection of lymph nodes, and on account of the pos- sibility of simultaneous infection of different nodes, it is not at all an easy matter to make a correct interpretation of many of these cases. As regards the respiratory group of cases, it naturally lies closest at hand to assume an air infection, but descending infection from the cervical nodes and ascending infection from the abdominal nodes frequently cannot be excluded. It may be suggested that primary tul)erculosis of the lymph nodes connected with the digestive tract (cervical and abdominal) does not at all necessarily mean infection with bovine bacilli, because there is often abundant opportunity, especially in children, for contamiiuition of the food and the mouth directly with tuberculous material of human source. It is highly interesting to note that in children tuberculous infection of the lungs probably most commonly results from the rupture of foci in the bronchial nodes into a large bronchus, generally near the hilus, and a consecutive caseous bronchopneumonia often with dissemi- nation to other organs. Primary tuberculosis of the lymph nodes also undoubtedly occurs in 62 TUBERCLE AND MORBID ANATOMY the adult, and careful post-mortem observations by Lubarsch, Harbitz, and others indicate that in a certain percentage of cases of adult tuber- culosis (5.9 Hof, 6.3 Lubarsch, 7.7 Harbitz) the primary localization takes place in the digestive tract, especially the intestine. Active discussion and investigation is now going on as to the rela- tive frequency of primary and secondary localization of tubercle bacilli in the production of pulmonary tuberculosis, the question having been raised by von Behring, Eibbert, and others whether ])ulmonary tuber- culosis in adults cannot be traced to some remote tubercidous process that existed long before — e. g., in the lymph nodes in childhood. At the present time the general opinion seems to be, however, that while the hematogenous and lymphogenous origin of instances of nonmiliary pulmonary tuberculosis cannot be denied, the disease, in the large major- ity of the cases, originates from a primary, air-borne infection of the lungs (Schmorl, "01-02). The most significant anatomic evidences in favor of the old view are that the oldest lesions generally are found in the lungs, and that in favorable cases it is possible to demonstrate the apparent primary point of invasion — ^namely, a subepithelial tuberculous infiltration in the wall of a bronchus of medium caliber, or a tuberculous pneumonia or bronchopneumonia with peribronchial tubercle. Birch-Hirschfeld ('99), who made special investigation of this point, found what he considered as the primary lesion most often in the right ramus apicalis posterior. It is evident, however, that even these lesions may result from the depo- sition in the vessels in the area concerned of l)aci]li by the blood. Auiong the reasons assigned for the peculiar predisposition of the apical parts to tuberculous localization are poorer nourishment of these parts, espe- cially at the time of puberty, because the corresponding part of the chest then takes only small part in the respiratory movements. It is also held that at the apex the bronchi branch at such angles that obstruc- tion easily occurs. DISSEMINATION OF TUBERCULOSIS WITHIN THE INFECTED BODY In its beginning tuberculosis is always, or practically always, a local disease. So far as known at present the actual primary infection under natural circumstances depends on the entrance and deposition in the tissues of a few bacilli from without. The sources of the bacilli and the various routes of entrance are discussed fully elsewhere. Now, what- ever the point of invasion, primary local tu])erculosis is likely at any time to become the source of secondary or metastatic tuberculosis. Most commonly the bacilli are carried by the lymph vessels, either free or DISSEMIXATK^X WITIIIX THE INFECTED BODY 63 within leucocytes. Cousequeiitly, iyiuph nodes draining regions contain- ing tuberculous foci frequently become the seat of secondary tubercu- losis from the arrest Avithin them of bacilli brought by the lymph stream. Progressive local tuljeiculosis usually is maiked by the development of tubercles in the lymph channels in the neighborhood, as shown very well, for instance, in the serous covering over tuberculous intestinal ulcers, about tuberculous foci in the lungs and elsewhere. And from one group of lymph nodes tuberculosis may spread by direct and retro- grade transport both upward and downward to neighboring groups, until extensive chains of nodes are involved. When this occurs in the cervical, tly^racic, and abdominal lymph nodes, as happens in children in whom lymphatic invasion appears to occur with great ease, then it may be impossible to form any definite conclusion as to whether the primary infection took place in the res])ir- atory or in the digestive tract. Harbitz considers it likely that in children tuberculosis of the lungs often develops as the result of retro- grade transport from the tracheobronchial lymph nodes, because he found tuberculosis in these nodes frequently without involvement of the lungs, but the reverse only rarely. Tuberculosis of the mesenteric, retro- peritoneal, thoracic lymph nodes, of the pleura, and of the peritoneum may lead to tuberculosis in the thoracic duct (first described by Astley Cooper, and then by Ponfick), from which bacilli may pass into the general circulation, and thus become distributed in greater or smaller numbers to various parts of the body, with the subsequent development of acute or more chronic generalized tuberculosis. Indeed, tubercle bacilli have been found in the lymph from the thoracic duct in certain cases in which there was no tulierculosis of the duct itself, showing that bacilli were being disseminated from parts drained Ijy the duct. In connection with the thoracic duct may be mentioned the highly interesting experiments of Pavenel and others, in which indications were obtained that bacilli introduced with the food into the stomach may pass into the thoracic duct and become localized in the lungs, without necessarily leaving any trace in the form of lesions in the intestinal tract or elsewhei-e that they had taken this route. While there is no evidence that this mode of infection ])lays an irnportant role in human beings, the possibility that tubercle bacilli may become localized at ])oints more or less remote from the point of penetration into the tissues, and thus set up lesions tiiat may become the center for other more or less remote foci, indicates the great diflficulties that may be encountered in the efforts to determine the route of entrance by anatomic methods of investigation. Tubercle bacilli mav reach the blood also as the result of direct 64 TUBERCLE AND MORBID ANATOMY tuberculous invasion of the walls of Mood-vessels and the discharge of bacilli directly into the Mood stream (see Miliary Tuberculosis). Dissemination of bacilli within the infected body takes place also by way of mucous and serous membranes. The routes of secretion and excretion are important means for the spread of tubercle bacilli to the outside of the body as well. Thus, the discharge of a disintegrating tuberculous focus in the lung or of peribronchial lymph nodes into the bronchi may result in the conveyance of bacilli not only to the outside of the body, but also to various parts of the respiratory tract, as well as, by swallowing the sputum, to the digestive tract, where secondary localizations in the intestinal lymph follicles often occur. Jn this way instances of primary infection, of the peribroncliial nodes, for example, may give rise to acute tuberculous bronchopneumonia. In the case of the urinary tract, the breaking down of tuberculous masses in the kid-, ney may cause widespread infection of the pelvis, ureter, and bladder. Finally, the entrance of bacilli into a serous cavity from some focus adjacent is often the cause of diffuse and acute tuberculous inflamma- tion. In the case of the pleura and the pericardium, general tubercu- losis may arise either from tuberculous pulmonary foci or from foci in the thoracic lymph nodes. Peritoneal tuberculosis often takes its origin in caseous lymph nodes, tuberculous intestines, and, in the female, in tuberculosis of the genital organs. In all these cases the bacilli are distributed by movements on the part of the walls and the contents of the cavities in question. In the leptomeninx the bacilli also spread rapidly. Inasmuch as the bacillus of tuberculosis does not possess the rapid power of growth in the body that characterizes th.e microbes of the typical acute infectious diseases, the acute manifestations of tubercu- losis — acute miliary tuberculosis, acute tuberculous pneumonia, and acute tuberculosis of serous membranes — all result from the more or less sudden or rapid dissemination of masses of bacilli that have accu- mulated in some preexisting focus. So far as we know, that is the only wa}^ in which acute human tuberculosis arises under natural conditions. ACUTE GENERAL MILIARY TUBERCULOSIS Acute miliary tuberculosis, in which innumerable tubercles develop in various parts of the body at about the same time, is now universally held to result from the introduction into the circulation of large num- bers of tubercle bacilli, either at one time or at frequent intervals. It is regarded as a secondary infectious disease. A primary form is not recognized. It is most frequently observed in connection with pul- monary and lymph-node tuberculosis, but it may occur secondarily to ACUTE GENERAL MILIARY TUBERCULOSIS 65 tuberculosis of bones and joints, of the pleura, pericardium or perito- neum, of the adrenal, urogenital organs, etc. The modern conception of the nature and genesis of general miliary tuberculosis takes its origin in the remarkable statement by Buhl ('72) that miliary tuberculosis is an infectious and resorption disease, the miliary nodules having the same relation to the caseous foci as the metastatic abscesses in pyemia have to the primary focus of suppuration. It was reserved for Carl Weigert to furnish the actual demonstra- tion of the manner in which tuberculous material may enter the blood, namely, by the tuberculous invasion of the walls of blood-vessels or of the thoracic duct. Older pathologists regarded tlie blood-vessels as immune to tuberculosis, and Weigert's observations put an end to this theory. He first described the extension of a caseous tuberculosis in a lymph node through the walls of the vena anonyma ('78), and shortly afterwards tuberculous invasion of the pulmonary veins. Shortly before the discover}' of the tubercle bacillus, Weigert ('82), who in the meantime had found tuberculous foci in the veins in ten and in the thoracic duct in two of three cases of acute general miliary tuberculosis, announced that a tuberculous lesion of a vein or other vessel must fulfill the following conditions before it can be regarded as the source from which the miliary tuberculosis has sprung: 1. The primary lesion must, by its appearance and structure (casea- tion, size, etc.), prove to be of greater age than the miliary nodules. 2. The tuberculous focus must occupy a portion of the wall of a vein or larger lymph channel which is patulous. 3. The eruption of miliary tubercles must be of such a character as to be only explainable by the theory that a large amount of tuberculous poison has entered the blood at once, and that, in other words, their development has occurred in a relatively short space of time. 4. The tuberculous poison must actually extend to the surface of the focus; that is, it must communicate with the lumen of the vessel. In the ductus thoracicus, where the nodules are placed on the free surface of the vessel lumen, this is usually the case. In tlie compact foci of tlie veins — for instance, the pulmonary veins — at least a portion of the focus must be softened or caseated. 5. The venous tubercle must not be located in the portal S3^stem, otherwise the tuberculous poison would all be deposited in the liver. With the possible exception of the fifth condition, we are not able to say that under the circumstances in question the portal capillaries will hold back all tubercle bacilli, and on substitution for tuberculous poison of tubercle bacilli, Weigert's conditions hold good to-day. Koch first demonstrated bacilli in tuberculous lesions of veins and of the thoracic duct, and soon Weigert was able to show their presence in his 6 66 TUBERCLE AND MORBID ANATOMY own specimens. Weigert's masterly grasp of the problems and liis brill- iant interpretation of his observations will always excite the highest admiration of students of tuberculosis. All subsequent investigations uphold his teachings in the main points. The attempt by Wild ('97) to show that general miliary tuberculosis is the result, at least in part, of the multiplication of the bacilli in the circulating blood, which they enter by more or less undiscoverable sources, has not received any gen- eral support. Tuberculosis of the walls of blood-vessels may develop in different ways. Direct extension may take place from adjacent tul)erculous foci or the process may be started by single or multiple metastasis on the vascular intima or in the wall itself, and rarely on the endocardium. Several instances of intimal aortic tuberculosis have been described as due to the implantation of tubercle bacilli (Blumer, '99), and Benda considers this the more frequent mode of origin of the vascular tuber- culosis that leads to general dissemination, but that view is not gen- erally accepted, at least not with respect to the blood-vessels. Tlie extension of tuberculosis from tlie neighborhood may involve arteries and veins, but the veins more frequently. The aorta has been found extensively involved in this manner also. Of blood-vessels, the pulmo- nary veins most often furnish the starting point for miliary tuberculosis, but the jugular vein, the suprarenal, the vena cava, the dural sinuses, the vesical veins, the endocardium, the aorta, and the pulmonary artery — all may play this role. Recent investigations indicate tliat tul)erculosis of the thoracic duct possibly is the most frequent cause of general miliary tuberculosis. Thus Benda ('99), in 19 cases found the point of origin to be the thoracic duct in 12, and Longcope ('06) in 19 typical instances of gen- eralized acute miliary tuberculosis found in 14 cases more or less exten- sive tuberculosis in the thoracic duct, usually with caseous nodules. In all of these cases Longcope noted that the mesenteric, retroperitoneal, or thoracic lymph nodes were the seat of chronic tuberculosis. In order to study the duct satisfactorily, it must be dissected free from its beginning in the receptaculum chyli to its entrance into the left subclavian vein. Solitary tubercles may occur in its extreme upper part. It is often difficult to determine the starting point of the acute generalization of tuberculosis, but in the hands of experts success has been achieved in as high as ninety-five and even one hundred per cent. Naturally it may be difficult to determine that a given focus of tuberculous vasculitis really is the point of origin, as there may be more than one such focus in the same body. In case the lumen is not closed by proliferation and thrombosis, it is easy to understand how a tuber- culous process in a vascular wall, on caseation and disintegration, may ACUTE GENERAL MILIARY TUBERCULOSIS 67 give off tuberculous material and bacilli into the blood or lymph, espe- cially since it has been found that tuberculous masses projecting into the lumen commonly contain enormous numbers of bacilli, often in heaps, in the parts near the current. Indeed, it seems as if those parts which sometimes are rough and irregular, and sometimes smooth from fibrinous deposits, present especially favorable conditions for the mul- tiplication of the bacilli. Generally the vascular tuberculous masses — " vascular tubercle " — appear as grayish yellow nodular elevations, and at times they may be distinctly polypoid; when the result of extension or erosion from without they are connected with an extravascular tuber- culous area. The localization as well as the number of tubercles in miliary tuber- culosis are subject to considerable variation, depending on the exact location and nature of the point of invasion and on the number of bacilli sent into the circulation. If the primary focus is situ- ated in the walls of a smaller artery, then the consecutive eruption of miliary tubercles may be confined largely to the corresponding capil- lary district, and we speak of a local hematogenous miliary tubercu- losis. Often the position of the original vascular focus ma}^ be surmised from the distribution of the tubercles; this is true especially of the lungs in chronic pulmonary tuberculosis (partial disseminated hema- togenous miliary tuberculosis). But even imder these circumstances, bacilli may pass through the nearest capillary filter and give rise to scattered tubercles in different organs and tissues, which is not infre- quent. In the chronic generalized tuberculosis peculiar to children, numerous widely spread, large caseous foci are found, due to dissemi- nation of few bacilli by blood as well as lymph vessels. Naturally there are all grades of transition between these various forms. In typical, generalized, acute miliary tuberculosis most of the organs are permeated by uncountable tubercles, but by no means to the same degree. Certain organs, by means of mechanisms that are not under- stood as yet, appear to resist the development in them of miliary tuber- cles, notably the pancreas, the salivary glands, and the skeletal muscles. Of all the organs the lungs, the liver, the spleen, the kidneys, and the serous membranes are most commonly and most extensively involved in general miliary tuberculosis. The occurrence of chorioidal tubercles is of much clinical interest. It is noteworthy that the tubercles occur most numerously in the vicinity of the blood-vessels, and intimal miliary tubercles are not uncommon, especially in the lungs and leptomeninx. The tubercles, while at first glance of about the same grade of devel- opment, as a rule will be found to vary in size from minute grayish transparent points that are barely visible to larger nodules with grayish- yellow or yellowish-white centers. And on microscopic examination 68 TUBERCLE AND MORBID ANATOMY numerous young tubercles will be found that clearly could not be recog- nized by the naked eye. On serous surfaces — e. g., the pleura — in the lungs, and on the surface of the kidney, they are usually surrounded by an areola of congested vessels. In the serous cavities there may be more or less exudate present when miliary tubercles develop on the lining. The spleen is enlarged; young tubercles are confounded easily with the Malpighian bodies; the tubercles, however, are somewhat more pro- jecting and easily peeled out with the knife point ; caseating tubercles are easily distinguished. The liver also is somewhat enlarged, and tubercles can be recognized in the interlobular connective tissue as well as in the interior of the lobules. In the kidneys miliary tubercles are found, particularly in the cor- tical parts and often in rows. Occasionally they are confined to the vicinity of a single branch of the renal artery. Tubercles on the surface of the kidney may form small prominences surrounded by injected vessels. In the peritoneum miliary tubercles occur frequently, and especially in the omentum, which may be rolled up and retracted. There may be peritonitis. In addition, tubercles occur in the genital organs, lymph nodes, adrenals, tonsils, the thyroid, the heart (pericardium, myocardium, endo- cardium, especially of the right ventricle), the bone marrow, and rarely in the stomach and in the skin. In the meninges, especially the lepto- meninx, miliary tul)erculosis gives rise to characteristic changes. Tuberculosis of the pia-arachnoid occurs by preference at the base of the brain and over the cervical spinal cord. Sometimes there is only slight turbidity of the membranes, but usually there is fibrino- purulent or gelatiniform fibrinous exudate most marked about the Sylvian fissures, the optic chiasm and interpeduncular spaces. There is acute hydrocephalus. Miliary granulations are seen especially about and on the middle cerebral arteries and the arteries of the anterior and posterior perforated spaces. The tubercles may be hard to see, and it is best to spread the membranes on a glass plate. Large or caseous nodules are often present and the inflammation extends into the brain tissue (meningo-encephalitis). In tuberculous meningitis there is an inter- esting endarteritis with tubercles and diffused subendothelial prolifera- tion, best explained as due to implantation of tubercle bacilli and their products from the blood. The infiltration often spreads into the other coats, all of which may undergo caseous and hyaline degeneration. Tu- l)erculous arterial and venous changes also are common as the result of extension from without. MORBID ANATOMY OF PULMONARY TUBERCULOSIS 69 THE MORBID ANATOMY OF PULMONARY TUBERCULOSIS In the lungs tuberculosis produces a complex variety of anatomic alterations, depending, on the one hand, on the mode of invasion, and on the other on the number and the relative virulence of the infecting bacilli, as well as on the kind of resistance offered by the infected body. Fig, 6. — Tuberculous Pneumonia and Conglomerate Tubercles. (.4) Spots of tuberculovis pneumonia. {B) Single tuberculous air vesicles and groups. Early stage of process. (From Holt " Diseases of Infancy and Childhood," 1908.) The anatomic pictures presented by pulmonary tuberculosis consist of miliary and larger nodules, pneumonic and l)ronchopneumonic areas, with, on the one side, caseous softening with ulceration and cavity formation, and on the other the production of fibrous tissue, cicatriza- tion and limitation. (Fig. 6.) According to the accepted modes of entrance of tubercle bacilli into 70 TUBERCLE AND MORBID ANATOMY the lungs, it is customary to speak of hematogenous, lymphogenous, and aerogenous pulmonary tuberculosis. When acute and typical there is no difficulty in the recognition from anatomic appearances of the first two ; all three modes of invasion may lead to the common manifestations of tuberculosis of the lungs in the clinical sense, and in well-established cases it may be difficult to determine from the anatomic lesions the exact route of entrance into the lung. Acute General Hematogenous Tuberculosis of the Lungs. — The nature and origin of general miliary tuberculosis have been discussed. It remains to describe the most striking appearances of the lungs in this disease which may appear in previously healthy lungs or in lungs the seat of existing tuberculosis. In either event, tubercles are found in the majority of the other organs of the body. The lungs on palpation are finely nodular or granular throughout, of increased weight and consistence, usually somewhat distended. They do not collapse on section. The tissue is red from congestion, frequently somewhat edematous, and everywhere permeated with tuberculous nod- ules which, in many cases, gradually diminish in size from the apices downward. Tliese nodules are not all miliary tubercles in the accepted sense; many are conglomerations, and Orth especially has emphasized that in miliary tuberculosis of the lungs there spring up about the proliferative nodules, as well as elsewhere, pneumonic and bronchopneu- monic — i. e., exudative, rapidly caseating areas that on gross examina- tion may appear as somewhat projecting round or angular nodules. This form of inflammatory reaction shows that the bacilli and products may act directly on the alveolar wall and reach the lumen even when the infection arrives by way of the blood. The proliferative tubercles occur mostly in the adventitia of the vessels of the septa, in the perivascular and in the peribronchial tissue. Tuberculous endarteritis is not infrequent. Often there are areas of moderate emphysema in the lungs of miliary tuberculosis. The reasons that the lesions in the upper parts are far- ther advanced than in the lower are not altogether clearly understood. It is thought that the upper parts are more vulnerable, because they con- tain less blood than the lower parts, and that the bacilli that escape into the alveoli are more easily removed as we approach the base. Under certain conditions the hematogenous foci may be found so much enlarged and caseous that the condition is designated as subacute or chronic. Pulmonary miliary tuberculosis is nearly always associated with typical tubercles on the pleura, which also may show more or less fibrin- ous or sero-fibrinous exudate. Partial Disseminated Hematogenous Tuberculosis of the Lungs. — This form, which is not common, arises when bacilli are distributed MORBID ANATOMY OF PULMONARY TUBERCULOSIS 71 by the blood over a limited part of the lungs. It usually arises in the course of existing tuberculosis in the lungs from tuberculous erosion of, or the breaking down of, intimal tubercles upon some branch of the pulmonary artery. One reason for its infrequence is the fibrous narrow- ing and occlusion of many vessels in chronic pulmonary foci. Natu- rally, single foci can arise from the lodgment in the lungs of few bacilli brought in the blood from tuberculous areas elsewhere, and such metas- tatic foci may become the starting point of chronic pulmonary tuber- culosis. Localized Pulmonary Tuberculosis. — The minute early steps in the evolution of local pulmonary tuberculosis may be traced somewhat as follows : Assuming the bacilli to be inhaled, lodgment may take place either on the wall of a small bronchus or in the alveoli (in either case usually near the apex). In the first instance a bronchial tubercle may result, followed by gradual extension and caseation, until the wall is converted into a partial or complete caseous ring. Caseous matter and mucus will accumulate in the lumen, and in consequence the corre- sponding alveoli may collapse, and if not rendered tuberculous, indura- tion can result. From the bronchial focus the process can extend outward into the peribronchial tissue and adjacent alveoli, where desquamated epithelial cells and lymphocytes accumulate at the same time as fibrin is precipi- tated; in brief, a pneumonic or bronchopneumonic area develops in which caseation soon takes place. In the meantime the blood-vessels in the alveolar walls become hyaline, and often the large vessels are plugged by fibrin, hence the area becomes bloodless and yellowish- white in color. Eadicals of the peribronchial lymphatics being included in the tuber- culous district, the bacilli easily find their way into the lymph vessels, and peribronchial tuberculous lymphangitis results, the tubercles some- times running around the bronchi like a string of beads, and now exten- sion may take place to the bronchial walls or to adjacent alveoli. Occa- sionally the process can be followed as peribronchial nodular cords clear to the lymph nodes at the hilus. If the bacilli enter the alveoli directly, then a minute pneumonic focus may result, or the bacilli may be carried by wandering cells into the interstitial tissue, there to form tubercles. In either case the exact mode of genesis would soon be obliterated because the interstitial tuber- cles Avould soon lead to pneumonic changes, and a primary pneumonic lesion would soon bo followed by interstitial processes. As a rule, tubercles with giant cells are the more numerous the slower the process, while in rapidly spreading pneumonic exudation, with early caseation, tubercles and giant cells may be few and even absent. 72 TUBERCLE AND MORBID ANATOMY Early stages of primary localization in the mode here outlined are not often seen at autopsies. Occasionally, however, one finds that a small area, usually near the apex, may show grayish or yellowish gran- ules and areas either in groups or more scattered. The further fate of such primary foci varies. Healing by connective- tissue replacement, or encapsulation, with calcification, is not uncom- mon; but frequently the opposite occurs — namely, softening and exten- sion. If the process involves a bronchus or bronchiole, either primarily or by extension, then the caseation may weaken the walls so that it dilates and the so-called bronchiectatic cavity results. Cavities arising from softening in closed caseous pneumonic areas usually empty them- selves into a bronchus. Early in the process caseous disintegration of the wall of a bronchus may cause rupture of small blood-vessels, and thus give rise to the spit- ting of blood that occurs so often in the first stages of pulmonary tuber- culosis. In" the further progress of local pulmonary tuberculosis there arise various more or less distinct anatomic forms, which correspond fairly well to recognizable clinical manifestations of the disease, according as certain processes outlined in the foregoing predominate. Tuherculous rncuinonia. — Cbaracteristic exudative pneumonic changes may develop at any time in the course of pulmonary tubercu- losis as the result of entrance into the alveoli of bacilli or their products, in sufficient quantities to cause exudation and immigration. Tuber- culous pneumonia differs from all other forms of pneumonia in that the end is caseation. This pneumonia may vary greatly in its extent and course so that lobular or bronchopneumonic and lobar, as well as acute and subacute and chronic forms, are recognized. Tuherculous hroivclio pneumonia is the more common. Tt develops oftenest in the lower lobes as the result of aspiration of tuberculous material from cavities and older lesions into the bronchi and alveoli, and there is usually a smaller or larger number of areas of more or less simul- taneous development. This form of pulmonary tuberculosis occurs most frequently in children (after measles, whooping cough, etc.) and young persons, in whom it commonly assumes a rapid progress. In such cases the peribronchial lymph nodes are usually large and caseous, and frequently the invasion of the lungs follows rupture of a tuber- culous node into a large bronchus near the hilus (Fig. 7). When asso- ciated with softening and the production of cavities, in which secondary infection may take part, it constitutes the acute phthisis or galloping consumption of the clinician. In the earlier stages the bronchopneumonic foci are grayish-red; as caseation takes place they become yellowish or whitish, opaque, dry and MORBID ANATOMY OF PULMONARY TUBERCULOSIS 73 prominent, granular on the cut surface. They vary much in extent; by fusion of contiguous areas larger districts and groups arise, between which lies crepitant lung tissue or a zone of grayish-red, gelatinous, sero-fibrinous infiltration (gelatinous pneumonia), in which proliferation and desquamation are comparatively slight. Such infiltrations occur par- ticularly about caseous districts that are rich in bacilli and are regarded, at least in many cases, to re- sult from the action of the products of the bacilli. Ex- tensive lesions occur without the eruption of tubercles, but there may be varying com- binations with proliferative tuberculous and fibrous changes. In more chronic forms the proliferative changes are more marked and bacilli then are found principally at the periphery of the caseous masses and sometimes in large heaps. As caseation extends the capillaries become hyaline, there is more or less oblit- erating endovasculitis, and eventually only |j coal dust and remnants of elastic tissue remain to indicate the former location of the alveolar and bronchial walls. In case the process becomes stationary, fibrous tissue may form at the periphery, and in time an encapsulated fibro-caseous or calcareo- caseous mass may result. Tuberculous lobar pneumonia is much less common. It may result from the coalescence of numerous bronchopneumonic areas (pseudo- 7 Fig. 7. — Section Through Lung, Showing Case- ous Tuberculous Lymph Glands. Lung nor- mal. (From Northrup.) 74 TUBERCLE AND MORBID ANATOMY lobar) or from simultaneous involvement of a whole lobe or even an entire lung in which there is then an older focus, usually a cavity near the apex, from which inundation of the tissue with tuberculous products, formed and in solution, has taken place. The affected parts are heavy and airless and the pleura usually covered with exudate. Distinct tubercles or groups of tubercles may be recognized in places on the Fig. 8. — Tuberculous Pneumonia in a Child Thirteen Months Old. Ver- tical section through right lung. Up- per lobe caseous (diffuse tuberculous pneumonia). Beginning excavation near center. Below simple pneumo- nic consolidation. Lower lobe ap- pears normal. (From Holt, " Diseases of Infancy and Childhood," 1908.) Fig. 9. — Cavity from Breaking down OF Tuberculous Pneumonia. Same lung as in Fig. 8. Normal lower lobe shown. (From Holt.) cut surface, which is grayish, gray- ish-yellow, or, in the older parts, peculiarly yellowish- white and case- ous. Sometimes a lobe and even an entire lung is caseous, with more or less extensive softening and cavity formation. Ulcerative Tuberculosis of the Lungs. — This group includes espe- cially the forms in which softening and ulceration are prominent features. The lungs present a variety of lesions, including tuberculous nodules. MORBID ANATOMY OF PULMONARY TUBERCULOSIS 75 pneumonic districts, caseous masses, cavities of various sizes and ages, and fibrous changes. The oldest lesions usually are at the apices, the disease having progressed downward, commonly more rapidly in one lung than the other. In addition to aspiration the lymph vessels take an important part in the spread of chronic pulmonary tuberculosis (peribronchial and perivascular extension). In some cases, notably in children, the mil- iary and larger nodules are distributed about the older foci in a radial manner. At other times the dissemination is more scattered. From peribronchial tubercles may arise caseous, fibrocaseous, and fibrous masses or by extension areas of bronchopneumonia. While the primary focus of lymphogenous invasion commonly is situated in the lungs themselves, it may be found also in parts directly connected with the lungs, either normally or as the result of inflammator}' processes, such as lymph nodes, ribs, sternum, spine. T3'pical bronchopneumonic areas develop in ulcerative tuberculosis due to aspiration of the tuberculous matter from the older lesions into the lower parts of the lungs. Such areas may soften or become trans- formed into encapsulated caseous, calcareo-caseous, or calcareous masses. Smaller tuberculous areas, whatever their mode of origin, may be found surrounded by grayish-red zones of pneumonic exudation. Tuberculous ulcerations may be found in the mucous membrane of the larger bronchi. Bronchiectasis is often present. The cavities are a distinguishing feature of this form of pulmonary tuberculosis. They arise because physical and chemical changes lead to the softening of the caseous substance into a thick suspension not unlike pus. More frequently this begins in the wall of a diseased bronchus which becomes more or less dilated. The detritus contains fragments of dead cells, elastic fibers, and usually numerous bacilli. Smaller cavi- ties by extension may coalesce, and in a short time large excavations result in acute cases. Breaking dowm may occur also in the center of a closed caseous area; in this case communication with a bronchus becomes established later. The size and form of a cavity depend originally on those of the focus in which it originates. If in a caseous peribronchial nodule or in a small bronchopneumonic area, then the cavity, at least at first, is small, circumscribed. In large areas of caseous pneumonia, spots of softening may coalesce, and there may form irregular caverns without definite walls. In acute progressive cases one or more lobes may be more or less excavated in a short time. In the chronic ulcerative tuber- culosis there are older cavities with definite Avails in the upper lobes, while lower down may be more recent ones without any definite limit- ing membrane. In older cavities a more or less distinct wall or mem- 76 TUBERCLE AND MORBID ANATOMY brane is present from which pus is discharged; by necrosis, and by caseation of tuberculous foci in the adjacent tissue, gradual extension is effected. Extremely large cavities may result. On the inner surface Fig. 10. — Tuberculosis of Eleven Years' Standing. Resident of Colorado one month. Right hmg shows cavity the size of a small orange at apex with ex- tensive consolidation. (Dr. J. A. Wilder's case, Denver.) of older cavities are bands and irregular projections, the remnants of the framework in which traces of bronchi and vessels may be recognized. (Fig. 10.) Occasionally minute aneurysms (1 to 3 mm.) form on the exposed branches, rupture of which is one cause of the hemorrhage of ulcerative tuberculosis. More frequently the larger hemorrhages result from ero- sion by caseation of suppuration. Decomposition of the contents of cavities may be followed by gangrene. In quiescent cavities the wall is cicatricial and the inner surface has a smooth lining. The neigh- borhood is then usually fibrous, and shrinking may have occurred to the extent that smaller cavities are obliterated or reduced to fistulous passages. At the apex pleural adhesions usually prevent obliteration of large cavities. The pleura is usually fibrous over old cavities and firm adhesions are the rule, especially abo^^t the apices, and thus rupture of cavities into the pleura is prevented. Sometimes the fibrous pleura contains tuberculous nodules, and exudative pleuritis is not infrequent. Rarely cavities rupture externally at the point of pleural adhesions ; fresh, usually small, cavities in the upper lobes or suppurating cavities, situ- MIXED INFECTION IN PULMONARY TUBERCULOSIS 77 ated closely to the pleura, may rupture into the pleural sac. The open- ing may be very minute. The usual immediate consequence is entrance of air into the chest cavity, on which follows, as a rule, suppuration (pyopneumothorax). The peribronchial lymph nodes are usually tuber- culous; in chronic, stationary, or healed cases often calcified. Tuberculous changes are frequent in other regions, and first of all in the larynx and intestines, in which they result from surface infection by bacilli from the lungs. The pericardium may be involved by exten- sion. Acute and chronic hematogenous tubercles may be found in the spleen, kidneys, 'brain, liver. The spleen, liver, kidneys, and intestinal mucus are often the seat of amyloid changes, and the liver is frequently fatty. MIXED INFECTION IN PULMONARY TUBERCULOSIS The variety of lesions in ordinary pulmonary tuberculosis long ago suggested the question whether in reality several simultaneous or super- imposed diseases were not concerned. While Laennec favored strongly the view that all the lesions were tuberculous, Virchow held that the tu- bercle and the caseous pneumonic foci were different processes etiologi- cally. This question of the unity or duality of the chronic pulmonary tuberculous (phthisical) process was settled finally in favor of Laennec's view, when it became possible, as a result of the discovery of the tuber- cle bacillus, to demonstrate the etiologic unity of tubercle and of caseous pneumonia. While the studies of Orth ("07), Frankel and Troje ("94), and others leave no doubt as to the correctness of this conclusion, the part played by secondary infection in pulmonary tuberculosis merits consideration. The actual investigations (Sata, "99; Ophiils, "00). as to the con- ditions in the lungs in more or less advanced pneumonic and ulcerative tuberculosis, have shown that secondary mixed infection is a frequent event. Thus in Sata's 21 cases actual mixed infection — that is, invasion by bacteria of the walls of cavities or the interior of bronchopncumonic foci, either alone or in conjunction with tubercle bacilli — was estab- lished in 12 (streptococci predominated in 6, pneumococci in 4. staphy- lococci in 1 ; among other bacteria were colon and pseudodiphtheria bacilli). Of 26 cavities examined by Ophiils, 7 contained the tubercle bacillus only; in the others were mixtures of bacteria (the streptococcus, pneumococcus, and pseudodiphtheria bacilhis predominating). Undoubtedly mixed infection may occur from the beginning; it may cause areas of bronchopneumonia and promote disintegration of caseous material and the formation of cavities. Prudden ("94) showed that in rabbits with caseous pneumonic areas, intratracheal injections 78 TUBERCLE AND MORBID ANATOMY of streptococci were followed by rapid softening and formation of cavi- ties. Or the infection may take place after softening in purely tuber- culous areas and open a communication with the bronchi. Naturally such foci constitute favorable soil for bacteria other than tubercle bacilli; vegetating here, their products, on absorption, producing toxic effects; they also may enter the walls of the cavities or be carried with other contents to other parts of the hmgs, in either case setting up foci of inflammation with more or less constitutional disturbances. It lies close at hand to assume that invasion of the blood often takes place from the foci of mixed infection in the lungs, but on account of other possibilities no final conclusions may be drawn. In 50 cases in which Teissier ('01) examined the blood bacteriologically during periods of hectic fever, streptococci or staphylococci were recovered in 9. FIBROID, QUIESCENT, AND HEALED TUBERCULOSIS OF THE LUNGS Limiting and indurative processes are encountered in various stages and forms in pulmonary tuberculosis. Frequently the earliest foci in the apices show extensive fibrous change, and scattered bronchopneu- monic as well as peribronchial foci may undergo fibrous transformation and heal, with or without calcification. Occasionally in the case of somewhat larger foci the central part becomes fibrous and hard, while small caseating nodules are scattered about at the periphery, the whole resembling somewhat a rosette with sunken center. When the fibrous process is extensive the condition usually corre- sponds to the so-called fibroid tuberculosis (tuberculo-fibroid phthisis), which may supervene on either the ulcerative or the more definite bronchopneumonic form of tuberculosis. In either case there is usually a cavity or a series of cavities in one apex, surrounded by dense fibrous tissue, with more or less extensive induration of the surrounding dis- tricts. The corresponding pleural cavity is largely or completely oblit- erated by firm adhesions, bands passing inward into the various parts of the lung, in which there is more or less extensive and diffuse or more nodular (bronchopneumonic) fibrous changes, wdth here and there scat- tered caseous areas. Usually there is some active tuberculosis some- where in the lungs. The scar tissue in the lungs may compress the bronchi so that areas of alveoli collapse, to be followed by a persistent edema or by progressive induration. The unaffected parts of the lung tissue may be emphysematous. A tuberculous process may be regarded as healed only when there has formed a more or less structureless connective tissue with or without calcareous deposits but without caseous material. Caseous foci, though TUBERCULOSIS OF THE LUNGS 79 evidently old, partly calcified, and encapsulated, may contain animal virulent bacilli (Bugge). Quiescent or healed tuberculous areas are found most commonly in the apices. There may be nodular encapsu- lated masses containing caseous or more puttylike material, often cal- careous, over which the pleura is retracted or corresponding to which there is adhesion. Microscopically the process may be clearly at a stand- still, the capsule being composed of fibrillary or hyaline tissue and fibrous tubercles may be scattered about. Occasional fresh tubercles are seen. Anatomically areas of healed tuberculosis oftenest appear as slaty indurations, usually apical and subpleural, flat or nodular, with retrac- tion or adhesion of the pleura, and inclosing small calcareous masses, fibroid tubercles perhaps being present in the adjacent tissue. Mere slaty indurations are not sure signs of healed tuberculosis, as they may arise from inhaled dust, in the healing of infarcts, and after non- tuberculous pneumonia. Bugge found that of 138 persons over one year of age who died from other causes than tuberculosis in the lungs, thirty-five per cent presented changes that could be interpreted as due to healed tuberculosis. At the International Congress in Washington (1908) Bartel empha- sized that because invasion of lymph nodes by tubercle bacilli may give rise to a lymphocytic hyperplasia and in some cases lead to no apparent changes whatsoever, it often becomes a matter of great diflficulty to determine the exact point of entry of the bacilli into the body. In other words, manifest typical tuberculosis is not a sufficient basis for the determination of the point of entrance. Bartel holds that infection from the pharynx, stomach, and intestines, especially early in life, is more frequent than generally believed. From post-mortem observations Wollstein concludes that in infants and in young children the instances of tuberculosis of respiratory origin are more numerous than those of digestive origin. CHAPTER III EESISTANCE, PREDISPOSITION, AND IMMUNITY By EDWARD R. BALDWIN RESISTANCE Animals in General.— So far as is known, no animal is absolutely immune against tuberculosis, but wide dift'erences obtain in the sus- ceptibility of different species. The herbivora are, as a rule, the least resisting, the carnivora the most, while the omnivorous varieties are probably intermediate in this respect. Guinea pigs, rabbits, and cattle evince great susceptibility to bovine tuberculosis, while dogs, cats, foxes, lions, tigers, etc., require larger doses or special conditions to produce infection. On the other hand, asses, goats, horses, rats, mice, and other rodents are higlily resistant, while swine, apes, and monkeys are very susceptible to both human and bovine tuberculosis. Nearly all birds are insusceptible to mammalian tuberculosis, but are very easily infected with the avian type, though the carnivora here also have more resistance. Man. — Mankind forms no exception among the animals by having a notably greater degree of resistance than other omnivora, yet he is less easily infected than the small herbivora, and quite resistant in healthy adult life. A greater difference would appear to exist between indi- viduals of the human race in their natural resistance than between the lower animals of the same kind. It has been an important question to settle as to the susceptibility of man for the bovine type of bacillus, and the matter may now be considered determined that there is no reason to think that mankind is less susceptible to it than to the human type. It is also held to be possible that the avian bacillus may occasionally infect human beings (Pansini, *94 ; Rabinowitsch, '04). Individual Resistance. — The resistance possessed by each individual is the chief object for study in order to arrive at a correct understand- ing of the nature of man's defenses against this disease. It is evident that such defenses may be considered normal when applied to a person in perfect health and of good physique, or subnormal if descriptive of one who is structurally and functionally " predisposed " to tuberculosis, in the broad meaning of the term. Still further, one may conceive of an 80 RESISTANCE 81 increased resistance, either natural or acquired, and finally the exist- ence of an actual immunity. In a problem of such inherent complexity it is not to be supposed that all the factors constituting resistance to disease will be considered here, but only those especially applicable to tuberculosis. It is, nevertheless, true that no other disease illustrates so fully the import of those principles of physiology that have to do with the protection of life from parasitic enemies. •NORMAL PHYSIOLOGIC RESISTANCE All clinical experience bears witness to the fact that adults of good physique, in functional and organic health, possess a nearly perfect protection against natural infection by iubercle bacilli. There is, first, the external skin, which is rarely inoculated with serious results; then the mucous membranes, which are amply protected by ciliated epithelia, and the mucous secretions, which, when in healthy condition, act mechanically in removing inhaled or swallowed bacilli. The reflexes, coughing and sneezing, the normal digestive and vaginal secretions also act mechanically or chemically as protective agencies. To these may be added intestinal peristalsis and the cleansing effect of the outward flow of the tears and urine. While it is very doubtful if any of the secretions mentioned act strongly bactericidal to the tubercle bacillus under natural conditions, the gastric juice and vaginal mucus probably weaken it. It is also questionable whether the epithelia of tlie lung alveoli are normally invulnerable by the tubercle bacillus. Influence of Age. — The influence of age is important in connection with resistance to tuberculous infection. Infants and young children are normally very susceptible, often in spite of apparent buoyant health. The frequency of tuberculous meningitis among the best-developed and healthy infants is testimony to this fact. Moreover, the delicate epi- thelial covering and easily permeable lymph spaces present but a slight barrier to infection during early childhood, and at birth the incomplete development of the gastro-intestinal mucosa is made responsible by von Behring ('03) for much infantile infection by means of food. With growth the resistance increases and attains its maximum between twenty- five and fifty, after which, doubtless, a second period of relative sus- ceptibility ensues, though clinically less easily discernible. Influence of Heredity. — The value of a good vigorous ancestry has always been recognized in connection with llio warding off of con- sumption, but a l)elief in its infallible protection has too often led to serious errors and procrastination among patients. In the ante-bacillus era the influence of heredity in the direct causation of consumption was considered paramount and nahirally overestinuited. The inheritance of functional characteristics which are attributes of good health is quite 82 RESISTANCE, PREDISPOSITION, AND IMMUNITY as obvious as the opposite, and is of great importance to normal resist- ance. Racial differences are also to be noted (vide infra). Nature of Physiologic Resistance. — Much study and speculation have been expended on the processes of cellular resistance in relation to tuber- culosis. No attempt to correctly interpret nature's methods has yet been vi^holly successful, but we may assume that they do not vary in es- sential features from those employed to combat other bacterial infections. The condition of the blood in possessing a normal content of salts, nor- mal alkalinity, and absence of an excess or deficiency of certain ingre- dients, are doubtless factors of importance. Normal coagulalnlity, agglutinating, opsonifying, and bacteriolytic functions attaching to the plasma are presumably of especial importance in the localization and destruction of tubercle bacilli, judging from their lessened power in the blood of persons who lack resistance. On the other hand, no one element has proved a safe criterion of resistance thus far, although it is possible that the determination of the opsonic index, as introduced by Wright and Douglas ('04), of London, may eventually become a measure of resistance values. In the last analysis all the phenomena of resistance depend on the reactions of the living cells of the body, and here we meet great dif- ficulty in observing the changes which accompany a successful struggle by the tissues against the tubercle bacillus. The polynuclear leucocytes are first engaged in phagocyting the invaders, but the lymphocytes and fixed cells evidently participate later in the process of disintegrating the bacilli. This appears to take place, at first, chiefly in the lymph nodes nearest their point of entrance into the body. The digestive functions of the various leucocytes best account for the mechanism of resistance, but further than this surmises cannot safely go at present. (A further discussion of this subject as related to immunity is to be found on page 95.) SUBNORMAL RESISTANCE— PREDISPOSITION A true predisposition to tuberculosis would imply a specific lower resistance to this infection in particular. This is, at present, hardly more than an hypothesis, since in former times many of the indications referred to as specific, such as scrofulosis, later proved to be actual manifestations of previously existing infection. In view of this altered conception, one may more accurately denote a predisposition as sub- normal resistance which may or may not be specific, inherited, or ac- quired, yet of great practical importance. In contrast to normal cellular vigor, the cell functions may be weak or a deficiency of certain mature forms may exist, as found by Arneth ('05) with the leucocytes. He discovered that polynuclear cells con- RESISTANCE 83 taining a large number of nuclei were diminished in persons in poor health. Likewise, Wright has found a lower opsonic index to the tubercle bacillus in " predisposed " persons. The normal serum anti- bodies, agglutinins, bacteriolysins, and opsonins are also weaker in per- sons fairly classed as subnormal in a clinical sense; hence the assump- tion that a changed condition of the blood fluids has an appreciable relation to lowered resistance is justifiable. Much stress is laid by Eobin and Binet ('01) and other French authors on a deficiency of the calcium and magnesium salts, and also of phosphates in the tissues as a result of increased respiratory activity which produces a greater interchange of CO2 and oxygen. This " de- mineralization " theory of predisposition is related to others, such as that of Schulz ('03), who finds the silicates in the connective tissue lessened or variable in amount. Furthermore, the degree of alkalinity of the blood, as represented in the bronchial mucus, is considered a factor by Hesse ('03) in favoring or opposing the growth of tubercle bacilli. The well-known susceptibility of diabetics probably depends on the excess of sugar, whether directly or indirectly may be an open question. Chemical conditions of the tissues cannot alone be considered a suf- ficient explanation of subnormal resistance, however important they may be, nor is there sufficient proof of their specific relation to the tubercle bacilli. Influence of Sex. — Females at the time of menstruation, pregnancy, and parturition are physiologically less resistant; this is also true at tbe menopause. The evidence of such lowered resistance in females is seen in the development of latent tuberculosis into activity at these periods, but with pregnancy the converse may often appear in an arrest of a previously active process. Analogous physiologic changes in males have not been associated with tuberculous infection. Inherited Predisposition. — The bearing of inherited weaknesses on the development of tuberculosis is apparently one of the most unmis- takable facts in medicine, but a modification of former views has been inevitable as the role of infection in early life has become clearer. A differentiation has been necessary : first, between actual congenital dis- ease, i. e., transmission of the bacillus in utero (see Hereditary Trans- mission) ; and second, a specific vulnerability of the offspring after birth. Close study has failed to establish the exact role of inherited disposition in this narrow meaning, yet statistical and experimental support has been forthcoming. On the one hand, there is an apparent racial susceptibility in the Negro and Indian which cannot be described as specific, since no evidence exists of the prevalence of the disease in former generations; while the converse seems true of tbe Europeans and Anglo-Saxons, whether due to gradual immunization or by the 84 RESISTANCE, PREDISPOSITION, AND IMMUNITY elimination of the weaker individuals, both of which theories are plaus- ible. On the other hand, the study of tuberculous families furnishes conflicting evidence of transmitted susceptibility. J. E. Squire ('97, '01) found that in 1,000 families only ten per cent more of the chil- dren of tuberculous parentage became tuberculous than those of non- tuberculous families in the same class of people, a difference easily accounted for by the greater chance for infection in the former. In the Faroe Islands the people have closely intermarried and had no out- side opportunities for infection for many generations, yet no proof of inherited disease or susceptibility Avas obtained by Boeg ('05). Davies ('00), however, finds the much greater prevalence of tuberculosis on the Isle of Man attributable to close intermarriage, which may or may not be interpreted as conferring a specific susceptibility. The genea- logic tables of Eiffel COG) and Leudet ("85) are made to support the latter theory, but are less conclusive. From the standpoint of biologic research Adami ('04) and Hueppe ('03) affirm a belief in transmitted specific vulnerability on the ground that the transmission of specific immunity implies the opposite as a quality of protoplasm subjected to a specific poison. Experiments along this line have not been fruitful of results. From the maternal side the young of animals subjected to tuberculous toxins are said by Carriere ('00) and Sicolla and Palmieri ('96) to be more susceptible, yet it is evident that pregnant consumptives in the active stages of the disease are likely to bear weakling children anyway, and if the fetus is exposed to injury by the toxins it will likely be a short- lived infant. When the disease is not in an active stage in the mother, no toxic influence can be assumed to play a part, so that much less ground exists in such instances for a specific inheritance. Moreover, tul)erculin susceptibility has not been proven to be transmissible. On the whole, a truly specific predisposition from maternal inheritance has no experimental basis, and from the paternal side there is much less warrant for a belief in it. Inherited Structural Defects. — While specific characteristics refer- able to the cell protoplasm which constitute disposition are not readily discerned with our present methods of research, there are many abnor- malities of structure and function which are inherited and may be acquired, that produce subnormal resistance to tuberculosis equal in importance to any assumed specific disposition. The shape of the chest formerly had more attention bestowed on it than at present, yet clinical experience bears out the old idea that the shallow or pigeon-chested individual has a poor resistance to tuber- culosis. On the other hand, Brown and Pope ('04) found no distinctive type in the chest shape of patients in the Adirondack Cottage Sani- RESISTANCE 85 tarium, but who, as a rule, are selected because of a favorable prognosis. They did find, however, an average longer thorax than normal. Sta- tistics of consumptives show about thirty-five per cent to have the phthisical form of chest, yet this is not enough to establish its promi- nence as a factor in causation unless we could exclude the cases in which it is secondary to the disease, a point generally disregarded in former studies. The habihis phthisiciis of Hippocrates was well recognized in olden times as a peculiar, fiat-formed chest, with protruding scapula, in per- sons with long bones, delicate features, and blonde skins. A long neck, sloping shoulders, and defective muscular development about the chest, with relative immobility, were prominent features emphasized by Roki- tansky ('46). Many years ago Freund ('58) found premature ossifica- tion of the first rib at the costosternal joint and shortening of the rib, frequently associated with apical tuberculosis, and ascribed this to the restriction of movement caused thereby. Hart ("06) has recently elabo- rated Freund's theory by an extensive pathologic study, and finds that it has much importance in causing a restriction of thoracic development and function at the apex. He considers it both an inherited and ac- quired maldevelopment of the costal cartilage of the first rib, which leads to an infantile type of apex, with proportionally greater antero- posterior diameter. Depression of the sternum, a restricted movement and diminished angle at the junction of the manubrium and gladiolus (Louis' angle) were associated with other anomalies by Rothschild ('00) in causing a predisposition to lung tuberculosis, but the studies of Hart failed to confirm this. (See Figs. 11 to 14.) Brehmer ('85) was one of the first in modern times to study the functional defects in connection with a Itahitus phthisiciis. He attached fundamental importance in the disposition to tuberculosis to a congeni- tally small heart with disproportionately large lungs. He conducted his sanatorium treatment Avith the idea of increasing the heart power, and by his success considered the correctness of his theory demonstrated. Many other functional and structural faults have been brought into relation to tuberculosis in the same way. Among these may be men- tioned changes in the numl)er and quality of elastic fibers (Hess, '04; Tendeloo, '01-02), deficiency of the thyroid gland (Lorand, '05), de- generation of the pneumogastric nerve (Mays, "00), and cerebral defects as found in imbeciles and markedly neurotic persons, ^lost of the in- born anomalies fall short as sufficient causes of predisposition when taken separately, and some, indeed, are probal)ly acquired as the result of tuberculosis quite as often as they are inherited causative factors. This is true of snuill hearts, imperfect thoraces, and nutritional faults described by Landouzy ('99) and Mosny {'02, '03) as " paratubercu- 86 RESISTANCE, PREDISPOSITION, AND IMMUNITY loses." It is, at least, hard to differentiate those which are due to inherited defects from those dependent on early and mild tuberculous infection; or, still further, those resulting from other diseases in the parents. Besides tuberculosis, syphilis and alcoholism in the parents are well known as potent causes of physical degeneracy in the children which render them subnormal in their resistance to disease in general. Local Predisposition. — Certain tissues and situations in the body seem to be especially' prone to tuberculosis, and while mostly explained by mechanical conditions, which favor the lodgment of the bacillus, there are suggestions of a greater adaptability for infection of the lungs, for example, as compared with the liver or muscles due to biologic dif- ferences in the cells. The predilection of the lung apices is explained in several ways : ( 1 ) by the slower air current favoring the deposit of bacillus dust; (2) by the irregularities and sharper angles of the bronchi in this situation tending to retain the secretions (Birch-Hirschfeld, '99) ; (3) a slower blood and lymph stream mechanically favorable to hematogenous infection, and because of the defective nutrition thus produced. Schmorl ('01) has located a fibrous groove in the pleura opposite the posterior segment of the first rib which is often associated with the anomalies of Freund and Hart previously mentioned, and which he regards as a local predisposition. These anatomic theories, taken singly, are less tenable than the physiologic ones so ably presented by Tendeloo ('07) and which attrib- ute the differences in vulnerability of the lung apices, as compared with other portions, chiefly to poorer nutritional conditions dependent on a slower blood and lymph flow, to restricted expansion and conse- quent slight atmospheric pressure changes, and to absence of venous stasis in the apices, the latter being unfavorable to tuberculous infection (see also Immunity). Another explanation of apical lung disease which should be remem- bered is that an extension of lymphatic infection in the neck by way of the pleura is possible. Aufrecht ('05) has long held that infection of the lungs in particular is accounted for by infarcts caused by bacilli lodging in the small arterial endings. Von Behring ('06) inclines to the same view of primary lung infection, no other reason than the physiologic conditions of the blood circulation, which makes the lung act as a filter, being needed to account for a predilection for this organ. The same reasoning accounts for the development of foci in the kid- neys and joints. On the whole, no satisfactory biochemic theory can be adduced which accounts for local predisposition, although there are such explanations for the relative immunity of some tissues, such, for example, as the stomach, where the presence of hydrochloric acid is inimical to bacteria. The endothelia of the alveolar capillaries and RESISTANCE 87 serous membranes are, however, believed to have a special affinity for the bacillus poison by von Behring ('06) (see page 95). An apparent hereditary locus minoris resisteniice has been observed by Turban ('00) in that the lung on the same side of the body as in the parent was first involved in the children of 19 out of 22 tuberculous families. This ob- servation was confirmed in 78 per cent of 28 families among the author's ('02) cases. In one family where the father and four children were con- sumptive, the left lung appeared to be attacked first in all of them. Acquired Predisposition. — In the absence of congenital defects or inborn weakness, there is no doubt that numerous causes are able to produce a temporary or permanent subnormal resistance to tuberculosis. These causes are frequently of greater importance than heredity and structural weakness because tuberculosis is no respecter of athletic con- stitutions temporarily made susceptible, and is oftener unconsidered in such persons, whereas greater care is bestowed on the weakling. SPECIFIC SUSCEPTIBILITY FROM PREVIOUS TUBERCULOUS IXFECTIOX Lymphatic (Scrofulosis). — The question of primary and secondary tuberculous infections has become of increasing interest and importance during recent j'ears, and largely through the observations of von Behring ('03) who attaches much importance to the ease of infantile infection and its remote consequences. It cannot be gainsaid that many young adults having pulmonary tuberculosis appear to have acquired their first infection in childhood, and subsequent infections led to the ulti- mate outbreak, or, as von Behring holds to be more probable, resulted from the latent bacilli which first found lodgment in the tissues. It is highly important to contemplate the three possibilities by which von Behring explains the result of the inhalation or ingestion of tuber- cle bacilli in early life and their primary reception into the tissues. In the first place, they may be of sufficient number or virulence to produce immediate and fatal infection. Second, they may be able, because of less nimiber or virulence, to produce only local disease in the lymph nodes or lungs, which accounts for scrofulosis and all its manifestations. According as the disease is more or less marked, it ma}^ or may not finally lead to lung tuberculosis aftei* this incubation stage. Third, the virus may be so weak that no infection results, but a degree of increased resistance is established, after a period of susceptibility last- ing several months has passed by. In this place we have only to do with the last two hypotheses, and more especially with the clinical evidence of a specific susceptibility under the name of a " scrofulous diathesis," as it is vaguely termed in tlie older medical works. It is a complex matter at best since no clear distinctions can be made 88 RESISTANCE, PREDISPOSITION, AND IMMUNITY between morbid processes due to the tubercle bacillus which set up chronic lymphoid hyperplasia and those due to other bacteria alone or associated with the tubercle bacillus. Clinically it is customary to dis- tinguish between a tuberculous and nontuberculous scrofula only by the test of time, and yet all forms are clearly predisposing, or at least are frequently followed b}^ some other form of tuberculosis. It is therefore proposed by many writers to abolish the term altogether and class all cases as lymphatic tuberculosis. Nevertheless, it seems to the writer justifiable to retain it for nontuberculous lymph-node affections pro- duced by the streptococcus and other pyogenic organisms, which are assumed to exist, and certainly prepare the soil for the tubercle bacillus. For the practical application of preventive measures, it is needful, there- fore, to consider scrofulosis as a strong predisposing factor. Pulmonary. — -An important practical question connected with former attacks of pulmonary tuberculosis concerns the danger of reinfection after the clinical healing of the disease, or in subjects with so-called latent pulmonary tuberculosis. Little proof has been produced that a special disposition to external infection is brought about by the first attack, yet it must be acknowledged that secondary autoinfection is frequent in the lungs, larynx, and intestine, as well as in other organs of individuals with open disease. It shoiild be recalled, however, that under these circumstances any weak moment, whether due to existing tuberculosis or not, may play the part of a predisposition, when great numbers of bacilli are ever present and ready to enter. On the other hand, the tendency to localization at the point of entrance into the mucosa is regarded as a sign of resistance by von Behring (see page 93), and may repel a secondary infection from outside sources more vigorously than normal, particularly in adult life under natural ex- posure. So far, then, as can be proved, the role of a specifically acquired susceptibility in favoring a fresh infection from without is at most very slight and not supported by animal experiments, while the reverse effect — i.e., an acquired protection, has an experimental basis (see Immu- nity). On its face this statement appears wdiolly contradicted by the clinical observation of successive attacks of pulmonary tuberculosis in subjects previously healed in the clinical sense. Yet it must be remem- bered that most of these relapses can be traced to autoinfection from an old focus and not to new bacilli from outside. Moi'eover, the idea of multiple cumulative infections in children exposed to family tuber- culosis is not necessarily incompatible with a relativel}^ increasing though insufficient resistance to external infection. The exact truth about specific susceptibility may require years of further observation to settle. RESISTANCE 89 NONSPECIFIC SUSCEPTIBILITY Infectious Diseases. — The other infections preceding or following the reception of tubercle bacilli into the body are probably the most important factors in predisposition. In childhood the familiar picture of meningeal and lymphatic tuberculosis following the exanthematous diseases needs no comment. Measles and whooping cough most fre- quently lead to acute outbreaks of tuberculosis; tonsillitis, diphtheria, and influenza to the scrofulous t}^es of the disease in the young. The role of these infections in adults, if not also in older children, is doubt- less more often that of spreading a preexisting latent tuberculosis. Influenza comes first in this class, comprising an antecedent history in 15.5 per cent of Ifi^Q of the writer's cases where an exciting cause was referred to, while colds were recorded in 22.2 per cent as forerunners of the onset of tuberculosis. Pneumonia and pneumococcus infections in general are associated with the etiology of pulmonary tuberculosis, but to what extent is not known. The principal difficulty arises in deciding Avhether lobar pneu- monia precedes or accompanies the pneumonic form of tuberculosis, or whether the latter is quite independent of it. A history was obtained in nearly six per cent of the cases collected by Jacob and Pannwitz ('01-'02), and in six and a half per cent of the writer's. In many cases the diagnosis is too indefinite to make the estimates accurate. Pleuritis. — A history of a former pleurisy as an independent affec- tion, either dry or exudative, was given by eleven per cent of the writer's patients. Such a large proportion of pleurisies have been found tuberculous in recent years, if one may judge by the results of the tuberculin test, that but little value can be given to such figures as an evidence of predisposition. Streptococcus and pneumococcus pleurisies, nevertheless, are probably locally predisposing. The subacute and chronic catarrhal respiratory affections, such as tracheobronchitis, when not symptomatic of tuberculosis are difficult to bring into a causative rela- tion to it. Bronchitis was a histor}^ in three per cent of the writer's cases, most of which were doubtless symptomatic. In the upper air passages the nasal obstructions, adenoid hypertrophies, and atrophic changes of the mucosa which are the sequelae of various acute infections probably play a more important part than the catarrhal processes per se. Typhoid fever is so often confused with tuberculosis that its relation to it is hard to establish. In 4.2 per cent of the writer's cases a history of alleged typhoid was associated with the tuberculosis. It could hardly fail to be an occasional factor, especially in infection by way of the intestine. 90 RESISTANCE, PREDISPOSITION, AND IMMUNITY Acute gastro-intcstinal catarrh is in the same category with typhoid as a means of producing conditions favorable to intestinal infection, particularly in infants. Malaria was mentioned as a causative factor by 2.09 per cent of the writer's patients. Such histories depend chiefly on the presence of malaria in the region in which these patients reside. The symptoms of tuberculosis are, no doubt, very often mistakenly attributed to ma- laria because of their similarity. Hence but a small role can be given to it in predisposition when measured by such standards. Rheumatic fever is rarely followed by tuberculosis, and the heart complications resulting in passive congestion are thought to act antago- nistically to it (see page 92). Of the venereal infections, gonorrhea and syphilis, both are fre- quently associated with tuberculosis, but whether as especially aiding its development may be doubted. In fact, the erroneous idea that syphilis is protective has been held (Portucalis, '99). Syphilis was present in 1.3 per cent of the writer's private cases, but in a large series of hospital cases from 3 to 6 per cent are recorded (Sargent, '07; Mauthe, 'OO-'Ol). Association with depraved habits which are equally harmful to health, and the large percentage of venereal diseases in the nontuberculous, renders a decision as to its importance impossible. Gonorrhea is said to favor localization of the bacilli in the kidneys, bladder, and testes; otherwise it acts only as a debilitating factor in general. Diseases of Nutrition. — Diabetes MelUtns. — One of the most serious predispositions from diseased conditions is conferred by diabetes. Over one quarter of its victims among young persons die of tuberculosis. A chemical basis is assumed for this susceptibility in that sugar favors the growth of tubercle bacilli, but other elements may be associated. Rachitis is probably the most important, next to diabetes, in favoring infection, because of the combination of thoracic deformities and defect- ive development in general. Turban ('99) found 10.8 per cent of his cases of this type; the writer found only 3 per cent, but in the latter were included only those cases with marked deformity dating from childhood. Gastric and intestinal dyspepsias and chlorosis are too often symp- tomatic of tuberculosis and other diseases to be classed as predisposing in themselves, though this cannot be denied of them. Nervous Diseases. — Epileptic families are very frequently tubercu- lous, while neurotic persons in general easily fall victims to tuberculosis, No direct connection can be assumed, but malnutrition accompanies nearly all of these affections, and is sufficient to account for their association. RESISTANCE 91 Insanity. — Tuberculosis carries off from thirty to forty per cent of melancholies and maniacal insane persons. The fasting and confine- ment, combined with opportunities for infection and traumatism, have much importance here. Miscellaneous. — XcpJiritis is occasionally antecedent to tuberculosis, but of doubtful connection with it in a causative way. Cancer is also occasionally mentioned as one cause acting by its debilitating effect. Eczema and other skin diseases may be included with predisposing factors by leading to inoculation from scratches, etc. Injuries (Traumata) . — Blows on the chest or concussions, as in rail- way accidents, athletic contests, or violent strains, are capable of bring- ing to light a latent tuberculosis. Contusions and the consequent ex- travasations of blood make a good soil for tubercle bacilli which may be lurking there at the time and gain access to the part through the blood. Thus joint and meningeal tuberculoses are rightfully associated with blows or falls. Severe nervous shocks and overstrain may here be included. The occurrence of tuberculosis among American college ath- letes is also significant in this connection. Surgical operations may give the impetus to a slumbering disease which is thus wakened to activity. This is occasionally seen after oper- ations on tuberculous lymph nodes, for appendicitis and other abdominal diseases. In thirteen of the writer's cases appendicitis with operation seemed to be connected with a subsequent tuberculosis. Aspiration of a pleural exudate and section of a fistula in ano have sometimes been followed by miliary tuberculosis, presumably produced by the oppor- tunity given for a large number of bacilli to get into the lymph cir- culation. INCREASED RESISTANCE Physiologic. — By appropriate measures persons of subnormal vigor may enhance their resistance to tuberculosis. One of the most impor- tant is to increase the digestive power and assimilation of food. Proteid and fatt}^ foods are especially adapted for this purpose, and are the ones usually least preferred by the so-called predisposed individual. Suitable muscular and mental exercises promote resistance, while recre- ation in the open air and athletic sports in moderation aid greatly. Occupation. — Open-air occupation increases the resistance of the respiratory tract to changes of temperature, and promotes heart power. Coal miners are said to be relatively immune because the dust lodged in the lungs creates an unfavorable soil for tlie bacillus — an improbable explanation. Likewise, it has been alleged that sulphurous-acid fumes formed in wood-pulp manufacture, the ammonia from stables, and the balsamic emanations in the forests act directly as a protection by their 92 RESISTANCE, PREDISPOSITION, AND IMMUNITY antiseptic qualities. Such theories are no longer worthy of attention, the freedom from infection, if any, being attributable to absence of other conditions necessary to bring it about. Diathetic. — A familiar observation is the relative immunity to tuber- culosis among lithemic individuals. The gouty diathesis also appears to promote chronicity in the disease, when present. On the theory that an excess of the products of nitrogen metabolism are in the blood, and make an unfavorable soil for the bacillus, the administration of urea was advocated by Harper ('01) as a therapeutic agent. Diseases. — Mitral Heart Disease. — The supposed antagonism from mitral heart disease, accompanied by venous congestion of the lung, rests on clinical observations of arrested pulmonary tuberculosis in individuals who have this complication. Whether an actual antagonism to infection from this cause really exists is questioned by G. W. jSTorris ('04) as the result of a collective study of pathologic material. The excellent results of Bier, who introduced the treatment of localized tuberculosis on the theory of venous stasis, nevertheless incline to sup- port the above explanation. Emphysema and asthma are supposed to confer some protection on individuals who suffer from these maladies. If they are not already symptoms of tuberculosis of a chronic t3'pe they may act by venous congestion, as in mitral insufficiency, to which some cases are related anyhow. Specific Increase of Resistance. — The possibility of an hereditary resistance acquired by certain races has already been referred to (page 83). If its existence is admitted, it is less discoverable in the indi- vidual than in the race or family as a whole. ^ There is more reason to assume a gradually acquired resistance after birth, which amounts to immunity in those individuals who were unquestionably exposed to the infection without evidence of infection having ever occurred. To this class possibly should be added those numerous instances of slight localized infections which leave cicatrices in the lungs or lymph nodes. On the other hand, it cannot be assumed that a specific resistance, de- veloped for a time by exposure to a harmless infection, necessarily per- sists beyond a limited period, especially when only fibrous or chalky remains of the transient infection are present. Fortunately, during good health adults enjoy a large degree of natural or acquired resist- ance, judging from the rare development of the disease under such conditions of exposure as serve to infect weaklings and children. > Reibmayr ('94) attributed the more benign course of tuberculosis in England and Germany to a decreasing virulence due to a gradual immunizing process in these races. IMMUNITY 93 In the families of sufferers from " inlierited " tuberculosis in the old meaning of the term, there is found some support for the idea of a partial immunity, inherited or acquired from parental sources. This is observed in the greater chronicity and duration of the disease in such families, and has been used as an argument both for the inheritance of the disease and a special resistance to it. The acquisition of lym- phatic or bone tuberculosis early in life, which is mild in character, as a rule, is often followed by a very mild type of pulmonary tuberculosis. It is, therefore, not necessary to attribute the increased resistance to an inherited influence, as early infection is the rule in family tuber- culosis. The late Dr. Edwin Solly ('95), of Colorado, made the inter- esting observation in his patients that more lasting " cures " or chronic forms among pulmonary cases occurred among those with a history of family tuberculosis than those without it. Turban ('99) noted the same thing, while H. M. King ('01) found the course of the disease a year longer in 103 carefully recorded fatal cases of tuberculous parent- age. Previous acute attaeks of tuberculosis may fairly be associated with the more chronic course of relapses, especially those in advanced age, as manifestations of specific resistance. The chronic course of lupus is also assumed by von Behring to be a sign of resistance in a previously infected " scrofulous " person who acquires an added infection which localizes in the skin because of the relatively immune lymphatic system. If true, it is an illustration that partial immunity, although conserving life, is not always desirable for the individual. IMMUNITY To use this term literally in connection with tuberculosis is unwar- ranted by any experiences of a clinical or experimental character thus far obtained. The possibilities of complete immunity under all condi- tions of natural exposure and experimental inoculation may well be doubted ; but the suggestions of relative auto-immunity, mentioned in the preceding paragraph, combined with the slowly evolved conviction from experimental research, have produced a belief in the possibility of a high degree of relative immunity against tuberculosis. This fact gives hope for its future application in the prevention of tuberculous infection in the human race, a matter of transcendent interest and im- portance. At present enough is demonstrated of the value of immuni- zation in bovines to make certain that when methods are perfected, it should not only apply universally to animals but to human beings as well. Experiments. — The history of experimental research in tuberculosis during the past fifteen years has much to do with attempts to protect 94 RESISTANCE, PREDISPOSITION, AND IMMUNITY animals against tlie disease by vaccination with bacilli, sterilized or weakened in various ways b}^ tlie use of extracts, or of varieties other than those capable of infecting the given species to be immunized.^ A certain degree of success was attained at the beginning of these studies by Dixon ('89), Koch ('90), Klebs, Grancher ('90), Hericourt ('92), and Trudeau ('93) on guinea pigs and rabbits. Later de Schweinitz (03) and Trudeau ("03-"06) found a very high resistance established in guinea pigs by inoculations of bacilli of weak virulence, while still later MacFadyen, von Behring, and Pearson ('02-'06), and Gilliland ('02) simultaneously found that cattle could be protected by inoculations of human bacilli. Koch, Neufeld ('04), and Schiitz ('03) also established the same fact. Methods by which success was obtained in diphtheria and tetanus were found of no avail by the majority of investigators. Maragliano ('95, '04, '05) has been the chief exponent of antitoxic methods, and more recently Marmorek ('03-'04) has claimed successful results by means of sera, but the proof has not been con- vincing. Preparations of dead bacilli confer some degree of immunity, but the greatest success has been obtained by living bacilli in a feebly virulent condition. All soluble extracts have failed to excite a specific immunity, although they give rise to certain antibodies in the serum of injected animals. In his painstaking researches over a decade ago Koch ('97) came to the conclusion that the washed body substance of pulverized bacilli (T. E.) of virulent strains was the best immunizing agent. Von Behring ('07), in his latest published statements, con- siders that partly extracted " Rest " bacilli, treated with chloral hydrate and other salts, produce the best results. The problem seems in a fair way to 1)0 solved by these diligent studies. Application. — Cattle. — The immunization of young calves has been carried on rather extensively in Germany and Austria by the " bovo- vaccine " method of von Behring, which consists of one or two intra- venous inoculations of human bacilli cultures. These have been passed through guinea pigs before cultivation for the preparation of vaccine, and are dried before use. The bacilli are not sterilized, but weakened by desiccation. Pearson has been the pioneer in this field in America, and has applied intravenous human bacilli inoculations in Pennsyl- vania to a large number of cattle, and demonstrated the value of the method by exposing immunized calves to natural infection together with unprotected animals, and with complete success in preventing infection in the protected animals. The tuberculin test and post-mortem exami- nations established this beyond a doubt. Valuable confirmation has also " A review of these experiments is presented by Pearson in the Second Annual Report of the Phipps Institute. IMMUNITY 95 been fiirnislied l^y Calmette and Guerin ('06) and Yallee ('06) in Prance, who carried on similar tests, and furthermore found that calves could be protected by feeding the protective virus in milk. The chief drawback in the immunization of cattle at present is in the use of living bacilli which, though harmless for cattle, may remain latent in the tissues and be a source of danger in the flesh and milk. If the later preparations used by von Behring, " tuberculase '' and " tulase," which are claimed to have all the properties of living bacilli except the power to grow, shall prove to be equally as good as the living virus, a great advantage will be gained. The application of specific immunization to man will then logically follow. It would be unsafe to predict the limitations of its use at present, or the duration of the protection. jSTo facts are available as yet to answer these ques- tions, but even if the protection is but a matter of months, the period of greatest danger, according to present views of primary infection (that of childhood), might be tided over when by the growth of natural resistance virtual immunity is assured. Explanation of Mechanism. — The study of immunity problems in general has brought aid in the understanding of the reaction of the animal tissues to a tuberculous infection. The tubercle, as a unit, has also much in its structure, reactions, and transformations that interprets the resisting mechanism of the body cells. Stress must be laid at pres- ent on the leucocytes and lymphoid tissue as being subject to changes during the immunization process, by which a more vigorous defense is presented to invading bacilli. The condition of tuberculin suscepti- bility is apparently a necessary phase of immunity, and may exist, according to von Behring, without the presence of tubercles, owing to functional alterations in the lymphatic tissues and endothelia of arteries and serous membranes. However this may be, the eye inoculations in the immunized rabbits in Trudeau's ('93) experiments resulted in a massive leucocytosis and more marked congestion than in control eyes, and with eventual healing. The evident destruction of the bacilli by the leucocytes, or at least their presence in greater number, points to a lytic function in the cells since the serum alone fails to reveal it. It is presumable, then, that so long as the susceptibility lasts there is heightened phagocytic and lytic power. "Whether at the same time tolerance is developed for the toxin set free in the blood and in these cells surrounding the bacilli or the tubercles, is more doubtful. Only when no local caseation, general dis- turbance, or cachexia follows the death of the inoculated bacilli — i. e., a toxin immunity — can a satisfactory degree of protection be consid- ered established. The assimilation and transformation of the endo- toxin by certain chemical groups in the body cells which have an affinity 96 RESISTANCE, PREDISPOSITION, AND IMMUNITY for allied groups in the bacilli, is, in essence, the explanation for the immunity phenomena given recently by von Behring, who has made a most thorough study of the problem. In the actually diseased indi- vidual but little impression is made on the cells outside of the aggre- gation about the tubercles until the malady has progressed to an advanced stage. Then increasing resistance may seem to be developed gradually and lead to an arrest or ehronicity of the disease. Such immunity comes too late to be efficacious in saving life, but by inilu- encing the cells outside the tubercle artificially during favorable stages of the disease one has the best rationale for the use of immunizing tuberculins, as introduced by Koch and von Behring. SPECIFIC SUBSTANCES IN THE BLOOD Agglutinins and Precipitins. — The most prominent change discov- erable in tlie blood of animals injected with bacilli or extracts of the same is the development of agglutinating or precipitating power for them. Its significance appears to be no greater than in other diseases, and it does not seem necessary to immunity. On the contrary, quite strong agglutination power may be present without immunity. It is probable that this function tends to localize the infection and that the precipitins are practically identical in effect. Opsonins were demonstrated by Wright as reaction products concerned in immunity, which aid in the process of phagocytosis. The specificity of this function in tuberculosis has been demonstrated, but its apparent independence of the agglutinating function is not to be assumed as yet. The opsonic index, as a measure of resistance, is of uncertain value in actual use thus far, yet in the hands of its discoverer tuber- culin treatment is claimed to be more successfully administered by its guidance. Antitoxins have not been demonstrable by the usual methods in vogue with diphtheria, etc., except in the hands of Maragliano ('95), Marmorek ('03), and a few others. The development of true antitoxin for tuberculosis is a priori unlikely, inaspiuch as the bacillus resembles typhoid, streptococcus, staphylococcus and other bacteria, etc., in which cell endotoxins, as distinguished from secreted toxins, play the prin- cipal part of the disease. To this class of toxins the antitoxic or neu- tralizing properties of the tissue cells are not free in the serum, so far as has been proved. Antibodies having two affinities (amboceptors) have been demonstrated in the serum by Widal and Le Sourd ('01), Camus and Pagniez ('01), and the writer ('04). These are not true antitoxins in the sense of diphtheria and tetanus, but are apparently related to the agglutinin or opsonin. IMMUNITY 97 Antituberculin was assumed by Wasserman and Brack ("06), who examined the serum and tissues of tuberculous subjects, to be an antibody set free from the tubercles by the secreting cells surrounding them. By the method used to identify it, differentiation from the agglutinins was not established. Lysins. — While lytic processes exerted on tubercle bacilli can be proved to take place in the tissues, the serum does not reveal such powers as does typhoid immune serum. In the disintegration of tubercle bacilli, the leucocytes are doubtless most important, but test-tube experiments here also fail to give information of value. The highly resistant wax composing such a large part of the bacillus is readily imagined to be difficult to dissolve and digest, and the process is doubtless slower than with most other bacteria for this reason. SUMMARY The biologic processes of specific immunity against tuberculosis are at least twofold: (a) a bacteriolytic function, involving in all proba- bility agglutinating and opsonifying action by the serum; (&) a toxin- binding or digesting function which establishes tolerance after a period of susceptibility, provided the amount is correctly adjusted to the capacity of the individual's cells and their nutrition is well maintained. 98 RESISTANCE, PREDISPOSITION, AND IMMUNITY ADDENDA Summary of Predisposition and Immunity, Presented at the Interna- tional Congress, held in Washington, D. C. Of the contributions presented to the International Congress of Tuberculosis at Washington, those bearing on the subject of predis- position and immunity should here be noted. The " demineralization " theory of predisposition has found a new supporter in this country. An explanation of increased calcium excre- tion in tuljerculosis is given by the studies of Croftan which tends to emphasize the importance of this ekment in neutralizing the fever- producing albumoses set free by the disease. Several valuable contributions have been made to the subject of inherited predisposition. To be mentioned particularlj'^ is the work of Prof. Karl Pearson, who has made a more careful study in recent years of family tuljerculosis, and comes to a conclusion decidedly favor- ing the theory of hereditary predisposition. Szaboky collected statistics from 1,456 tuberculous and 1,433 non- tuberculous individuals from which he determined that hereditary pre- disposition was of equal importance to acquired disposition. The largest proportion of the tuberculous had an inherited taint which was one half from the paternal and the other half from the maternal side. In a third of the cases the disease showed itself in the parents before the birth of the children. A small percentage had tuberculosis in grand- parents, and the least in brothers and sisters. Von Unterberger explains a transmitted specific vulnerability by qualitative differences in the embryonic chromosomes. Hart has continued his studies of structural anomalies of the upper thoracic aperture, and maintains his views as to their importance as a predisposing factor. This predisposition is at first local and holds for any manner of infection, whether by inhalation, blood, or lymphatic routes. This leads to the development of the first foci in the apices. Disarticulation of the first rib cartilage has been seriously proposed as an aid in over- coming this disposition (Harrass, '08). The theories of Hart as illustrated in the accompanying photo- graphic reproductions (Figs. 11 to 14 ^) have the best claim to recog- ' These four excellent radiograms have been kindly supplied by Dr. Carl Hart and are reproduced from original photographs with his permission and through the courtesy of his publishers, F. Enke, Stuttgart. (See Bibliography, Hart, '06 and Hart and Harrass, '08.) J ^ mS^f ■■^ p I>>^J^^ M ' ' ^^^^ J IH^v': ''l^^ Ni j^^^ ^ Fig. 11. — Normal, Well-Developed Upper Thoracic Opening ■mxH Good Pronunciation of Paravertebral Spaces. Marked age ossification of costal cartilages. Fig. 12. — Typical Stenosed Upper Thoracic Opening with Asymmetry. Pri- mary deformation of ribs. Sheath forming ossification of cartilage. Transition of the higher human form, the longitudinal oval, to the lower mammalian form, the transverse oval. Absence of lateral posterior spaces. Pressure of ribs has caused Schmorl's furrow in lung tissue. 99 Fig. 13. — Asymmetrical Thoracic Opening with Slight Scoliosis of Cervical AND Upper Thoracic Spine. Abnormal shortness of costal cartilages with sheath forming ossification. Fig. 14. — Formation of True Joints with Epiphyses and Capsules. Total senile ossification of first costal cartilage. Healed tuberculous foci in lung. 100 ADDENDA 101 nition in explaining apical tuberculosis where anomalies exist in the thoracic structure. Under the name of " asthenia universalis," Stiller describes similar defects, including enteroptosis and floating tenth rib due to congenital absence of the tenth costal cartilage. A contribution to the fact that tuberculosis is a potent cause of mental degeneracy is to be found in the statistics of 6,000 cases reviewed by Barr, from England and America. In the former tuberculosis was placed second and in the latter third in importance as etiological factors. The familiar effects of strain, both physical and mental, in bring- ing latent tuberculosis to activity are certainly logical reasons for the belief that they frequently prepare the soil for infection. No better argument for an eight-hour working day is needed than the importance of tuberculosis preventive measures. The classic experiments of Charrin and Eoger, where animals which were made to overwork on treadmills showed lessened resistance to infec- tions, illustrate the principle clearly. The effects of worry and care are equally potent when combined with overwork and great responsibilities. Special dangers are associated with dusty occupations, such as stone- cutters and metal polishers. Organic dust is of less importance, but in statistics can be shown to bear some relation. Hoffman has collected an interesting table of thirty dusty occupa- tions showing the increased incidence of tuberculosis in them. Experiments with the purpose of inducing artificially immunity in animals have been continued, but the prol)lem is not yet sufficiently solved to warrant any positive assertions about the value of these methods. Eecently certain oleate soaps have been found by Koguchi to have restraining or bactericidal properties for tubercle bacilli which render them useful for immunization, while the studies of Bartel on the modi- fying influence of lymphoid tissue on their virulence which serves the same purpose, are at present hopeful fields of research. A method to prevent the danger by inclosing the living bacilli in capsules which are permeable for the poisons, is employed by Heymans. The capsules are introduced subcutaneously or intraperitoneally, and are claimed to confer a high degree of protection. Klimmer, of Dresden, claims equally good results from subcutaneous inoculation of living cultures of human type wliich are modified by passing through lizards, so as to lose tlieir virulence for mammals. Enough experience has been gained at present to show that the pro- tection of calves is of limited duration. From six months to a year after vaccination exposure to infection is well resisted. Afterwards 102 RESISTANCE, PREDISPOSITION, AND IMMUNITY bovine tuberculosis may be readily inoculated or acqjuired in infected stalls. It is therefore plain that repeated vaccinations would be required to maintain the resistance, at least until the maturity of the animal fortified by previous vaccinations was a sufficient safeguard. It has also been noted that for two months after the immunizing inoculation a state of lowered resistance exists, during which time pro- tection from infection is important. Altogether the outlook for a prac- ticable vaccination against tuberculosis is fair, though subject to some limitations. Many new theories have been offered as explanation of the mechan- ism of immunity. Of interest are the experiments of Opie, pointing to a proteolytic enzyme activity on the part of the leucocytes surrounding or containing the bacilli. Of interest also are the recent experiments by Calmette, which have shown that the serum of cattle and of man during the earlier stages of the disease will act as complement in completing the hemolysis of erythrocytes saturated with cobra venom. This property is said to be absent from the normal serum and in the acute or advanced stages of tuberculosis. The substance is thought to be an antibody of the nature of lecithin. PAKT II FREQUENCY AND DISTRIBUTION CHAPTER I FEEQUENCY OF TUBERCULOSIS By ARNOLD C. KLEBS GENERAL CONSIDERATIONS That tuberculosis is a very frequent disease and that it seems dis- tributed over the civilized world is now a more generally understood fact, since many painstaking investigations have supplied the data for infor- mation. Whether such investigations, however, can ever furnish exact results, as almost every text-book or monograph attempts to show, must be viewed with grave doubt. All collective information on frequency and distribution of a disease is naturally based upon individual infor- mation, and in chronic diseases it is almost entirely supplied by mortal- ity figures. Individual judgment as regards diagnosis is subject to error, and in official returns is often influenced by outside factors, and mor- tality statistics cannot give exact information as regards the importance and disability-producing qualities of a given disease, since it counts only the dead and not the wounded. These general considerations do not allow us, however, to set aside all statistical informations, only it is essential, in order to get a clear conception of actualities, to weigh very carefully the source of information before basing conclusions thereupon. As regards the frequency of tuberculosis the paradoxical statement may be safely made that tuberculous infection is enormously frequent, affecting at some time almost ever3'body in a civilized community, while the disease itself, in a health- and life-threatening degi'ee, is relatively much rarer. FREQUENCY IN AUTOPSIES An examination of all bodies would undoubtedly give the most accu- rate information as to the frequency of tuberculosis in the human race. Lender present conditions, however, only a very insignificant number of all dead comes to autopsy, varying in different countries in accordance to a greater or lesser public prejudice. In this country large series of postmortem examinations are not obtainable, and for the required infor- mation one has therefore to turn to the countries of the European 9 105 106 FREQUENCY OF TUBERCULOSIS Continent, where autopsies are more frequently performed — as a rule, on all those who liave died in hospitals. The hospital population, of course, does not typically represent the whole ])opulation, especially not as to age distribution and social condition. Its largest contingent is furnished by the working classes. For this reason it has been main- tained (Cornet, '07) that it is entirely erroneous to base calculations about the frequency of tuberculosis among the people at large upon tuberculous findings in autopsies. But since tuberculosis forms par- ticularly a problem of the working classes, and since they undoubtedly constitute the vast majority, information derived from an investigation among those classes not only touches, but throws the strongest light on the situation as it is. On the other hand, it must be borne in mind that only the sick enter the hospitals, and of these only those dying form the basis of such investigations; also, that in some of these hos- pitals a considerable number of consumptives find admittance. There is therefore a good reason for the assertion that the percentage of tuber- culosis found among such a material is not applicable to the population at large. As ])ointed out recently by Beitzke ('09), a final decision about the frequency of tuberculosis is at present impossible. This applies with equal force to the calculations by which the frequency is most usually determined, based upon death certificates and clinical observation. But while a final decision cannot be formed, one sufficiently accurate for the practical appreciation of the magnitude of the tuberculosis problem can be deduced from observations made. The principal question as to what is to be considered tuberculous and what not has given consider- able trouble not only to the statistician compiling death certificates, but also to the pathologist. Eelatively slight divergencies in opinion as to what lesions are to he regarded as tuberculous often are responsible for the figures obtained by different observers. It is also true that the results of the more recent serial examinations cannot be compared with those of earlier times, because of late a more diligent search has been made for tuberculous lesions. And it is well demonstrated that it requires special training to discover tuberculous lesions. The discovery of healed and apparently insignificant lesions is not irrelevant, as has been held, because only through a painstaking study of the manifold reactions caused by the tubercle bacillus within the tissues can the real significance of tlie disease be determined. The most important contribution to this subject was made by Nageli ('00). He investigated 500 bodies with particular attention to tuber- culous lesions, and found a greater frequency of tuberculosis than was previously found in a smaller number (100) of autopsies performed by Hanau and Schlenker (G6 per cent). His figures have been widely FREQUENCY IN AUTOPSIES 107 quoted, and substantiated by some and repealed by others. The differ- ence in the figures obtained by later observers seems to be due less to a varying frequency of tuberculosis in the districts where the exam- inations were made than to different methods of investigation and also of classification. The strongest corroboration of Niigeli's findings was made by Burkhardt ('06). His investigations were made in 1,453 autopsies of patients who died of various diseases in Schmorl's clinic at the Dresden hospital. He used the same methods Niigeli employed, except that he did not include as tuberculous " slaty " indurations and simple adhesions and scars of the apex unless there was distinct reason for doing it. Probably, therefore, his figures are somewhat lower than Nageli's. Outside of lethal tuberculosis he distinguishes (1) latent- active tuberculosis, which Avas not the cause of death, and in this definition he includes all fresh caseations in the lungs, glands, or elsewhere; (2) latent-inactive tuberculosis, as the former being found accidentally, and consisting in calcifications (cicatrization and "slaty" induration only when distinctly tuberculous). Cornet has raised an objection against including as tuberculous cal- cified foci, because they contained no virulent bacilli, an assertion re- cently disproven clearly by Lubarsch ('08). The findings of Burkhardt are best illustrated by the accompanying chart (Fig. 15), which shows the distribution of tuberculous findings in the various age groups. It is seen here that tuberculosis proves most dangerous (53 per cent) in the most active years of life — i.e., between eighteen and thirty — a circumstance noted also in general mor- tality statistics. Another acme of lethality is reached between the ages of five and fourteen. This latter feature is absent in the curve obtained from percentages of mortality, probabl}^ because of a different nomen- clature used at those ages on the death certificates. The curve of the eases in which tuberculosis was the cause of death descends gradually but distinctly from the thirtieth year on. It is very probable that this descent would not be as marked in a much larger material. The total number of cases at the more advanced ages is too small to give reliable percentage figures. Of great interest is the curve indicating total tuberculous find- ings. Its gradual rise up to 96 per cent (Niigeli, Burkhardt 93 per cent), between the ages of twenty and ninety, while the fatality curve gradually descends, indicates that while with increasing age tubercu- lous infection takes place more frequently, its danger decreases for the individual. Translated into plain language, this would denote that all adults harl)or in their bodies evidences of tuberculous infections. Beitzke ('09), on the basis of his findings in 1,10() autopsies of a similar material (Charite, Berlin) examined by the same methods and 108 FREQUENCY OF TUBERCULOSIS with a similar classification as the one used hy Nageli and Burkhardt, believes that only about 50 per cent of all persons become infected. 100 90 80 70 o 60 cr 50 40 30 20 10 AGE PERIODS 30 40 50 60 70 90 TOTAL JUBl LRCULO ljs find INGS _^^ „oooooo ,0000 1% / 1 ^< 3 1? ' s V i-t-"^ 1 o /^ \< .xf,^-^"" .>-^l i-*-^ 1 A . / V <^ i^ v^^' 1 / V .-^^' K N^ /" ..y .- rAS X _-c --0 / / • / / / /I \ \ iV^' \^^<>-- — -O-"" s \ .+'" y Fig. 15. — Distribution of Tuberculosis at the Various Age Periods (per 100 cases at the same ages) in a Series of 1,400 Autopsies. (After Burkhardt, '06.) He agrees, however, with the other observers, that of those who are examined postmortem at metropolitan hospitals, this is the case in prac- tically all adults. AUTOPSIES IN CHILDREN Most of the examinations so far cited include only comparatively small numbers of children. The question as to frequency of tuberculosis among them has received distinct attention in the last years, and has brought forward most significant data. Also here we find a great diver- gence of figures, not exj^lainable altogether, as has been done again and AUTOPSIES IN CHILDREN 109 again, by different local conditions. A slight variation of method will alone alter the percentage figures very considerably. In reviewing them, this mnst always be borne in mind. The followinsr table will o^ive a good survev of the various findings: Author Age of Children Miiller ('89) to 15 yrs. Number of i Number of Autopsies Tuberculous ('01). Councilman, etc. Baginsky ('02) Orth ('04) Nageli ('00) Burkhardt ('06) Hamburger and Sluka ('0.")). Hamburger-Ghon ('07) Sehlbach ('08) Beitzke ('09) Otolo ' Otolo ' 6 weeks to 15 ' 0tol4 ' 0tol4 ' 0tol4 ' Otolo ' 500 220 806 435 88 190 401 848 1,423 397 209 35 144 43 15 72 160 335 180 54 Per Cent Tuberculous 42 16 18 10 17 40 40 40 13 13.6 The variations in these findings are quite startling. The influence of method has already been mentioned as one cause for them. Another one must be found in the greater or lesser number of very young children (under one year of age) which help to make up the total figures. Thus Beitzke, for instance, finds these relations : Age Newly born. . to 1 year . . 1 to 5 years . 6 to 15 years Number 199 109 63 26 Tuberculous 11 26 17 Percentage 10.1 41.3 65.4 If he, therefore, subtracts from his material all children under one year of age, his figure for tuberculosis frequency would be 48 per cent. If the same thing is done in some of the other statistics we would have : Miiller, 44 ; Hamburger and Sluka, 55 ; and Sehlbach, 40 per cent. A special search for tuberculous lesions in early childhood in larger series of autopsies has been made in few instances only. Quite recently Martha WoUstein ('09) has analyzed the autopsy material of the New York Babies' Hospital. This hospital admits only children under three years of age (78 per cent under one year). The analysis embraces 1,131 autopsies. In 185 (16.4 per cent) evidences of tuberculosis were detected. She compares her results with those of Hamburger-Ghon ('07) during the first year of life in the four (juarters, as follows (Hamburger, 318, Wollstein, 88.3 autopsies) : 110 FREQUENCY OF TUBERCULOSIS First Second Third Fourth 4% 18% 23% Wollstein 1.8% 11% 16% 23% For the second year: Hamburger (179 autopsies), 40 per cent; Woll- stein (192 autopsies), 34 per cent, first half; 44 per cent, second half. It is not the place here to try to explain the reasons for the very rapid increase of tuberculous findings with advancing age. It is inter- esting to note, however, that the two series of figures from Xew York and Vienna pursue a remarkably parallel course. FREQUENCY INTRA VITAM Since the discovery of the existence of hypersensibility to tuberculin in tuberculous individuals, new light has been thrown on the frequency of tuberculosis. Here, also, the results vary according to method used and cases selected. But in general it can be maintained that the tuber- culin findings corroborate those obtained at autopsy. Thus Franz found among several hundred soldiers of the Austrian army 61 to 68 per cent reacting to comparatively small doses of tuberculin (1 to 3 mgm.), and he believes that with the higher doses he would have reached the 96 per cent of Nageli's autopsy series. Yon Pirquet also found that practically all adults react to the cutaneous tuberculin test, thereby, as he believes, proving that almost everybody at one time or another has been infected with tuberculosis. Of particular interest are von Pirquet's ('09) tuberculin findings in childhood. They are best illustrated in the accompanying graphic charts. In Figure 16 all cases (1,407) are shown, with the exception of those suff'ering from measles, in which the cutaneous test is always negative. The shading denotes all reacting cases. From 5 per cent in the first year the percentage of reacting cases increases rapidly, until it reaches. 80 per cent in the tenth and eleventh years. The percentages of those cases, however, which showed evident clinical signs of tubercu- losis (marked by black bars) are distinctly below those with positive tuberculin reaction. But it is also clear that the earlier the age the more often patients reacting to the test also have signs of manifest tuberculosis. Latent tuberculosis, therefore, increases with succeeding years. In Figure 17 all the manifest and suspected cases of tuberculosis (also bronchitis, anemia) are omitted, leaving 1,134 children. In the first two years there is no shading, indicating that at that age, if tuberculous infection occurs at all, it produces always some clinical symptoms bronchitis or anemia. Latent tuberculosis revealed by the ^ 1 1 Hi III 1 ^^B Iff lllplplllllllllllplly^l^,^^ V > IfMj ■%lHlrtWfTl"l M^T^imT MlTl^ffln^^if^ rt n iMj^^^i^i'iW a. i ll m^^mi mmmm uM m 11 i i! * ^^ ^ 1 Il = m ml -'^f i||ii TTTfi ^ a c { 1 . 1 M -U^Hi. Ml X 2 £ mt^ ^. 1) 2 8. 1 ;i ^ppPn^ TM'i i||i|a44-m ** 1 Mpi^ MbSSf III i 1 i M i M^^t .i„.i PSiyiipgi 'WTO' 2; li- I 1 i ; ! i i ^jf ■■> in i j i Hlfi 1 ! i .^L i . tH- 1 I i 1 i i 1 < c * < ji* s < 1 S 1 J 3 <,; J Tt< •^ cc 1— 1 1— 1 c g !z o ^ z -«: u "^ rt ^ ^ X 2 o D o '73 IS P |i! o n >J ►3 D H O t/. ^ a o u H z ?; < ^ o -' s I-H "< t^ 111 112 FREQUENCY OF TUBERCULOSIS tuberculin test, on the other hand, reaches in similar manner as before 70 per cent in the tenth year.'^ It is notable how closely von Pirquet's results correspond with the percentages fovmd by Hamburger and others in autopsies. The subject will of course need further investigation, but these findings of early tuberculous infections are extremely suggestive, especially as regards the phthisiogenesis in later life. It will be remembered that von Behring, in his Kassel address ('03), laid the greatest stress on the occurrence of infection in early childhood for the production later of pulmonary phthisis. Andvord ('08) believes that only 20 to 30 per cent of the lethal cases can be ascribed to acute infections of short duration, while the balance was acquired primarily during childhood. The time between tuberculous infection and death is therefore of very variable length. "TUBERCULOSIS A CHILDREN'S DISEASE" The view that tuberculosis is eminentl}^ a children's disease, some- thing like measles, producing fatal results at once in early childhood or an increased resistance against evil influences in later years, Avins more and more adherents during the last years. The excellent work of Harbitz ('05), demonstrating the great frequency of latent glandular tuberculosis in childhood, has probably first drawn more general atten- tion to these important facts. This great frequency of latent tuber- culosis in childhood need not cause grave apprehensions, as expressed by Schlossmann ('08). The tuberculous infection, even if it remains perfectly latent, produces a certain degree of immunity against a sec- ondary tuberculosis (Hamburger, '09). Under certain not yet clearly defined conditions a soil can be prepared for pulmonary phthisis. These exceedingly interesting considerations are as yet largely speculative. Their full meaning is discussed elsewhere in this work in greater de- tail (von Pirquet, Tuberculosis in Children). MORBIDITY STATISTICS There are no reliable figures which can give anything but a very approximate idea only of the amount of sickness produced by tuber- culosis in a given population. The formula, number of deaths from tuberculosis multiplied by three, is usually employed for such an esti- mate. The result is entirely meaningless, and exploited mostly to im- ^ In this chart a distinction is also made between primary and secondary re- actions, according to whether the children reacted to the first test or the second test only. Von Pirquet notes it as a common occurrence that especially older children react only after some days ("torpid reaction") or only to a second test. MORTALITY STATISTICS AND DECREASE OF TUBERCULOSIS 113 press the public witli the magnitude of the proljlem. Tlie insidious onset of the disease and its eminent chronicity protect it from discov- ery. It often disables its victim for months and even years before its true nature is recognized. Even a rigidly enforced system of registration can never furnish a basis for accurate estimation of the damage done by the disease. The nearest approach to it can be found in the statis- tics of standing armies, although the figures must necessarily be much smaller than in total population, being derived from a corps of men scrutinized carefully as regards their physical fitness. For 1,000 of active troops in the various armies of the Powers, the fol- lowing figures for cases of pulmonary tuberculosis are obtained : United States ('06), 4.72; Great Britain and colonies ('06), 2.4; France ('04), 5.3; Germany ('03-'04), 1.5; Austria ('06), 1.0; Russia ('04), 2.7. MORTALITY STATISTICS AND THE DECREASE OF TUBERCULOSIS If mortality statistics are analyzed even with such precautions as have been alluded to, it must still be remembered that absolute figures are meaningless, and that total numbers of deaths without a statement of their distribution in the various age periods conveys no valuable and purposeful idea about the frequency of the disease. The age distribution of tuberculosis mortality in the United States is shown in the accompanying table and Figure 18. These figures of the Consumption. 1900. 1890. Under 1 year 1 " 18.3 9.4 5 3.6 2 2 10 ' 6 17.1 70.6 136.7 153.7 132 . 7 113.6 82.0 67.0 50.0 39.5 31.4 25.8 17.5 11.2 4.4 1.6 0.3 0.1 18.3 10.3 2 years 5 3 " 3.1 4 " 2.4 9.9 10-14 " 18.9 15-19 " 78:7 20-24 " 142.2 25-29 " 149.0 30-34 " 124 . 7 35-39 " 102.5 40-44 " 78.8 45-49 " 65.4 50-54 " 50.4 55-59 " 40.1 60-64 " 34.7 65-69 " 27.8 70-74 ." 17.7 75-79 '• 11.9 80-84 " 5.2 85-8!) " 2.0 9()_94 " 0.4 95 and up 0.2 114 FREQUENCY OF TUBERCULOSIS two last censases show the tremendous mortality at the ages between twenty and forty years, the active working period. Of interest is the comparison of the sets of figures for the two census years which indicate rsso ^tm 1900 I I H0M5kQk5|#3M-WTO-feM-70|-75|-80|-85l-90! £>ecreose /ncreose J/-af/onary Fig. 18. — The Age Distribution of Consumption Mortality. Proportions of deaths at each age per 1,000 at known ages from consumption 1890 to 1900. (12th U. S. Census Reports, vol. iii, 1902, p. 179.) an increase of tuberculosis during the age periods of from twenty-five to fifty years of age, while at other periods it has either decreased or remained stationary. If one compares the figures of death from tuberculosis to tlie total population at given ages, as has been done in Figure 19, the age distri- bution of tuberculosis' assumes a somewhat different aspect, coi'respond- MORTALITY STATISTICS AND DECREASE OF TUBERCULOSIS 115 Pneumonia. C Consumphion. I -5 |-l0]H5|-20|-25l-30|-35|-40lwt5l-50l-55l-60^ Fig. 19. — Proportions of Deaths from Pneumonia and Consumption at Cer- tain Ages to 1,000 Living at Those Ages. (12th U. S. Census Reports, vol. i and iv.) 116 FREQUENCY OF TUBERCULOSIS Consumption. Pneumonia. Age. Total number of deaths. Per 1,000 living. Total number of deaths. Per 1,000 living. Under 1 year 2,011 1,168 622 375 278 4,454 1,287 2,210 9,104 16,031 - 15,811 12,805 10,833 8,376 6,456 5,465 4,424 3,652 3,193 2,396 1,459 615 214 49 23 0.47 0.14 0.27 1.20 2.10 2.40 2.30 2.10 1.90 1.80 1.80 2.00 2.03 2.40 2.70 2.80 2.40 2.40 2.04 2.30 19,662 9,796 4,.349 2,189 1,310 37,206 3,322 2,042 3,474 4,326 4,077 4,065 4,532 4,431 4,400 4,700 4,566 5,198 5,325 5,156 4,170 2,725 1,229 336 115 1 " 2 years 3 " 4 " 5 " 3.90 5—9 years 0.37 10-14 '' 0.25 15-19 " 0.45 20-24 " 0.58 25-29 " 0.62 30-34 " 73 35-39 " 0.91 40-44 " 1.04 45-49 " 1.20 50-54 " 1 50 55-59 " 2 06 60-64 " .... 2 90 65-69 " 4.08 70-74 " 5 80 75-79 " 8 02 80-84 " 1 08 85-89 " 1.30 90-94 " 1 40 95 and over 1 17 ing to the lesser number of people living at the more advanced age periods. The comparison with tlie mortality from pneumonia brings out the significant fact that this latter disease is fatal particularly at the two extremes of life, while tuberculosis overwhelmingly affects the Avhole adult life periad. By virtue of this fact as well as by its great disabling power, not for a short period as in the case of pneumonia but for long months and years, tuberculosis constitutes the grave social problem which is now engaging the whole civilized world in a common effort against it. GEOGRAPHIC DISTRIBUTION Here, again, our knowledge is based more on impression than on a calculation resting on accurate figures. It would lead entirely too far to enter into the details of the laborious studies of the subject in various districts of the earth made by Lombard, Hirsch, and others. The chief fact they brought out is the even distribution of tuberculosis in civil- ized lands very little influenced by climatic differences. The causes for this must be looked for in certain features of civilized life itself. The attempt made to assign to some particular defects in civilized society the chief responsibility for the prevalence of tuberculosis must be re- GEOGRAPHIC DISTRIBUTION 117 garded as futile, as a great complexity of conditions exists in different countries. From the foregoing it has been seen that the fact of infec- tion itself (of "exposition," as termed by the strict contagionists) plays probably a lesser role in the varying production of tuberculosis in dif- ferent age periods, individuals, and races, but that the individual resist- ance to the more or less unavoidable infection is the determining factor. The last shot has not yet been tired in this battle of opposing theories. CHAPTER II TUBERCULOSIS AMONG THE DARK-SKINNED RACES OF AMERICA By THOMAS D. COLEMAN Medical history teaches that there are exciting and predisposing factors at work in the production of disease; that certain races are especially subject to some diseases, while they are markedly resistant to others. Two concrete examples are sufficient. The negro under his present environment is subject to tuberculosis and syphilis; he is resist- ant to malaria and yellow fever. The Jew is susceptible to cancer and diabetes; he is resistant to tuberculosis and syphilis. Additional evidence is furnished by the animal kingdom of suscep- tibility and immunity. According to Roger, Algerian sheep are refrac- tory to anthrax and the black sheep of Bretagne are immune to murr. ;, Animals of the same species possess varying degrees of immunity, according to their environment — e. g., white rats fall a ready prey to anthrax, while gray rats are to a large extent immune. To the monkey in his jungle life tuberculosis is unknown ; in captivity it destroys more of the species than all other diseases combined. Cattle in Japan have been singularly free from tuberculosis; in this country and Europe it is much too prevalent, causing enormous financial loss and, in the light of our present knowledge, is a prolific source of infection in man. Tuberculosis was almost unlcnown to the negro in his savage state, and even in his condition of slavery in this country; whereas under his changed condition of freedom, broadly speaking, it carries off three to four of this race to one of the Caucasian. The North American Indian furnishes still further evidence in this direction. Before the invasion of the white man and the attendant civilized modes of life to which he introduced this son of the forest, tuberculosis was unknown among the Indians; now it is a frequent invader and destroyer of his race. A similar condition of affairs is noted in the other dark-skinned races, and even the light-skinned races which are newly subjected to the infection. These are matters of fact, and an adequate explanation of them can only be found by appeal to the theory of immunity. Modern pathology is 118 TUBERCULOSIS AMONG THE DARK-SKINNED RACES 119 based on the theory that pathogenic organisms lose their virulence in healthy serum. Immunity is probably not absolute in any disease except syphilis; however, it is relatively so in such diseases as variola, varicella, scarlatina, measles, pertussis, yellow fever, etc. Immunity is transient or evanescent in diphtheria, pneumonia, in- fluenza, malarial fever, etc. Immunity may be inherited or acquired; it is in these two latter phases of the subject that we find a working h3^pothesis to explain why tuberculosis is rare or infrequent in some races and yet decimates others. In the Jewish race it is difficult to explain the relative infrequence of tuberculosis except on two theories: first, an immunit}' acquired throughout an eventful history of more than forty centuries, and second, tlirougli the careful meat inspection which is still practiced by the orthodox Jews. The former is the more logical explanation. It is now thought by many that a relative immunity may be trans- mitted from parent to child; then why not from generation to genera- tion? On this theory only can we explain why whole families are not destroyed, instead of one or two members, by tuberculosis, when it occurs in one or both parents. Additional arguments may be obtained from other infectious diseases. Small-pox, when introduced among a new people in Iceland in 1707, caused the death of 18,000 out of a total population of 50,000. In Mexico and other newly exposed countries a similar sequence of events happened. Xow, through ages of infection and vaccination, it is a milder disease, is comparatively rare, and a read- ily controllable infection; so much so that its spread to any material extent is a reflection on the health authorities of any community. Syphilis is believed by some to have been introduced into the Old World from the Xew. Whatever may be the merits of this question from an historic standpoint, it is true that it flrst attracted widespread attention in 1191, when the troops of Charles VII of France were fighting in the expedition against Naples. It spreads with alarming rapidity among new peoples. Measles appeared for the first time in the Faroe Islands in 181G. Of 7,782 inhabitants, 6,000 were attacked. In 1875 in the Fiji Islands, 40,000 out of a population of 150.000 died from measles. No such invasion occurs among races that have been exposed to this disease throughout centuries, or even years. Roger states that predisposition and immunity exists in varying degrees in peoples of the same race, in families, and that there are numerous individual variations. These are usually called idiosyncrasies, a good example. being those individuals in whom vaccination fails. In the absence of a better explanation, and from a survey of clinical ex- perience, both past and present, we cannot but conclude that there is at 120 TUBERCULOSIS AMONG THE DARK-SKINNED RACES present, and doubtless always will be, a racial immunity and suscep- tibility. By this we do not mean to imply that the immunity or susceptibility of any race to any specific disease is perpetual or will continue in- definitely; on the contrar}', it is likely that these conditions will undergo change with time and environment. It is possible, therefore, that suc- ceeding generations of these dark-skinned races will develop a constantly decreasing predisposition to tuberculosis, and they may develop a degree of immunity to it that is now enjoyed only by the Jew^^. Until such time we are brought face to face with the problem of a special sus- ceptibility in these dark-skinned races. Admitting, then, that these peoples are at present more susceptible to tuberculosis than are the whites, it is interesting to inquire into the causes which account for this particular susceptibility. The writer has chosen to call this susceptibility racial, not because these peoples have black or red or brown or yellow skins, and therefore their opsonic index is low or high, but liecause these races are for the most part recently introduced to civilization and infection. The negro, the Indian, and the Eskimo have but comparatively recently passed from an uncivilized to a civilized existence, and the Eskimo in many instances still holds to his semisavage life, living in thinly populated districts and arctic regions. The same influences which have kept tuberculosis from being a scourge to cattle in Japan have dou])tless operated to make the disease less frequent among the Chinese and Japanese at home; it is simply a matter of exposure, or the lack of it. The civilization of these people antedates that of many of the»white races, but they are not protected by that degree of immunity which has come to the latter through centuries of exposure; consequently, when this raw material comes to us and adopts our lower — not higher — hygienic modes of living, tuberculosis makes rapid and fatal inroads among them. This point finds additional proof in the Irish. The Emerald Isle is venerated by the Irish as is Jerusalem by the Jew and Mecca by the Mohammedan; outside of Dublin, Cork, and a few other large cities the Irish follow largely a bucolic existence. When they migrate to this country for some reason they settle in densely populated cities, and make a radical change in their methods of exist- ence. Instead of becoming farmers, as they were in their own country, they throng the cities, becoming politicians, liquor dealers, clerks, etc. Many of them yield to the temptations and dissipations of urban life. Few of them take to farming, and as a result statistics show the Irish to be more vulnerable to tuberculosis than any other white race. Here again, dissipation, environment, and a new people account for the prolific harvest. TUBERCULOSIS IN THE NEGRO 121 TUBERCULOSIS IN THE NEGRO After having studied this problem for nearly two decades and having known the habits and vices of the negro for a lifetime, the writer has often wondered that the disease is not more prevalent among them. As a class they are shiftless, accepting literally the biblical injunction, " Take no thought of the morrow." Necessity with them is not the mother of invention, but the one and only incentive to work. In study- ing the evolution of the race it is interesting to note this phase of its character. In their condition of bondage they were still in large meas- ure Nature's children, living for the most part in the open and tilling the soil. They were well housed, well clothed, well fed, and when sick were attended by a competent physician, for, irrespective of any motives of humanity, it was to the financial interest of the planter to have his slaves receive as good medical advice as could be obtained. Except for the yoke of bondage they were care-free and had all their material wants supplied. After their emancipation they required for their maintenance forty to fifty cents per working day. Heads of families and farm hands received before emancipation $8 to $10 per month, and their rations consisted of one peck of meal, four pounds of bacon, and a quart of sirup per week. Usually a cabin was furnished them, and around this they cultivated veg- etables such as they needed, consisting mainly of cabbages, collards, etc. On this dietary and under these surroundings they waxed strong and re- mained free from tuberculosis, but they had to work more or less con- tinuously. Freedom, the march of civilization, the additional demand for labor, and politics, have made them forsake the plantation for the town. Instead of being care-free, they have been forced to care for themselves; instead of physical work for which they are at this time fitted, their brains are being filled w^ith Latin and Greek and other accomplishments of a higher order, for w^hich they are not fitted; re- straint is withdrawn from them, and they run riot in dissipation and vice; they reach for the enjoyments of a higher civilization without I)roper preparation or equipment, either mental or moral. Instead of the farm hand receiving $8 to $10 per month and his keep, he receives $10 to $20; instead of the city laborer receiving seventy-five cents per day, he receives $1 to $2.50 per day. The result is inevitable — the farm hands drift to the city, where they live under most unhygienic surroundings. Instead of having to work twenty-four or twenty-six days per month to obtain a livelihood, this can be gotten in half the time WMth their increased wages, and the rest of the time is given over to idleness and dissipation. Tlie race is undergoing an evolu- tionary stage at present which for the most part leads in the direction 122 TUBERCULOSIS AMONG THE DARK-SKINNED RACES of their improvement, but those philanthropists who think to benefit them by teaching them Latin and (Ireek and the Komance languages, are working a double injury instead of a blessing, for it produces a hybrid which, like the mule, has no " pride of ancestry nor hope of posterity." It gives the negro a false idea of his position, and henceforth he will do no more physical work. It robs the country of a type of labor that might be beneficial both to it and to the laborer, and aside from this emphasizes the difficulties of the race problem. The average negro is ignorant of the fundamental laws of hygiene, and the following picture may be mviltiplied throughout the South not by thousands but by hundreds of thousands of times: A negro, once a hostler, went to New York and became a waiter. He had returned home to die of tuberculosis. He and his family lived in two rooms and a kitchen; the front room was used as a parlor; the back room, in which the family slept and which was perhaps 15 X 15 feet, was lighted by one window and a door which looked to the west and caught the last rays of the setting sun when they were left open, which, was infrequent ; the other opening to the room led into the parlor. The bed clothing was doubtless changed, but never to the writer's knowledge. A common towel served the family, as did also a tin basin ; flies literally swarmed in the room and were crawling over the patient's face and the tomato can, which was used as a cuspidor, when the patient was inclined to use it instead of the floor. The air in the apartment was heavy and noisome. A brother of this man, who slept in this house, was a coach- man. It is needless to state that several of this generation died of tuber- culosis. The others have been lost sight of. This presents a picture which, so far from being an exaggeration, is above the average of what one finds in studying this race. Negroes are given over to dissipation; sexual excesses and venereal diseases exist among them to an extent scarcely to be comprehended by one who has not lived among them. It is claimed that from fifty to seventy-five per cent of the negro population has syphilis, either hereditary or acquired. While statistics ■ on this point are lacking, this opinion is verified by every Southern practitioner. Whisky and other alcoholic drinks prove irresistible temptations. Nervous diseases and insanity are increasing among negroes with terrific strides. In Georgia, before the Civil War, there were known to be only five insane negroes; now the State lunatic asylum contains more than a thousand, and hospitals, jails, and poorhouses and many homes are burdened with them. There are two other ])hases of the tuberculosis problem that stand out prominently in the negro. The first is this: When the negro de- TUBERCULOSIS IN THE NEGRO 123 velops tuberculosis it rarely leaves its victim alive; in other words, the mortality is much greater than among the whites. The second pertains to tuberculosis among the mulattoes; in these it seems to be more fatal than in the full-blood negroes. The medical profession of the South is unanimous in the opinion that in the negro's condition of slavery tuberculosis was comparatively unknown. These facts, which are chiefly medical and partly sociologic, will explain the excessive death-rate from tuberculosis in this race. They will also be suggestive to philanthropists who wish to benefit the negro and physicians in the South Avho must assume the duty of treating and caring for them; for aside from that duty which falls to the lot of every physician to heal the sick, whether poor or rich, there comes the additional call to protect the innocent. WTiile tuberculosis exists as such a scourge among the negroes, it is plain that the white population is benefited when the disease is checked in the negro, for these people serve in the households of the whites as nurses, washerwomen, cooks, chambermaids, etc. The statistics from cities in both the North and the South cannot but carry their lessons, and the philanthropists who really wish to ele- vate the race will do better to devote their money to the erection of hospitals and dispensaries and instructing these people in trades, rather than to the erection and maintenance of colleges for the exploiting of higher mathematics, sciences, and the dead languages, for which the present status of the race finds little or no preparation. The writer does not wish to be understood as decrying or disparaging the progress of the negro. What he has said concerning him applies with even greater force to the Indian, and with less excuse. The negro, transplanted from his African home, enslaved, and finally freed, has become a pro- ducer; from this point of view slavery was therefore to the negro a blessing in disguise; the Indian, on the other hand, although given or allowed to retain lands, fed and pampered by a sentimental govern- ment, is a parasite. The comparison is all in favor of the negro, but the medical and sociological facts concerning both races remain undisturbed. Since the tendency of the negro is toward the congested districts, the statistics concerning him are fuller and more reliable than for any other of the dark-skinned races except the Indian, who, like a Government note, must be accounted for by the Government, but who, for manifest reasons, is not so available for comparison as the negro (see Fig. 20). 124 TUBERCULOSIS AMONG THE DARK-SKINNED RACES Thomas J. Jones ('06) makes the following observations to this chart: In the cities of the South with a negro population ranging from twenty-seven per cent in New Orleans to fifty-six per cent in Charleston, S. C, the death-rate of the negroes from consumption is two and three times that of the whites. Though the proportion of negroes in Northern cities is small, the actual niimber is quite large. New York and Phila- delphia, each with over sixty thousand negroes, have a very high death- MORTALITY FROM CONSUMPTION 1900 RATE PER HUNDRED-THOUSAND NEW YORK CITY BOSTON NASHVILLE RURAL TENN. MEMPHIS ATLANTA RURAL GA. SAVANNAH CHARLESTON RURAL S.C. MOBILE, ALA. FLORIDA NEW ORLEANS RURAL LA. U.S. CITIES RURAL U.S. U.S. GENERAL ]00 200 300 400 500 600 700 800| M 1 II 1 1 1 1 1 ... ^M M T 1 1 illll ^m^ Ui 1 ^^^^^^ ^^^^ rtt r ^^ ^^^1 4 T "^ uT\ ^ ^ J ^T '1 Z^ ■■■■ T ^^^^^ ^^ 'Mil! ^^^T ^, ^^^ 1 1 1 1 n n TTnT t 1 1 1 1 1 1 ^111 ! WHITE 1 1 COLO REDIHH Fig. 20. — Comparative Mortality from Consumption op Whites and Blacks IN Cities and Districts of the United States. (Thomas J. Jones.) rate from tuberculosis. Boston, with a negro population of about twelve thousand, has the highest rate of negro mortality from consumption of any city in the United States. According to the census of 1900 for the District of Columbia, the mortality of the 87,000 colored people from con- sumption was 448, while that for the 172,000 whites was 403. Thus a little over half of the total number of deaths is credited to a third of the people. If, as was stated in Charities for May 12th, there is one con- sumptive to every one hundred Washingtonians, it follows that there TUBERCULOSIS IN THE NEGRO 125 are one colored and one white consumptive to every two hundred Wash- ingtonians. In Charleston, S. C, Augusta and Atlanta, Ga., and Xew Orleans, La., typical cities of the South, the mortuary tables for tuberculosis for whites and colored are as follows : Charleston, S. C. Deaths from Tubercu- losis. Total Deaths. Population. Year. White. Colored. White. Colored. White. Colored. 1898 47 221 491 1,258 28,870 36,295 1899 42 223 526 1,277 28,870 36,295 1900 40 194 484 1,242 24,285 31,522 1901 46 159 477 1,149 24,285 31,522 1902 36 181 461 1,154 24,285 31,522 1903 53 165 426 1,041 24,285 31,522 1904 44 162 455 1,089 24,238 31,569 1905 36 167 440 1,056 24,238 31,569 1906 33 159 442 1,102 24,285 31,522 1907 24 152 433 968 27,470 29,899 Year. 1 White. Colored. 1898 Ratio of deaths from tuberculosis to total mortality 1-10.44 1-5.69 1899 1-12.61 1-5.72 1900 1-12 . 10 1-6.40 1901 1-10.37 1-7.22 1902 1-12.80 1-6.37 1903 1- 8.30 1-^.30 1904 1-10.34 l-€.78 1905 ( (( 1-12.22 1-6.32 1906 1-13.39 1-^.93 1907 " " 1-18.04 1-6.39 Augusta, Ga. Deaths from Tubercu- losis. Total Deaths. P0PUL> ITION. Year. White. Colored. White. Colored. White. Colored. 1898 19 87 293 509 30,435 19,565 1899 31 94 366 530 30,435 19,565 1900 45 . 95 343 612 30,435 19.565 1901 28 112 317 600 22,876 16,565 1902 24 60 351 556 24,865 16,576 1903 23 75 291 473 24,465 16,916 1904 35 70 340 522 26,065 17,316 1905 34 59 330 444 26,665 17,716 1906 37 62 371 503 28.000 19,200 1907 39 64 386 449 29,520 19,680 126 TUBERCULOSIS AMONG THE DARK-SKINNED RACES Augusta, Ga., Continued Year. White. Colored. 1898 Ratio of deaths from tuberculosis to total mortality 1-15.27 1-5.83 1899 " " ' 1-11.80 1-5.82 1900 1- 7.62 1-6.44 1901 1-11.32 1-5.32 1902 1-14.66 1-9.26 1903 1-12.65 1-6.30 1904 1- 9.71 1-7.45 1905 1- 9.70 1-7.52 1906 1-10.02 1-8.11 1907 " " " " " ' 1- 9.89 1-6.85 In other words, though the colored population is ten per cent to six- teen per cent less than the white, in ten years tuherculosis carried off 778 white persons and 315 colored. In round numbers, allowing for the discrepancy in population, about twice as many colored people die annually from tuberculosis as in the white race. Atlanta, Ga. Year. Deaths from Tubercu- losis. Total Deaths. Population. White. Colored. White. Colored. White. Colored. 1899 1900 1901 1902 1903 1904 1905 1906 1907 97 80 87 110 88 115 108 111 114 148 134 135 153 133 165 171 161 114 1,045 916 914 979 926 1,053 1,128 1,182 1,275 1,197 1,014 1,227 1,092 1,015 1,253 1,206 1,299 1,258 75,000 79,000 82,000 60,000 66,000 72,000 75,000 80,000 85,000 50,000 52,000 53,000 40,000 44,000 48.000 50,000 55,000 55,000 Year. White. Colored. 1899 1900 1901 1902 1903 1904 1905 1906 1907 Ratio of deaths from tuberculosis to total mortality. Same ratio of whites would give death-rate 222. Ratio of deaths from tuberculosis to total mortality. Same ratio would give white mortality 203. Ratio of deaths from tuberculosis to total mortality. Same ratio would give white mortality 208. Ratio of deaths from tuberculosis to total mortahty. Same ratio of whites would give death-rate 229. Ratio of deaths from tuberculosis to total mortaUty. Same ratio of whites would give death-rate 201. Ratio of deaths from tuberculosis to total mortality. Same ratio of whites would give death-rate 247. Ratio of deaths from tuberculosis to total mortality. Same ratio of whites would give death-rate 256. Ratio of deaths from tuberculosis to total mortality. Same ratio of whites would give death-rate 234. Ratio of deaths from tuberculosis to total mortality. Same ratio of whites would give death-rate 176. 1-10.77 1-11.45 1-10.50 1- 8.09 1-10.52 1- 9.15 1-10.44 1-10.64 1-11.19 1- 8.08 1- 7.56 1- 9.06 1- 7.15 1- 7.63 1- 7.59 1- 7.05 1- 8.44 1-11.03 TUBERCULOSIS IX THE INDIAN 127 New Oklean.s, La. Year. Deaths from Tubercu- losis. Total Deaths. Population. White. Colored. White. Colored. White. Colored. 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 405 546 544 512 483 549 549 578 540 499 575 454 447 490 500 452 494 504 564 543 483 480 4,268 4,275 4,913 4,318 4,037 4,067 4,200 4,222 4,689 4.150 4,665 4,462 2,551 2,980 3,106 2,441 2,505 2,505 2,597 2,640 2,668 2,968 195,000 195,000 210,000 210,000 210,000 227,000 233,000 239,000 245,000 251,000 258,000 80,000 80,000 90,000 90,000 90,000 83,000 84,000 86.000 88,000 90,000 93,000 Cases of hemoptysis included. Pneumonic tuberculosis included. Year. White. Colored. 1897 Ratio of deaths from tuberculosis to total mortality 1-10.53 1-9.82 1898 1- 7.82 1-5.70 1899 1- 9.03 1-6.08 1900 1- 8.43 1-6.21 1901 1- 8.35 1-5.40 1902 1- 7.22 1-5.07 1903 1- 7.46 1-4.95 1904 1- 7.47 1-4.60 1905 1- 8.68 1-4.86 1906 1- 8.31 1-5 . 85 1907 1- 8.11 1-6.18 TUBERCULOSIS IN THE INDIAN It is generally conceded that pulmonar}' tuberculo-sis was not known to the Indian in his barbaric state — at least, that it was a disease of rare occurrence. The Indian is of a face of people over whom our Government has felt it needful to keep an accurate supervision. The physicians who have cared for them have, for the most part, been selected. Their positions have demanded that they make an accurate report of their stewardship. The reports, therefore, of the sanitary condition of this race are more perfect than for any race in America. For the Indians, then, they may be accepted as approximately accurate. There has been an impression both among the laity and the medical profession that tuberculosis is a scourge of this race since its contact with the white man, and an inquiry into its history is essential to fix the accuracy of this conclusion. 128 TUBERCULOSIS AMONG THE DARK-SKINNED RACES Dr. James Jl. Walker ('06), of Pine Ridge, Soutli Dakota, states that : Tuberculosis existed among these Indians before they came into con- tact with the white people, but at that time the disease was rare among them and remained so until they changed their nomadic to a settled life in houses. When they began to live in houses, tuberculosis began to increase among them, so that the conditions which caused this increase must have been different from those surrounding them when they lived in tepees. They were filthy both when they lived in tepees and when they lived in houses. It was statistically demonstrated that those who were most cleanly were less liable to infection by any disease than were the most filthy; and, conversely, that the most filthy were most liable to infection of every kind. In 1896 it was asserted that more than one half of the Oglalas were tuberculous, and that more than seventy-five per cent of the total deaths among them were caused by this disease. This was an exaggeration that is common in discussing tuberculosis among the Indians. The facts were that there were at that time 4,893 Oglalas, of whom 741 were tuberculous, and of these 124 died that year. That is, 148.7 per 1,000 were tubercu- lous, and the annual death-rate from this disease was 24.88 per 1,000. As the entire annual death-rate was 52.88 per 1,000, the deaths from tuberculosis were but forty-seven per cent of this. But this death-rate was appalling, for the annual birth-rate was but 41.54 per 1,000, which showed a decrease of 11.64 per 1,000 because of the excess of the death-rate over the birth-rate. As the percentage of deaths from tuberculosis was so great, this disease was exterminating this people. Dr. I. W. Brewer, of Fort Chiliuahua, Ariz., has made a careful study of the Indians of the Southwest. Woods Hutchinson ('07) sums up his findings as follows: Among the Mojaves tuberculosis was responsible for ninety-five per cent of the deaths. Among the Hopis and Navajos it was, according to one agency physician, " very prevalent," and according to another. Dr. Parshell, " the greatest cause of death in children." On another Navajo reservation it was reported as " not very prevalent, but always fatal." Among the Apaches it had " gained a strong hold." Among the Pimas and the Maricopas it caused sixty-six per cent of the deaths. Among the Havasupi and Walapai it caused seventy-five per cent of the deaths ; on another, sixty per cent. Among the Pueblo Indians at Santa Fe it was " rare, less frequent than with other Indians." Among the Zunis the actual amount was small, "but the mortality one hundred per cent." The average, from the percentages actually given in these cases, was seventy- two per cent of all the deaths. This, with my Northern studies, pretty well covered the Indians of the Pacific Northwest and of the Coast and most of the great Southwest. TUBERCULOSIS AMONG THE JAPANESE AND CHINESE 129 At the Black Feet agency Dr. George Martin reports that " sixty- seven per cent of the deaths were dne to that disease in that year." From tlie Crow Creek agency, in South Dakota, Dj-. J. Silverstein reports that " most of tlie deaths are due to this cause." Among the Rosebud Sioux Dr. W. H. Harrison decLares it to be "the greatest menace to the health of the tribe." (Hutchinson, '07.) To Sum up. — On nine reservations where the actual figures are given, the average proportion of deaths due to this disease is sixty-six per cent. When one attempts to explain this enormous death-rate he is confronted with much the same conditions as the negro presents, only in a more exaggerated form. The inclination of the Indian to dissi- pation and his disinclination to work, his filthy habits, his ignorance and utter disregard of the laws of hygiene, and finally his lack of im- munity and racial predisposition — all account for the enormous death- rate among them from tuberculosis. TUBERCULOSIS AMONG THE JAPANESE AND CHINESE Statistics are often misleading when accurately kept. When inac- curately kept they are worthless. With medicine occupying the place it has in Japan and China throughout all recorded history, it is clear that little can be expected from a statistical study of this disease in these countries. It is a matter of common observation that Chinese and Japanese who come to this country are especially lia])le to contract tuberculosis, and such statistics as are recorded show a relatively high mortality for these races as compared with our native white populations. The United States Census for 1900 gives the death-rate of 239 per 100,000 living Japanese, as compared with 173 in the white population. Hutchinson states that " in the Portland and San Francisco China- towns the mortality was more than double that of the surrounding white population," and the United States Census for 1900 gives 658.5 per 100,000 living, nearly four times that of the general white popu- lation. The cause for this a])palling death-rate will be readily apparent, par- ticularly in the case of the Chinese. To begin with, we have brought to our shores a new and relatively susceptil)le race of jteople. They are densely ignorant and utterly disregardful of the finidamental laws of hygiene. They represent the lowest grade of citizenship in their own densely benighted land. Their intelligence is sufficient to make them hold to two purposes, viz., the preservation of the cue, which is the "open sesame" to the Chinese Fmpire, and the accumulation of suf- ficient money to live out their remaining days in China without further work when they return home. 10 180 TFBERCrLOSIS AMONG THE DARK-SKINNED RACES Xcither the prcsci-vjitiitn of tli(' cue nor llx- aceumulatioi) of wealth are ignoble, nor do they concern ns, beyond the inroads which the acquisition of the latter make on the races. The average Chinaman coming to this country was of the coolie class, therefore too much should not be expected of him, but liis menace to his immediate neigh- bors does concern us. The writer believes that they are in this country cleanly of body and careful of what they eat; they are also industrious, probably beyond reason. This is unquestionably to their credit, and if that were all, these people would make a desirable instead of an unde- siralile citizenship. When one passes to the other phases of their char- acter he does not wonder at the amount of tuberculosis that is ])revalent among them. Notoriously and ahead of all the other dark-skinned races is the Chinaman given over to dissipation and vice. He cares nothing for the comforts or restraints of the home. (Jambling is his pastime; he inclines to sexual excess; as a race he is addicted to tlie opium habit, and to this in America he often adds alcohol; finally, where their least discretion is shown is in their sleeping apartments. Ventilation is a thing unknown to them, and a not unusual sleeping apartment in the Chinatowns of this country is four l)v eight feet. T'sually there is a gathering room, but this only increases the liability to infection, not only from their numbers, which make the air foul, l)ut in addition from their expectoration on the floors and their general unhygienic behavior. CHAPTER III FREQUENCY OF TUBERCULOSIS IN INSANE ASYLUMS By RICHARD H. HUTCHINGS ATTE:\rPTS to arrive at an accurate estimate of the number of the insane in custody who are tuberculous have not achieved satisfactory results. But little has been published bearing on this point. The New York State Commission in Lunacy, in 1904, estimated that there were among the 25,000 insane in custody in that State 500 cases of tuber- culosis, a ratio of two per cent. Dr. i\[ott investigated the question in the London County Asylums and estimated the ratio of tuberculosis at 1.72. (F. Peterson, 'OL) At the St. Lawrence State Hospital. Ogdensburg, N. Y., in 1904, a careful physical examination of the entire population, amounting at that time to 1.T20, revealed T8 cases of tuberculosis of the lungs of greater or less degree. In this test tuberculin was not employed. This percentage is 4.5. In the Middletown State Hospital, Middletown, N. Y., there has been constantly for the past fifteen years about three per cent of recognized tuberculosis, according to a statement of Dr. Ashley, the superintendent. Some very notable investigations on this subject have been made by Dr. W. F. Menzies, who examined 647 patients, the entire population of the Staffordshire County Asylum in 1905, and found positive physical signs of tuberculous disease in 123 and doubtful signs in 133. He gives the accompanying table, showing a Admitted during the year Admitted with positive physical signs. . . . Admitted with doubtful physical signs. . . Admitted who reacted to tuberculin Deaths from tuberculosis Other P.M's disclosing active tubercle Other P.M's disclosing healed tubercle. . . Examined with positive physical signs. . . Examined with doubtful physical signs.. . Examined who are probably tuberculous. Numbf;rs. 98 13 11 76 13 4 16 77 56 80 6 4 60 8 10 46 77 178 19 15 136 21 4 26 123 133 348 Percentage on Averagk Numbers Resident. 7.54 23.90 5.34 5.03 42.5 3 17.01 2.38 3 36.82 5.20 20.82 3.82 3.98 39.56 53.78 131 132 FREQUENCY OF TUBERCULOSIS IN INSANE ASYLUMS year's statistics of tuberculosis in that institution with a population of 647.1 Thougli l)ut little lias been i)ublishecl in regard to the frequency of tuberculosis in the population of hospitals for the insane, some idea of its frequency can be gained from the mortality from this disease. In a report of the New York State Commission in Lunacy for the year ending September 30, 1906, it was reported that the deaths from all causes from October 1, 1888, to September 30, 1906, in the Xew York State hospitals had tjeen 28,106. Of these, 4,059 have been from tuber- culosis, a ratio of 14.4 per cent. In the annual report of the Govern- ment Hospital for the Insane, Washington, D. C, for the year ending June 30, 1906, Dr. William White, the superintendent, gives a state- ment of deaths from tuberculosis occurring in that institution during the twenty-one years (1885-1906) inclusive. During this period there were 3,746 deaths from all causes, of which 2,103 were examined into post mortem. Active tuberculous disease was found post mortem in 432 cases; latent or limited tuberculosis, post mortem, in 586 cases. There were also during that time 236 deaths from tuberculosis, in which the diagnosis was based on clinical signs and not verified post mortem. Total of all cases of death from pulmonary tuberculosis, clinical and post mortem, 822. Percentage of tu1)erculous cases among those tliat died, recognized clinically and at autopsy, 21.9. Per- centage of those examined post mortem which showed tuberculous lesions, 27.08. From the seventeenth annual report of tlie Asylums Committee of the London County Council there were 1.481 deaths, of which 164 were attributed to tuberculosis. The number of post mortems is not stated. Dr. Menzies, superintendent of the Staffordshire Asylum, states that of the post inortems 68 per cent showed gross signs of old or recent tubercle, and of 51 cases of tu])erculosis proved by post mortem exami- nation, 26 had definitely recovered long previously. The State Board of Insanity of Massachusetts reported in 1905 that of the deaths in the institutions for the insane in that State during the preceding year, 14.27 per cent were caused by tuberculosis. In the annual report of the New York State Department of Health for the year ending Decem- ber 31, 1906, the total deaths from all causes throughout the State were 140,343. Of these, 14,027 were due to consumption, a ratio of 1 to 10; while during the same year there were in the hospitals for the insane in New York 2,071 deaths, of which 345 were attributed to tuberculosis, or 16.6 per cent. » Annual Report, 1905-1906, p. 18. TUBERCULOSIS IN HOSPITALS FOR THE INSANE 133 TUBERCULOSIS IN HOSPITALS FOR THE INSANE That this disease prevails to an alarming degree in institutions for the insane is conceded. Its frequency varies in different institutions and in the different wards of the same institution. It is the experience of the writer that tliere are certain wards in which a case of tuljerculosis has not developed in more than eleven years, and other wards which yield one or more cases every year. The wards in which the disease occurs with greatest frequency are those occupied hy the most demented class of patients. These, by reason o.f their mental condition, cannot be usefully employed ; but, on the con- trary, they lead sedentary and inactive lives. Many of them are so stupid that any voluntary effort is practically abolished, and they sit in one attitude for hours at a time and until recjuired to change their position. These are the wards in large public institutions which tend to become overcrowded, even wlien in the institution, as a whole, the overcrowding is not serious. The so-called untidy wards are very apt to be badly overcrowded both day and night. The fact that the wards are crowded rendei's rather urgent the necessity of keeping people in their places, and the requirement of good order, as construed by the attendants and nurses, is to have each patient seated quietly in his place and to discourage all motor activity. The ventilation under these cir- cumstances is rarely good, and when patients spend weeks and months, and sometimes years, in a ward of this character, it is not surprising that many of them succumb to tuberculosis. Many of these patients are of untidy and careless habits. They pick up from the floor strings and small objects of any kind and put them into their mouths, and even in some cases the contents of cuspidors find their way into the patients' mouths. The mere fact of patients being crowded together appears to predispose them to tuberculosis, even where the ven- tilation is regarded as good and the housekeeping is above criticism. Dr. Menzies, in a report already quoted, speaking of his experience with tuberculosis and dysentery, says: Although it is difficult to say how overcrowding can cause disease, provided cleanliness and thorough ventilation are properly attended to, still the fact remains that dysentery, erysipelas, and tuberculosis always increase in overcrowded asylums, and one is driven to the conclusion that infection occurs more easily because the patients are actually placed closer together, and not because the overcrowding i)roduces less efficient attention to the ventilation and t-leanliness of the wards and patients. Those })atients wlio canlx; employed, and who, therefore, are off the ward a portion or a greater part of each day, unless crowded in sewing 134 FREQUENCY OF TUBERCULOSIS IN INSANE ASYLUMS rooms or sliops, are usually in liiueli healthier eondition and freer I'roni tuberculosis than those remaining in the ward unemployed. At the St. Lawrence State Hospital there are two detached cottages, accommodating together 140 patients, who are employed at garden and farm work, and during the past eleven years not a single case of tuberculosis has occurred in any of these patients, though the disease has shown a steady increase in the institution as a whole. As most institutions for the insane have farms or large gardens attached, it is comparatively easy to find suit- able employment out of doors for men, and difficult to find work for the women, except housework and indoor occupations, such as sewing, rug-making, chair-caning, and other more or less sedentary occupations. Let us see how the prevalence of tuberculosis differs in the two sexes on account of this well-recognized difference in the employment of our hospital inmates : In the period 1888-1906, according to the report of the New York State Commission in Lunacy, there were reported 28,106 deaths from all causes, of which 15,f the history and the current symptoms. In this con- iieetion it is a great mistake for the physician to l)elittle or neglect syin))t()ins noted hy the patient without first carefully investigating them. Wliile the neurotic can develop many and unimportant symp- toms, it is not rare to have an intelligent patient notify us of feelings which we dismiss as unimportant hut wliich the later course of the case proves to have heen early, and had they heen heeded and rightly valued, very useful warnings of impending hemorrhage, congestion, pleurisy, etc. Hence it is advisahle to give careful attention to all reports of unusual sensations, and not to dismiss them from consideration too quickly. Again, in the course of a recovering case of pulmonary tuherculosis, the symptoms disappear at a time when physical signs can still Ik- easily found, and since the former are the only evidence the patient has of his sickness, he is apt, unless he is unusually carefully trained and taught, as soon as they cease to trou])le him, to forget that he is a sick man, thus frequently leading to imprudences and relapses. Finally, at the risk of repetition, let it he once more noted that the rational study of a case implies a consideration, not of any few promi- nent features, whether from the history, previous examination, or clinical study, hut a broad-minded consideration of all and their correlation into a complete whole, so that we may get a broad and clear picture of one malady which we are called to treat. Only so will our results be a credit to ourselves and of benefit to our patients. SUBJECTIVE SYMPTOMS Fever. — Of the constitutional symptoms, fever occupies the most important place from a diagnostic and prognostic point of view, and as a guide to treatment. It gives one of the earliest evidences of the Day 4 5 6 7 8 y 10 11 IJ 13 U 15 16 17 18 19 20 21 22 23 24 25 26 27 28 SP?-i?-::EESfe^ Fig. 24. — Stage I. Typical Moderately Subnormal Temperature. Marked neurasthenia. (Case G. E. B.) activity of the bacillus, and while some have maintained that simple, uncomplicated tuberculosis is afebrile, the consensus of medical opinion is against such a contention. Tiiis view seems to be fully justified, not only because of the well-known effects of the injection of the products 160 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS of the bacillus into the human body, but also because of the elevations in temperature wliich so uniformly accompany increase in activity of the tuberculous process, and the falls which follow each decrease in activity. Fig. 25. — Stage I. Marked Subnormal Temperature in Young Woman of Very Poor Vitality. Note effect of moderate amounts of alcohol. (Case B. G.) Technic of Measurements. — Temperature observations, to be of value in the diagnosis of tuberculosis and, although in a less degree, in the treatment, must be taken every two hours. The usual custom of taking the temperature three times a day, or only in the afternoon, is a bad one, because then important fluctuations are often missed. The patient can easily be taught to take his own temperature accurately, and it is better for tbe doctor to fear a mistake in diagnosis than to fear alarming a nervous patient. Day Hp^^s-aK^:£^^is||pe??:|fe^ Fig. 26. — Stage II. Slowly Spreading and with Gradually Rising Fever. Progressing general dissemination. (Case J. C.) It is very important also, in a disease in which a few tenths of a degree of variation in the temperature have so much significance, that we use a thermometer of whose accurac}^ we have a better evidence than the certificate of its maker. Experience has taught the writer that a large percentage of thermometers sold to physicians have errors greater than three tenths of a degree. At the same time the temperature curve must not be relied on exclusively to the neglect of other important data, for not rarely an unfavorable case has a very satisfactor}^ temperature curve. Harris and Beale ('95) note that the individual idiosyncrasy must be taken into account ; different people, under similar conditions, show very different febrile reactions to the same stimulus, and very wisely they say : " The absence of high temperature must not be regarded as SUBJECTIVE SYMPTOMS J()l wholly a favorable symptom, if other sMiiptoms of active disease are present." The measurements, to be accurate, must Ix' taken for a full tivc minutes, no matter how rapidly the thermometer registers, and out- doors in cold weather for eight, ten, or even fifteen minutes. In very cold weather the patient should come indoors to take the reading. An interesting study of this subject w^as made by Bluhm ('01), who showed the effect of the external temperature on that in the mouth. She noted that in the case of a patient with an occluded nose, who unconsciously from time to time opens his mouth to inhale the air, readings may be imreliable. She also found that the difference of temperature produced by the outdoor cold varied in different patients, but that the effect could be lessened by covering the face. Some German writers (notably Walther, of Xordrach. and Pen- zoldt) have strongly recommended taking the rectal temperature be- Day 22 23 24 23 2 6 27 28 1 I 3 4 > 6 T 8 g 10 11 12 13 14 15 16 17 18 IT __j_- T 1 /V — &^ M . -^ r*' 1 — -^ A. /^ A r^ ^ >- 98"— U ^7 ^ ._-z:7c- \ J\^ •' ^^^ 3,a7 szaid?^ I ! V ^ >r c Y 1 4- ±_ 1 Fig. 27. — St.\ge III. Extensive Lesions with Normal Temperature. Temporarily no activity of process. (Case Mrs. M.) canse it is more reliable, but the majority of clinicians prefer to take the mouth temperature. Such trials as the writer has made of the rectal method have led him to consider it unnecessary, in the large majority of ca.^es, and this agrees with the conclusions of Schroder and Briihl ('02), who studied the subject carefully. Tf the temperature is taken long enough, the mouth readings, in my experience, have generally run par- allel w'ith those in the rectum and axilla ; not as high as the former i)y about a half degree, nor as low as the latter by the same amount. Ostenfeld ('04), who uses rectal measurements, found 70 per cent of 25(t cases had nearly parallel rectal and mouth temperature curves. Against the procedure is not only the fact that the manipulations are most disagreeable, and no doctor can afford to disregard the sus- ceptibilities of his patients, but, much more, that it necessitates tlu- patient's going to his room each time, which, if two-hourly observa- tions are made, is extremely inconvenient, and for ordinary use its defects are not outbalanced by sufficient compensating advantages. Braine-Hartwell ('01), who is an enthusiastic advocate of the rectal method, considers it essential to accuracy, and gives temperature curves showing great variations between the mouth and rectum, as does Saug- 12 162 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS man. In the case of bedridden patients, or in those wliere we suspect a temperature which the mouth does not reveal, or in afebrile cases in which exercise has a bad physical effect not explained by the ther- mometer, it is wise to use this method long enough to satisfy oneself that the mouth temperature is not deceptive. In the large majority of cases mouth readings can safely be relied on to guide us in the study of patients. In doubtful cases it may at times be necessary, as noted, to resort to rectal measurements as a control of mouth readings, as the former are less affected by external influences and are more abso- lutely accurate. Despite the advocacy of rectal measurements by a few well-known authorities, they have not won general acceptance by the special workers in this field. So good an authority as Turban is satisfied with mouth readings in most cases. Course of the Fever. — While many attempts have been made to distinguish a temperature curve typical for tuberculosis, such as exists for typhoid, the polymorphism of the disease renders this impossible. Day 7 a ii lo U iJ 13 U 15 16 17 18 I'J 20 21 2 23 24 25 20 2T 28 29 30 31 t 4 Alt I 4i . . . . ^ A 4 ^4 ^ J J I J i^ ^ ^ . i r. ""° \ Ik ^ tffu-t-Mtt- 1 if i t C A t ^ ^ i -, ' i JZ , ,oc,°j\A^M^r i 1 t*^ t I L i ^t t i 7 ] 1 i 100 /if^yjt f f t t 1 jff I ^ j fi it 99°'^ r '^qt ^ »- h f f »y r r ^. ^ / ' 1 1 1 1 1 98° J --- -:^V44t--Zzzz Fig. 28. — Stage III. Active Spreading Process in Both Lungs and Com- mencing Cavity Formation. Continual fever. (Case C.) The temperature may be absent, intermittent, remittent, or even, though rarely, continuous. We may have a scarcely recognizable intermittent fever with a normal morning or, more generally, subnormal temperature, and a very slight evening rise to 99.4° F., or a little later a more pronounced intermittent temperature with an evening rise to 100° F. or over. A remittent temperature with a morning temperature of 99° F. to 100° F. is often seen, though if the temperature is taken as early as seven o'clock it will still be found to be subnormal. In the evening such cases rise to 101° F., or in more severe cases as high as 103° or 10-1:° F., though the average case of tuberculosis, unless far advanced, will not generally show a temperature higher than 103° F., except during acute exacerbations. The hectic temperature is associated with the late stages of tuber- culosis and extensive ulcerating cavities, with profuse purulent spu- tum, often showing streptococci. There is a sulmormal morning tem- perature, as low as 96° F. or 95° F. plus, and with or without an early SUBJECTIVE SYMPTOMS 163 afternoon chill and a subsequent rise to 102° to 105° F. The study of the temperature in early cases is of great value, and, as has been stated, in no other disease do such relatively slight differences of temperature possess such importance. ilost of the writers on the subject, with the exception of C. J. B. ^Yilliams, have not laid sufficient weight on the significance of morn- Dec. Jan. Day 27 28 29 30 31 1 i i 4 5 6 7 ~r . 1 102 * f loi-^ ±1 - ,, '" \ Jni t I . p- . ^t 100' 4t t itrz.ar t ± zt ^ ^f^ H^ ± i 99<^ -i -. 1 ± 7 z: 7 p«. , t -i ^ ^ 4 J 2 f -.^ t 98°^l A v^x- / 1 it I 2 2 J ^ .,* 07 ° - -i -J / I- :± r +i .-^ _ +_ : : : : ::: Fig. 29. Day 104° 103° 102° 101° % t- ?; ii tK -4 ff Fig. 30. Figs. 29 and .30. — Non-resolvixg Tuberculous Pneumonia with Chills, Sweats, Hectic Fever, and Rapid Breaking Down of Lung, with Mixed Infection. (Case W. G.) ing subnormal temperatures in such cases. In the experience of the writer, who has made two-hourly temperature observations in all cases for a month at least, and often for longer periods of time, for years, tlie morning temperature in tuberculosis is rarely up to normal, and tliis subnormal morning temperature is of real diagnostic value. Often before any evening rise can be found, the temperature on waking is 97° E. or under, which, however, soon becomes normal, so that if the first temperature is not taken early enough, this subnormal tem- perature will be overlooked. As the case goes on to arrest or to apparent cure, the evening hyper- thermia disappears long before the patient loses his morning hypo- 16-1: SYMI'TO.MATOLOGY OF PULMONARY TUBERC'l'l.OSIS tliermia. The evening rise in early cases is rarely more than a few tenths of a degree, and while Vierordt gives the range of normal temperature as from 1)7.8" to ilDJi" F., a persistent evening rise lu 99.2° F. can be considered as fever, providing the digestive tract is in order. A morning temperature below 97.8° can be considered sub- normal, except in very cold weather. Turban ('99) considers a tem- perature of 98.9° F. the limit of normal mouth temperature, and a temperature of 99.3° F., with the patient at rest, if frequently recur- ring, as fever. In such early cases there is generally a subnormal tem- perature at 7 or 8 a.m., before the patient leaves his bed, which rises to normal at 9 a.m., remaining normal until after midday (though a little later the rise begins at 12 M., or even earlier), from which time it rises, reaching its maximum somewhere between 2 and 6 p.m., gen- erally about 4 P.M., and falling back to normal very quickly in early cases, more gradually in more severe cases. Unless a two-hourly tem- perature record is taken, this fluctuation is very easily overlooked. Here it should be noted, however, that if a 1 p.m. dinner is taken or a heavy lunch, there will be a postprandial rise in temperature within fifteen minutes or a half hour after eating, higher than the general average, and which does not give a true idea of the real two-o'clock temperature. This postprandial rise is normal in health, but is mag- nified in tuberculosis, so that a heavy eater or a dyspeptic will have the highest temperature of the day between 2 and 3 p.m., after his midday meal, but this slight postprandial rise, as already noted, is in ordinary cases separated from the real maximum, which usually comes later. In view of this fact, slight after-dinner rises have of course less value than those coming at four or six o'clock, and it should also not be forgotten that cases of anemia (as noted by Papillon) show such a rise. In somewhat more advanced cases the temperature begins to rise about twelve o'clock, rises gradually to its maximum, and falls gradually, reaching normal about eight or ten o'clock at night, and falling steadily after that, to reach the lowest point at about 3 a.m, Certain cases, how- ever, and they are generally bad ones, have their maximum in the night, and at times it may he necessary for diagnostic purposes to wake patients at intervals for a night or two in order to find this out. A flushing of the face after meals is often noted in tuberculous patients, even before a temperature rise can be discovered, and this at times is a useful hint. All tuberculous patients are easily affected by both physical and mental disturbances, such as overexcitement, overexercise, grief, anger, worry, all of which make their mark on the temperature curves of these sensitive organizations. In apparently afebrile cases one can disclose 81 BJECTIVE SYM1'T(L\1S 1()5 ;ni otlienvise hidden temperature by ordering a long walk. In some eases the temperature is depressed. Again, a patient who is improving will lose his evening rise long before his morning subnormal temperature, which persists until normal vitality has been restored, and no patient should be considered as being cured until this subnormal temperature is lost. Even after a return to nornuil and an arrest of the process the temperature is apt for some time to be easil}^ affected by nervous influences. The graphic curves of the majority of women patients show a rise of tem])erature just preceding and during the first two days of the menstrual period, and when, in a woman, the temperature is normal at ordinary times, it is wise to wait for the next menstrual j^eriod l)efore making a final decision. Except in the case of very excitable people, there is no subjective sensation of temperature in this stage, and even considerably later, so that these patients will report various symptoms which make certain the presence of increased temperature long before the time when the patients themselves have noted it. Xeu- lotic patients notice fever much earlier than others, and if they know that fever is Ijeing sought for they will often note flushed cheeks and feel fcMrish when the thermometer shows no rise of temperature. It must never be forgotten, in studying the temperature of a sus- picious case, that incipient cases often show periods of normal tempera- ture, followed by rises above the normal, so that a diagnostic study of temperature, if negative at first, should be continued for two weeks or a month if certainty is desired. As the disease progresses and evi- dent consolidation appears, the evening temperature rises to about 100° F., or more rarely to 101° F., the morning temperature still being subnonnal, though it tends to reach normal at a progressively earlier hour. The course of the temperature is also marked by occasional more active rises as new areas of involvement manifest themselves. This irregularity of course is very typical of the temperature of tuberculosis, and while at times the curve remains unchanged for months, it is not the rule, the graphic curve of the average case showing very beautifully, l»y the perturbations of its course, the various harmful influences which affect the patient. The graphic curve is a very valuable aid in the study of the patient, and should be noted in all cases for the first few weeks at least, and in some cases foi- a longer time. As a general I'ule, a poussee dc rongestion, as the French term the exacerbations so typical of the; dist'jise. does not come on suddenly, but is preceded by two or three days of slowly rising temperature and accelerating pulse liefore any otlici' symptoms show themselves. 'J'his gives the doctoi' an invaluable oppor- 166 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS tiinity to attack and cut short the congestion before it gets beyond control. Digestive disturbances, so common in tuberculosis, generally produce a sudden and much higher rise, which usually begins earlier in the day, with symptoms of gastric discomfort. The prompt removal of such complaints by means of calomel and starvation lays bare their nature. Some cases of temperature of moderate degree but great obstinacy dis- appear completely on the discovery and correction of gastric dilatation and stasis, and such cases demonstrate the close and important relation of stomach conditions to the course of tuberculosis. Day 20 21 22 23 24 25 2U 27 28 29 3U l 2 J 4 5 7 8 U 10 11 12 13 U 10i° 103° ^^7-lP^^^^-^-^--^-^^^-'~- ^m 5 ^5j- Fio. 31. June July Day 13 14 15 10 17 18 10 20 21 22 23 24 25 28 27 28 29 30 1 2 3 4 5 6 7 102 A ^ a\ ,. \ ^ ^ 100° \ H>. S A : 1^-^ -J J v\t y t^ \\ 99° _,:, H^ *^^3i ^11* X =4h\,-3\.S { ^^^^^-^-1% vjs^^^"-"* 98° \ i ^ ^ i y ^ * * ^ 97° I Fig. 32. Figs. 31 and 32. — Stage III. In.yctive, Showing Effect of Oveuexertion (Railroad Journey) .\nd of an Acute Bronchitis. (Case L. R.) Even acute pneumonic attacks are generally preceded by a slow rise in temperature before the sudden ascent in temperature and chill which usher in the actual attack. Ischiorectal abscesses, for some time before they trouble the patient sufficiently to draw attention to the seat of the trouble, affect the temperature considerably. In a case seen by the writer, an afternoon temperature of 100° to 100.8° F. persisted for several weeks before the patient felt any pain or inconvenience in the rectum, but when this appeared and a small abscess containing not more than two drachms of pus was evacuated, the temperature dropped to SUBJECTIVE SYMPTOMS 167 nearly normal and has remained there ever since. Therefore, it is necessary to make sure that the increased temperature is not due to extrapulmonary causes before it is ascribed to the lung condition. When, in a case of tuberculosis with fairly extensive lesions, there is a persistent low temperature with symptoms more mild than the extent Sept. Fig. 33. — St.^^ge II. Showing Effect of Intercurrent Bronchopneumonia ON Fever Curve. Fall by lysis and recovery. Patient made complete recov- ery. (Case C. M. C.) of the trouble would seem to justify, it should always suggest the pos- sibly fibroid nature of the case, such a temperature record being very characteristic of this type of cases. As the process reaches the third stage, with extreme infiltration and destruction of tissue, with excavation, the temperature, as a rule, ranges from 101° F. up, the rise coming on as early as ten or eleven o'clock in the morning, or not later than midday, and lasting until quite late at night. This long-continued fever naturally severely affects the patient's constitution. Softening of involved areas is generally accompanied by high and obstinate temperatures which will not fall until the necrotic area is sufficiently softened to be expectorated. Cavities whose contents tend to collect and dam up instead of being expectorated freely, will also cause rises of temperature, though not being accompanied by inflammation the rise is not generally as high as is that caused by softening of lung tissue, but is rather of a hectic type, and it falls when the pus is expectorated. These are the cases in which posture aiming at emptying such ill-draining spaces, is so effective. When excavation is extensive and drainage is poor, an irregular re- mittent or hectic type of fever appears, marked by a very low subnormal morning tem})erature and high but irregular afternoon rises, often pre- ceded by chills and followed by sweats, and associated with rapid emacia- tion. There is generally a profuse purulent expectoration which, even when properly collected and washed, shows swarms of streptococci. This 168 SYMITOMAroLCXiY OF PULMONARY TUBERCULOSIS is generally considered as o -^ 5 > « t^ W X cc ^ 0) "^ § a r O C w a; _ o g-g g Q 53 M W m rn "-^ t- o 9 q W J S c^ ?i justifying a diagnosis of mixed infection — • that is, the existence and j)athogenic activ- ity in the lung of other organisms along with the tubercle bacillus, usually the streptococcus. Many excellent authorities deny the ex- istence of this condition and have brought forward considerable experimental proof against mixed infection, but the clinical evidence, which, after all, should have the greater weight in coming to a decision in this matter, seems to justify the be- lief that the symptoms spoken of are not produced by the tubercle bacillus alone, but demand tlie cooperation of pyogenic microorganisms. In these late cases there may be in rare instances a typus inversus, in which the night and early morning temperature is high, and the midday and evening tem- perature low. Its presence is always omi- nous. The writer has noted in a few cases of hectic fever that any attempt to lower the temperature by means of coal-tar anti- pyretics produces such a typus inversus, the cause of the fever being so active that when it is repressed at the usual hour it reap- pears at another. In old cases, with moderate activity and large, relatively dry cavities, with tendency to fibrosis, it is not at all rare to see a nor- mal or nearly normal temperature present for months, and while not improving the ultimate outlook, it is of benefit in so far as it allows of better nutrition and rest, and adds to the patient's comfort. A double or triple rise of temperature in twenty-four hours, punctuated with sweats, occasionally occurs. It is a bad prognostic sign. A temperature remaining persistently above 101° F., despite absolute rest in bed in the fresh air and proper dieting, is a uniformly unfavorable sign, speaking for SlBJECTnE SVMrXOMS 1(39 wide dissemination and a rapid spread of the disease, and unless the system can be given strength enough to conquer it, a downward course and a fatal termination may be anticipated. ]!^ot infrequently the patient, despite rest in bed in the fresh air, runs a persistent temperature for weeks. When these patients are gotten out of bed and allowed to sit up a little and to walk around, the tem- perature, contrary to expectation, gradually drops to normal. The writer has noted this in numerous cases, and can vouch for its accu- racy, although he cannot explain it. unless on the ground ^that the tem- perature is due to a disordered digestion, which erect posture and a less sedentary life improved. Except in old. dry, fibroid cavity cases, where, as noted above, there may be a good temperature record with a hopeless outlook, a gradual fall of temperature is almost always evi- dence of a lessened activity of the process in the lung and an improved prognosis. In advanced cases there may at times be sudden drops in tempera- ture. These speak either for the approach of the end or for shock accompanying the occurrence of a pneumothorax. The bad effect of fever on the patient's digestion is so great that everything possible should be done to control it. The patient with a high temperature has neither appetite nor digestive ability. After he eats, his temperature is greatly increased, and it is necessary to arrange meals so that the heaviest meal is taken at the time of the least fever. In such cases coal-tar antipyretics may be vised, if necessary. In advanced cases the morning appetite is apt to be wanting, and these patients should eat late in the evening, after the fever falls. Continuous fever is rare in tuberculosis, occurring only during the existence of complications or in acute cases. Remittent fever is the rule. It is unfortunate that so frequently fever is initiated by a chill and followed by sweats, and is intermittent, because this often gives rise to a diagnosis of malaria, which mav cause the loss of much precious time. In view of this, it need hardly be said that such symptoms, even if appearing in a malarial region, should suggest not simply a search for the parasite of malaria in the blood but a careful examination of the lungs. Chills. — In the incipiency of chronic tuberculosis, chills are rare, save a slight temporary chilliness, Avhich, if inquired for, may be dis- covered. As a rule, it is only in acute pneumonic phthisis, or in acute miliary tuberculosis, that there occur pronounced chills in the beginning. In the second stage they are also rare, except when they usher in a con- gestion or some complication. In the third stage, especially if severe 13 170 SUBJECTIVE SYMPTOMS 171 mixed infections exist, the}' are common, generally occurring early in the afternoon and preceding high rises of temperature. Hoarseness. — In delicate people, who are apt later to develop tuber- culosis, the voice is weak or it has a tendency to become husky on changes of weather. In a few early cases there is pronounced hoarseness, due either to a slight adductor paralysis from gland pressure on the recurrent nerve or a slight catari'h, and Schaffer ('83) considers this an early symp- tom ; but slight hoarseness can be caused by so many other conditions that, while it justifies a careful examination of the whole respiratory tract, it cannot be considered diagnostic. In more advanced cases hoarse- ness from a simple catarrh is often seen, but if it persists it strongly suggests tuberculous larj^ngitis. (See Larynx.) Sweats. — ^Vhi]e sweats are a very common s^'mptom in tul:)erculosis, this does not apply to the early stages of the disease, where they are not often seen, although a tendency to undue moisture of the skin of the forehead, neck, chest, and abdomen on slight exertion, or if the room is rather warm, is often noted. Profuse sweats in earl}^ cases, as re- ported by such a good authority as Sokolowski ('OG),^ the writer has not seen. The nervous strain of a physical examination is apt to cause profuse sweating in the axilla-, but. though it has been classed as such by some, this cannot be called a symptom of tuberculosis as it may occur in any nervous individual. In the second stage sweats are a common and typical symptom. They generally occur in the night, usualh' shortly after going to sleep, and are often repeated again in the early morning; but they may occur at other times, especially after overexertion or if the patient dozes in his chair. They are closely associated with the fever, and I have not known them to occur in really afel)rile cases, but, unlike the sweats of malaria and the acute infections, they do not promptly follow on the fall of temperature in every case, although the night sweat generally does so. In this stage sweats are rarely profuj^e or obstinate, and disappear with few exceptions without any especial medication shortly after the beginning of an outdoor rest life and proper hygiene. So generally is this true that the sweats in the second stage rarely need cause any anxiety, and one may count almost with certainty, on their ceasing within one, or at most two, weeks of the commencement of an outdoor rest cure. In these cases the patient goes to bed feeling well, and on arising next morning finds his night clothes moistened around his neck and chest, but he is not generally disturbed by the sweat unless it is quite profuse. If it is profuse, he is awakened shortly after going to sleep 172 SYMPTON[ATOI.OfiY OF prLMOXARY TIBERCri^OSLS by a " gone '"' sensation, to find his night clothing wringing wet. After a change of clothing he falls to sleep again, to he awakened in, the early morning by a repetition of this occurrence. Patients very soon learn that heavy bedding favors sweats, as does free water drinking or hot drinks, and in light cases proper attention to these causes is at times sutticient to prevent sweats. Tn the Ihird stage cases the sweats form a very serious and trouble- sonie featuic of the case, exhausting tlie strength of the patient and ])mducing the greatest discomfort. Such patients soak the sheets .sev- eral times a night, and their sleep is greatly disturbed, and even in the daytime, if they sleep, the sweats appear. These '"colliquative sweats" are most obstinate and often fail to yield to any treatment. The view of Cornet ('07), who ascribes the sweats to the action of a toxin of the tubercle bacillus, or other bacteria on the sweat or heat regulative centers, is now generally accepted. While many excellent authorities deny that the various pus organ- isms play any part in the symptomatology of tuberculosis, the clinical picture in the late stages is so similar to that of septic infections that it is difficult to think that the streptococcus or other pus organisms have not some part in producing the sweats of this stage. By no means, however, do all advanced cases sweat ; fibroid cases rarely present this symptom unless there are present secreting cavities. Languor. — There are few early symptoms of tuberculosis more sug- gestive than languor, yet none is so often ascribed to other causes, the undue weariness which marks the beginning of ind down the lungs as to cause dyspnea. The sudden development of dyspnea at this stage is generally of serious import, and speaks for extension of the area of involvement or possibly for pleuritic effusion. Apparently causeless dyspnea, in cases without marked limitation of respiratory area, should always excite suspicion of an acute, or at least a very general, dissemination. It is found quite frequently in those subacute cases w^hich present the signs of a miliary tuberculosis, but which run a relatively slow but uni- formly fatal course. A case in point seen by the writer was that of a girl of twenty-four, with tuberculosis of a relatively slow course, and with no sign of exten- sive infiltration, but rather of disseminated tubercles. There was a ]U'(mounced dyspnea of obscure origin, and the bad prognosis based largely on this symptom was borne out by the subsc(|uent history. In some cases where the dyspnea is not noted in the daytime there are severe asthma-like attacks in the night, but these generally yield to potassium iodid. They were probably ordinary cases of asthma in tuber- culous subjects. In advanced cases the degree of dyspnea, in spite of the extensive destruction of lung tissue, is astonishingly small; except on exertion, the dyspnea of tuberculosis, as West notes ('02), bearing a much closer I'elation to the rate of development of the disease than to its extent. Thus the gradual development of the process in tuberculosis gives Nature time to bring into play her wonderful adaptability to new conditions, and it is only when such time is not allowed, as in rapid disseminations, sudden pleural eifusions, or more especially in pneumothorax, that d3^spnea can be e.xeessive, agonizing, and at times fatal. When the moderate dyspnea of third-stage cases is spoken of, it must be recalled that such cases are usually at rest; v/hen from their financial condition they are obliged to keep up physical exertion, dyspnea can be a very painful feature and one that cannot be relieved. 178 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS Cyanosis. — Cyanosis is not ordinarily seen in the chronic forms of pulmonary tuberculosis, though some degree of cyanosis of the finger tips and of the face is found in advanced cases or where there is rapid dissemination, and it is also to be seen in the clubbed fingers. In acute miliary cases, however, it is an early and alarming symptom. The Circulatory System. — The circulatory system very early in tuber- culosis undergoes modifications which aft'ect both the pulse-rate and the blood-pressure. Tachycardia appears very early in the disease, and, in- deed, often exists for a considerable time befm'e any pulmonary lesion can be discovered, so that those who have assumed the existence of a " pretuberculous state " have picked this out as one of its most marked symptoms. While not admitting the existence of such a state, the active presence of the bacillus in the body before it can be definitely diagnosed, which probably corresponds to what its advocates call the " pretubercu- lous state," can undoubtedly be strongly suspected when, in a patient whose normal rate is known, there is a })ersistent or even intermittent rise in rate which cannot be accounted for otherwise. That this tachycardia, occurring so early, can be explained on any other assumption than the action of the poison of the germ does not seem possible, though it has also been ascribed to atrophy of tlie heart, and while the pressure of enlarged bronchial glands on the vagus can produce severe tachycardia, such enlargement is by no means as com- mon or as early as is the symptom. It can occur long before any rise in temperature is evident. It may at first be paroxysmal and brought on by excitement or by food. Wells has noted that the pulse of the tuberculous, unlike that of the normal man, is not notably increased in rate by change of position from lying down or sitting to standing, and Papillon and other French Avritors have made much of this symptom; but the contrary is reported by Kuehle and Thomayer ('04), and in investigating the matter the writer has found it as often absent as present. When the disease becomes evident the pulse is almost always increased in rapidity, generally running from 85 to 110 in average cases, but in severe cases from 110 to 120, and at times even higher. A persistently fast pulse of over 110 is a symptom of serious import, unless it yields to rest and treatment. On the other hand, a lessening of the pulse-rate is most encouraging, and is an excellent sign of lessening trouble, with decreased discharge of toxins into the blood, and speaks for increase of vitality and recu2:)erative power; while the persistence of a nearly nor- mal pulse-rate, despite demonstrable lesions, is probably the best index of a robust constitution and good fighting power. In old third-stage cases a rapid pulse is never absent, save toward the end, when a slow pulse and the appearance of intermissions speak for a failing heart ; but at this SUBJECTIVE SYMPTOMS 179 stage the tachycardia is doubtless due largely to the fever. In an arrested case one cannot feel safe as to the continued progress of the patient as long as the pulse-rate remains high — over 90 in men or 95 in women; but rarely does the pulse return entirely to its former nor- mal rate, however otherwise satisfactory the results may be. Tachy- cardia cannot be assumed to exist until it has been verified at many different times, the excitement caused by the physician's presence tend- ing to produce a temporary acceleration, and when the patient knows the doctor well, the readings will differ from those secured at first. Blood-pressure. — That there exists a hypotension of the pulse in pul- monary tuberculosis is generally recognized, but there is considerable difference of opinion as to the time of its first appearance. Certain authors, especially those of the French school, believe it is low in the earliest stages of the disease, often before any other change can be noted. This, however, is not the general view, and the writer has not found low pressures in his very early cases, but it has been in the mod- erately advanced cases that a low blood- j)ressure is common. Burckhardt ('OG) found hypotension in progressive cases, whether afebrile or not, but in nonprogressive or afebrile cases he got normal readings. A fair number of the writer's patients at this stage have shown a pressure of from 90 to 120 mm. of mercury, and Teissier ('05) considers 120 to 130 the usual figure in first- and second-stage cases, and 80 to 100 in third-stage cases. Cornet quotes Marfan as finding low pressure in 97 out of 100 cases. Different authors have different views as to Avhat can be considered a low pressure; any pressure under 130 mm. is so regarded by West. T. C. Janeway, in his recent work on blood-pressure, quotes the estimates of normal pressure made by various authors, using the Riva- Rocci apparatus, which is practically similar to Janeway's and Stanton's sphygmomanometer. In adult males Gumprecht found an average of 140 mm. ; Hayaski, 132 mm.; Heuser, 137 mm.; and Thayer, of Johns Hopkins, in his cases, between twenty and fifty years of age, found 139.9 mm. The whole series averaging 137 mm., with maxima and minima varying from 96 to 180. Janeway himself considers from 110 to 150 normal. In tuberculosis, Xaumann, in 100 cases, found a pressure over 130 in 69 per cent, over 115 in 13 per cent, and under 115 in 18 per cent, and considers 115 low pressure. Stanton, in a personal communication, tells me he considers 115 low pressure in this disease, and after considerable use of his instrument, controlled at times by Janeway's, I am inclined to consider this a fair estimate; but when formerly I used Gaertner's instrument, which is applied to the finger tips and not to the arm, I found rather higher readings. However, in my early cases pressure has 180 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS not usually been low, and I have been surprised to find that pulses which by the linger estimation seemed to have poor tension, would show quite fair readings with the instrument. In advanced cases low pressure is so common that high pressure should suggest renal changes, which should call for investigation of the urine, or a pulmonary congestion, or an impending hemorrhage. Teissier notes that high tension is present in tuberculosis tem- porarily preceding hemorrhages or acute congestions, and ])ermanently in fibroid phthisis with emphysema, in cirrhotic kidneys, or in diabetic tuberculosis, and a gradual rise exists when the process in the lungs is lessening in intensity and a cure is occurring; or in tuberculosis of arthritic subjects. The low ])ressure in tuberculosis has been asciibed, like so many other symptoms, to the effect of the tubercle toxin, as also to a weak heart, or to anemia, Bouchard ('05) having extracted a vasodilator prin- ciple, ectasine, from tuberculin. Just as a lessening of tachycardia has a good prognostic meaning, so a rise of blood-pressure and a good ten- sion of the pulse, if the kidneys are sound, is almost as favorable a sign as a slow pulse. The heart presents few sym])toms in tuberculosis. Since Laennec first pointed it out, a diminution in its size was, until recently, uni- versally admitted, and Brehmer regarded the small heart as a causal factor and used it to fortify his views as to the etiology of the disease. Louis long ago reported 112 auto}>sies in tuberculous cases, in which about fifty per cent showed unduly small hearts ('04), and Kesch (\)5), in 120 cases, found altout the same percentage. Similar results have been gotten by other ol)si'rvers. In recent years, as the result of autopsies, some have denied that the heart was small, Hirsch furding it enlarged in forty-four ])fi- cent and small in but five per cent; but, as he himself admits, in old cases there is a hypertrophy and later a dilatation of the right side, due to pulmonary obstruction. Bouchard and Baltazar ('05), by orthodiagra- phy, measured the heart in 100 nontuberculous people, and in 100 with tuberculosis, and in the latter, in the first and second stages, found the heart smaller than normal. That autopsies should differ from clinical findings can easily be understood when we recall that autopsies are, with few exceptions, made on advanced cases of tuberculosis and on hospital material. In the for- mer, as is well known, diminution of lung area and fibrosis place a strain on the lieart which results quite commonly in its hypertrophy and dilatation. In the latter, as a result of alcoholism, the kidneys are very often cirrhotic. Thus autopsies would be a]:)t to show large hearts SUBJECTIVE SYMI'TOMS ISl where fluoroscopic and otlier examinations in earlier cases would show the reverse. As a result of systematic percussion and mensuration of the heart, and of fluoroscopic examinations in all cases, it may be said that in a large number of cases such a small lieart will be found, though whether it is congenita], and to be considered as a cause, or due to atrophy, and to 1)0 regarded as an effect, cannot be stated, .\nyone who will use the .\-iay carefully will agree with this view. Hutchinson ("Ofi) has lately made the interesting discovery that in the animals at the London Zoological Gardens, those most prone to tuberculosis had hearts whose weight was less than y^ of their body weight, while those wlio were immune had hearts heavier than y^^. Thus the deer, with a heart -g'g- its body weight, is almost insusceptible, while the antelope, with a heart yo^ its body weight, is very susceptible to tuberculosis. The sheep, with a heart y^ its body weight, is rela- tively immune ; the cow, whose great susceptibility -is well known, has a heart only 25-0 of its body weight. As a result of a few carefully made measurements on sanatorium cases, he thinks he has confirmed his views drawn from these animal measurements, finding the heart small in the majority of the cases, and he has come to consider a weak, under- sized heart as " one of the most constant and significant conditions present in consum])tion.'* Displacement of the heart in moderately or far-advanced cases is very common, and is due chiefly to fibrosis. It can come on relatively soon, develops slowly, and can reach a very pronounced degree, the heart often being dislocated completely into the right side or displaced far over to the left. Such displacement is presumptive evidence of fibrosis, and the location of the a])ex should, therefore, be determined carefully in every case. In pleurisy with effusion, or more especially in pneumothorax, dis- placement occurs rapidly, can be very marked, and may be accompanied by circulatory disturbance from bending of the great vessels and trac- tion on the vagus. In a rapidly collecting pleuritic effusion purposely left /// sUn for its pressure effects, the writer saw a severe and alarming syncopal attack from this cause demanding immediate relief. In left- sided pneumothorax the heart will show extreme degrees of dislocation, and the writer has several times seen it drawn entirely into the right thorax, though after a while, unlike in fibrosis, the heart in these cases [lartially returns to the left. Aside from pulmonary stenosis, whose causal relation to the develop- ment of tuberculosis in the lungs cannot be doubted — Meisenburg ("0"?) found eighty per cent of all patients in the Leipzig clinic died of tuber- culosis — valvular lesions have no relation to tuberculosis, though retrac- 182 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS tions can at times give rise to various indefinite murmurs. Mitral stenosis was at one time considered to antagonize tuberculosis, and D. Eothschild ('05) considers that it confers a marked immunity, and that if tubei'culosis develops on a preexisting heart lesion, it runs a mild course; but this is contrary' to the writer's experience, and Norris ('04), in an excellent paper on tlie heart in tuberculosis, says: "In view of the frequency with which tuberculosis of the lung has been found asso- ciated with valvuhar heart disease, we are forced to conclude that the latter exerts, if any, but very slight influence on the former, either as an inhibitive or curative influence, even if satisfactory compensation is maintained." Hypertropb}^ and dilatation of the right side of the boart, owing to resistance in the lesser circulation in the lung from obliteration of so many blood-vessels, is seen in some cases of extensive tuberculosis, being })resent in 4G out of 1,276 cases (Phi])ps Institute Histories). Such a condition may ojiiite frequently be demonstrated by the fluoroscope when other metliods fail to reveal it. A subclavian murnmr (see auscultation), due to kinking of the artery by apical contractions, is not uncommon, but has not the diag- nostic value ascribed to it b}' Euehle, as it has been shown that it can occur in other conditions. Accentuation of the pulmonic second sound, with or without redupli- cation, is very commonly found, but is not of diagnostic value. The same ma}^ be said of a roughening of the tricus])id systolic sound, which the writer has noted in a large percentage of his cases. Pericardial frictions are at times found, but tuberculous pericarditis is usually overlooked, and is found more commonly at tlie autopsy table than by the bedside. Systolic retraction of one or other of the left inter- spaces, commonly the second, near the sternum, is often seen in eases with emaciated chests, and, as Euehle points out, is due simply to air pressure on the thin, wide interspaces, and should l)e distinguished from retractions occurring at tlie apex of the heart as the result of pericard ial synochia\ Digestive System. — On the integrity of the digestive system in tuber- culosis generally depends the result of the conflict, and he wlio treats tuberculosis very soon learns to study its symptoms with especial care. On it, more tlian on any other part of the body, depends the outlook of the patient for recovery, for unless a proper amount of nourislunent, prop- erly prepared by it, is given to the cells, they will surely fail in their battle with tlie disease. From the moment the food enters the mouth, until its useless residue is thrown off, each step of the digestive act is of tlie utmost importance, hence every part of the alimentary tract should be most carefully watched to see that it functionates properly. SUBJECTIVE SYMPTOMS 183 The mouth in early cases presents no symptoms of value, unless we accept the views of Fredericq, Thompson, and others, to which G. Sticker, in 1888, drew attention. He described a sliar])ly marked red line at tlie border of the gums, especially of the incisor teetli. While this line is present in some tuberculous cases, it is also found in other conditions, and in tuberculosis it is found chiefly in advanced cases and rarely in incipient ones. It is not a sign of value. The tongue in early cases shows no alterations which can be con- nected with tlie disease, though wliere digestive disturbances are present it is apt to be slightly coated. ■ Tlie frequency of dyspepsia in moderately advanced cases accounts for the frequency of a coated tongue in such cases, while in advanced cases there is very frequently found the red, shiny tongue of all chronic cachexias. The condition of tlie teeth in pulmonary tuborculo?is should always be carefully looked into, as the bad effect of cai'ies on digestion is well known, and in advanced cases such caries is unduly common and gives much trouljle. In those in whom we find what has been called the tuI)erculous constitution the teeth are apt to be unduly transparent and delicate, probably from a deficiency of lime salts, and not infrequently transverse ridges are present, which, like the transverse white marks on the nails, probably correspond with periods of lowered vitality. The jjhaiijnx shows chronic pharyngitis, with undue prevalence of adenoid tissue on the posterior and lateral pharyngeal walls, which often are studded all over with the small lymphoid masses of follicular phar}Tigitis. Extreme pallor of the hard and soft palate and posterior pharyngeal wall and epiglottis is common in old cases. Follicular pharyngitis is very common and develops in old severe cases into pharyngitis sicca, which can cause considerable inconvenience, while thrush and aphthous stomatitis are at times troublesome in the last stage. Bohr found twenty-five per cent of chronic granular, or dry cases of pharyngitis. Tuberculous pharyngitis is fortunately very rare, for it is excessively painful and its course is uniformly fatal. It occurs, according to the classification of Barth ('80), who has written a very complete mono- graph on the subject, in three forms: (1) An acute tuberculous follicu- litis, (2) a diffuse miliary tuberculosis, and (3) a chronic; ulcerous tuberculosis. It begins with pain and the appearance of isolated or confluent whitish-yellow elevations, rapidly spreading and coalescing into ])latelike masses, hard to the touch and with little or no inflamma- tory areola. The pain in the throat becomes lancinating and ])urning, and does not remit. Dysphagia ai)pears, and there is troublesome saliva- tion and pain running into the ears. In a very marked case, in which death occurred before ulceration took ])lace, the tubercles s])read u]) the 184 SYMPTOMATOLOGY OF PULMONARY TriJERCTiLOBLS posterior pliar3ngeal wall, and from the soft to the hard palate with surprising rapidity, each day showing a distinct advance, while the pain was excessive and scarcely affected Ijy anodynes, ff tlie patients live long enough, ulcers form and spread rapidly. The tonsils, while frequently enlarged, Behr ('05) finding ahnormal tonsils in sixteen per cent of cases, show no special ocular changes. TTypcrtrojihy of the lingual tonsil, while not more common in tubercu- losis than in otlier conditions, is more troublesome, as it often causes an obstinate hard cough hy pressure on tlie epiglottis, disappearing on the removal of this pressure. The stomach presents marked alterations from tlie normal. A large number of cases of pulmonary tuberculosis begin as a dyspepsia, and few fail sooner or later to show some evidence of gastric "disorder. Janowski ('07) found gastric disturbance in fourteen per cent of 700 incipient cases, and eight per cent of gastric and intestinal disturbances. Many patients report themselves as having always been poor or fickle eaters, and Behring ('04) regards this lack of good appetite as an early symptom of the presence of tuberculosis in the system. It could usually be considered rather as an excellent predisposing cause through its depressing effect on the general nutrition. In incipient cases we find ver}^ commonly loss of appetite in a mod- erate, but not at this time in an extreme, degree, a sense of discomfort, fullness and Aveight after eating, belching, pain, signs of motor insuffi- ciency and hyperacidity. Fox ('91) quotes Fenwick, who found hyper- acidity in fifty-six per cent of 200 cases. Pasquier ('03) found hyper- chlorhydria in sixty-nine per cent of his incipient cases and in fifty-seven per cent of his second-stage cases. Vomiting after meals, which Grancher and Barbier ('97) and Fox ('91) regard as a very early symptom, was not found in the writer's early cases, which agrees with Janowski ('07), who foimd it rare, though it is quite common in somewhat more advanced cases, being usually excited by the cough whicli eating is so apt to produce, but at times by the effort to bring up very tenacious sputum. It can be very obsti- nate, and coming on after meals may at times seriously affect the nutri- tion. Tenderness in the pit of the stomach on pressure, or pain appear- ing after eating, those common accompaniments of hyperacidity are frequently seen. Fermentative dyspepsia is a very common complaint with tuber- culous patients, and is often seen very early. The taking of food is shortly followed by a sen.se of fullness and distention with belching, and few of the lesser symptoms are so hard to remove. The frequency in tuberculosis of those sequelfe of motor insufficiency, dilatation, and dislocation, has not been sufficiently recognized. ]\rarfan SLfBJECTlVE SYMPTOMS 185 alone laying slross on ii. 11' the .stomach is niapijed out in all ca>es, dilatation will be I'onnd in a large percentage of the moderately ad- vanced cases, and in some of the early cases dilatation, often of an extreme degree, at times accompanied by dislocation. In view of the importance of perfect digestion in tuberculosis, we should, therefore, never omit from our physical examination a mapping out of the stomach. In advanced cases there are present the signs of chronic atrophic gastritis, a severe and often absolute anorexia, a disgust for food so great that tiie very sight of a meal induces vomiting, hyperacidity, and absence of heartburn. Pasquier ('03) found hypochlorhydria in seventy-six per cent of his advanced cases. Digestion is, moreover, fur- ther hindered by the effect of the high fever, and, as has been noted in discussing anorexia, the chief meals must, therefore, be taken at the periods of lowest temperature. Since the progress of the case depends so largely on a proper func- tioning of the stouiach, it is evident that in future more and more attention will be paid to analyses of gastric secretion in tuberculous patients, and their diet will be regulated accordingly. When this is done we shall get better results than ever before. The Intestinal Canxil. — In early or in moderately advanced cases constipation is surprisingly common, and cathartics are frequently needed. While this may in part be explained by the limitation of exercise in the beginning of a rest cure, this cannot explain the undue frequency of this trouble in the tuberculous, and it must have some connection with the presence of the germ in the body. Autopsies demonstrate intestinal lesions in a large number of cases, Heinze, reported by Miiller ('01), finding them in 630 out of l,22(i cases of pulmonary tuberculosis; Janowski ('07) found 13 per cent of intestinal symptoms in 700 incipient cases and 8 per cent combined gastric and intestinal ; Fenwick and Dodwell, in 500 out of 883 ; Eisen- hart in 556 out of 1,000. From these statistics it would be natural to suppose that diarrhea and intestinal pain would be prominent in the disease, but, strange to say, this is not the case, and even where after death extensive ulceration has been found, often there will not, during life, have been the least intestinal disturbance. Fox ("91) found diar- rhea in 72 acute cases where ulceration was present, only 36 times, and in 36 chronic cases he found 66 per cent of ulcers and -11 per cent of diarrhea. In the beginning tin it aic no intestinal symploms. unless we so con- sider the nuirked tendency to constipation already noted, the dyspepsia at this stage being chiefly gastric. The diarrhea which Fox considers at times an early symptom has not been presenl in Ibc wriU'r's early cases. Fo\ believes tbal tboro is an irriJablc coiKlitidii nf tlic lowei' 186 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS bowel and undue liability to diarrhea on slight provocation, such as slight dietary errors, chilling, or hot weather, and due to a catarrhal inflammation of the mucous membrane. Cornet also considers it an early symptom, and ascribes it to the swallowing of sputum, the mucous membrane being irritated by the proteins of the bacillus, or else to the effect of the absorption by the Ijlood of large amounts of toxin, but early cases do not have large amounts of sputum, and undeniable as are the remote effects of the tubercle toxins on which Cornet so fre- quently insists, it would seem improbable that they are present in large amounts in incipient cases. In moderately advanced cases there is very frecjuently flatulence and intestinal indigestion, which can at times be very troublesome, and in this stage also we will find, though not often, an obstinate diarrhea due to catarrhal colitis, which may simulate a tu bercu 1 ou s d i a r rh ea . However, it is usually only in the third stage that the intestinal canal gives much trouble, and diarrhea is at this time much more com- mon. Fox's statement that fifty per cent of old cases have diarrhea is correct, if dealing with patients of all social classes, but it must be remembered that this will vary according as the patients are hos- pital or private patients, the careless habits and poor hygiene of the former in their past life, and the generally unfavorable conditions under which they have lived, rendering them more liable to the severe manifestations of the disease than the more carefully nurtured patients one generally sees in ])rivate practice. Tuberculous diarrhea is due either to ulceration of the bowels, or, less commonly, to amyloid change, but Fox, and more recently J. Walsh ("06), consider that the nephritis of late tuberculosis may account for some cases. It is wise to be guarded in a diagnosis of amy- loid diarrhea, which cannot be made safely unless changes in the liver and spleen and albumin in the urine and polyuria are found. Williams ('87) would differentiate the amyloid from the ulcerous diarrhea by the fact that the former is not very profuse, is watery, and has some corre- spondence with the sweats, lessening when these are profuse. There is no tenderness of the bowels, the tongue is more furred than red and raw, as in the ulcerous form, and the liver and spleen are enlarged. The majority of diarrheas in the third stage can safely be ascribed to tuberculous ulcers, but a positive diagnosis is almost impossible, the presence of bacilli in the stools being rendered valueless by the impos- sibility of excluding the swallowing of sputum. The stools of such a diarrhea are apt to be unusually fetid and slimy and contain pus, and at times are streaked with blood. Louis, quoted by Eenzi ('94), con- sidered a diagnosis of tuberculous ulceration justified when a tubercu- lous patient suffered more than six weeks with a continuous diarrhea, SUBJECTIVE SYMFrOMS 187 and Traube thought such a diagnosis safe in the presence of persistent and active diarrhea if dietary errors and amyloid change could be ex- cluded and the stools were colicky and bloody. The combination of colicky pains coming on shortly after taking food, pain on palpation, ravenous appetite, rapid emaciation, and pus in the stools, point with practical certainty to a tuberculous ulcerative enteritis, and the appear- ance in a tuberculous patient of obstinate colicky pains after meals should excite suspicion. Intestinal hemorrhages are much less common than in typhoid, and intestinal perforation is still rarer, Eisenhardt giving the frequency of the latter as five per cent of all cases of intestinal tuberculosis; Fen- wick and Dodwell, ten per cent. Unlike the perforations occurring in more acute diseases, they may produce few or no symptoms, and appar- ently not infrequently heal spontaneously. Two rare forms of intestinal tuberculosis are the hypertrophic and the stenotic. Tlie former is described by Mathieu ('04) as being char- acterized by hypertrophy of the cecum and ileocecal region of the bowel, coming on gradually in cases of very chronic course. There is dull pain in the right iliac fossa, with attacks of colic and diarrhea with vomiting. Slowly there develops a sausagelike mass in the cecal region with signs of chronic stenosis. The stenotic form is due to scar forma- tion in the circular ulcers, and is confined to the lower third of the small intestines. It is commonest in fibroid cases, and often there are no pulmonary symptoms at all, so that these cases are apt to be mis- taken for cases of syphilitic stenosis. They are, as a rule, very gradual in their development, and, as the constrictions are located in the small intestine, constipation is usually absent. The chief symptoms are periodic and increasingly severe colicky attacks, generally accompanied by vomiting, during which, in emaciated patients, the distended coils of the intestines can be seen to move under the thin abdominal wall, and the gurgling of gas can be heard. Tuberculous peritonitis is, strictly speaking, a complication. Buschke found it in 1G.5 per cent of 1,3^3 autopsies. While a peritonitis can occur acutely as the result of the perforation of an ulcer, or by exten- sion of inflammation through the peritoneum covering the base of a deep ulcer, this, of course, is not a real tuberculous peritonitis. Chronic tuberculous peritonitis generally comes on insidiously, with tlie collection of fluid in the alxloinen and a gradual development of tympanitic distention. However, the fluid is often encapsulated, and thus may not be demonstrable, while at times there is no fluid at all. Pain is usually present, but is rarely severe, and generally there is only a sense of abdominal distress. The temperature is variable, often being absent for some part of the time. Palpation of the abdomen will INS SYMPTOMATOLOGY OF PULMONARY TUBERCILOSIS demonstrak' tiimoiiike masses produced by the adliesion oi' the coils of intestine, but this may not be discoverable if there is much distention. In some cases if the peritoneum is richly studded with tubercles, pal- pation gives a crepitus. The Liver. — The liver does not present any symptoms, but signs of imperfect liver function in patients who are practicing hyperalimenta- tion are common, and while most of the so-called " bilious attacks " which are then so frequent are probably due to gastroduodeual catarrh, il is reasonal)le to su|)i)ose that the liver, as well as the stomach and Ijowels, are deranged. UUom ('06), while finding liver tuberculosis in a hirge percentage of cases at autopsy, found its clinical recognition impossible. In nearly every case he also found passive congestion of the liver, but his material consisted of advanced cases in the very poor, and doubtless examinations in earlier cases, if possible, would show othei' results. Urinary System. — While the kidneys are affected in a large number of cases, the symptoms are usually not marked and are more often over- looked. In incipient cases the bladder and kidneys are usually normal, altliough Papillon ('97) and Eobin ('!>7) speak of frequent micturition and polyuria as early symptoms. The urine is usually negative in the beginning of the disease, but later on, if carefully studied quantitatively, can give valuable evidence of the tissue waste that is occurring, and French authors consider that a demineralization of the system is shown by the excess of earthy phosphate in the urine, although Ott ('03) does not corroborate this. Croftan ('03) found an excess of calcium ex- cretion. This phosphaturia is considered by ({rancher ('97) an evidence of cell destruction, and what he says is so suggestive that it is well to quote from him at length : The pecviliar demineralization of the tuberculous from this point of view is worthy of great attention by all observers. It shows that uncom- plicated tuberculous consumption follows special laws, and that its mechanism does not resemble that, for example, of diabetic consumption. The low content of the urine in sulphur, the considerable increase of phosphates, combined with the nitrogenous derivatives of insufficiently hydrated albuminous substances, indicate a destruction bearing especially upon the phosphorized albuminoids, nucleo-albumins, and nucleins. These bodies exist only in the cells and especially in the white cells. . . . From the first the tuberculous utilize, as we have seen, against the bacillus, the polynuclear leucocytes, and then the mononuclear. The destruction {con- fiommafion) of these elements is in direct proportion to the iiroduction of toxins. The necessity for the tuberculous to meet this waste of leuco- cytes is shown by the special activity of the bone marrow which one sees in the 1 ubcrculous, or which one ean produce experimentally by the SUBJECTIVE SYMPTOMS ISO iuoculatiou of tuberruliu <>r the rormation at a distance of a local tuber- — Small Erosions or Ulcers ^reeBorder of the Cords Giving ; Characteristic "Xibbled-out" 'EARANCE. (After Schnitzler.) 3. — Thickening of the Rigi False Cord which Overlaps a> Hides Most of the True Cor There is also Moderate Thicke: ing of the Center of the Aryt noid Region. (After Tiirck.) 4. — Thickening and Injectk OF Insertion of Cords and S.m.\ Ulcer at the Base. (After Schiiit ler.) 5. — Superficial Erosion of the fER Surface of the Vocal Cords, jy Typical of Tuberculosis. In- tion of Cords. (After Krieg.) 6. — Grayish Wrinkling of the jTERiOR Commissure, not Di.\g- iTic, but very Suspicious if Com- ed with Other Sy.mptoms. Of 5S V.\LUE in those WHO USE THE ICE IN Public Spe.^king. (After initzler.) 7. — Ulceration of the Fi Border of the Right Cord, P nuciNG THE Appearance of a Re plication of the Cord. (A: Krieg.) S. — W.vrtlike Growth, Ris FR<1M the Posterior Commissi Xear the Insertion of the C< (a Favorite Location). (A Krieg.) SUBJECTIVE SYMPTOMS 199 These tablelike elevations tend to break down into idcers, but as such ulcers are seen in profile from above, and as their bases tend to fill with exuberant pointed granulations, which hide the ulcer itself entirely, their nature may be mistaken. Later on these granulations may, and often do, enlarge to such an extent as to greatly affect the voice and embarrass respiration. In the place of such infiltrations we have at times tumorlike masses, althougli these are hardly an early occurrence. These solid excrescences or granulomata (Fig. 8) do not break down as do the infiltrations, but can persist for a long time un- changed, and are usually associated with a benign course, and are so firm and fibrous in texture as to render their removal difficult. At times we find, instead, pointed or even forked papillomata. iS^ext to the posterior commissure as the site of early changes is one cord, and more especially the posterior insertion of a single cord and its processus vocalis (Fig. 4). At this latter point we will often find very- early some thickening and reddening, which soon develops into a small ulcer with a wdiite slough, but its tuberculous nature is not as easily determinable as are the changes in the commissure. Lake ("01) considers paralysis of the cord an early sign and due to a tuberculous myositis or to a toxic effect. The writer has found paralysis of the arytenoideus, but not in incipient cases. The cord itself shows either patches of congestion, going on to ulcer formation, or a solid, red, brawny infiltration of its whole length, by wdiich it loses its luster and becomes spindle-shaped. This is followed by erosions of the free edge or upper surface and the formation of ulcers. The ulceration of the edge is frequently in spots, so that the cord looks as if small pieces had been nildiled out of its edge (Fig. 2), or it may extend the whole length, in which case the parallel edges of the ulcer give the cord the appearance of being redu- plicated (Fig. 7). The characteristic feature of tuberculous ulcers is their multiple character and their tendency to coalesce and extend later- ally, rather than deeply (Fig. 5). Such ulcers on the cord are much conmioner in the posterior third or one half, and frequently this [)ortion is entirely eaten away while the anterior portion is well preserved. In the false cords there is most often a very marked thickening and infiltration which broadens the cord considerably so that it overlaps, and often entirely hides, the true cord below (Fig. 3), like a folded blanket. The congestion is apt to be patchy, with areas of yellowish pallor between, and the surface of the cord granular, and in early cases ulcers are not common. The arytenoids often show for a long time, before definite lesions are found, localized patches of redness, so that they Iodic mottled and angry (P'ig. 4), with sometimes a wiiite spot of anemia where the cartilage of Santorini projects. 200 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS In early cases they are not usually much enlarged, but at times will be found conaiderably swollen. The pear-shaped swelling running into the aryepiglottidean folds is of later appearance. The anterior com- missure, as noted, is usually free at this time, but now and again there is seen protruding through the anterior ends of the cords a small polypoid mass of red granulation. The epiglottis at most shows small localized areas of thickening of its sharp upper edge, ulcers of its edge, the turban-shaped swelling and the edema of the epiglottis and ary- epiglottidean folds not being early changes. In the same way, the ring- like ulceration involving the posterior commissure and both cords is also a much later condition and usually implies severe and hopeless trouble. Severe dysphagia and aphonia are also late symptoms, but if tlie arytenoids ulcerate early the former may be present. Aphonia usually accompanies ulceration of the cords, and is not associated with dys- phagia, while the dysphagia, which is often extreme and harassing, and yields to no anodynes, is commonest when there is epiglottic ulceration or, to a less degree, trouble with the arytenoids. Perichondritis of the larynx is never seen in early cases, but gen- erally results from infection of the cartilage from deep ulcers, the infec- tion finally dissecting out the cartilage, which is thrown off as a seques- trum. It is accompanied b}^ agonizing, throbbing pain. In conclusion, it must be noted that usually the earliest tuberculous laryngeal manifestations are coincident, not with very incipient pul- monary lesions, but with moderately .advanced ones, and that while primary laryngeal tuberculosis can exist, laryngeal involvement is not usually determinable in pulmonary tuberculosis until a considerable time after that in the lung. Cough is one of the earliest and most constant symptoms of pul- monary tuberculosis (Eoepke reported it in 93.8 per cent of 144 first- stage cases), and is so rarely absent that Euehle ('87) says: "There is no consumption without cough," and while this is subject to certain exceptions, it is, on the whole, a fair statement. A large percentage of early cases give a history of cough, or at times of clearing of the throat, as the first change noted; no other symptom is so often the first to appear. Aufrecht ('05), it is true, denies this, saying that the cough of consumption is onl}' a sequel of the laryngeal catarrh, and that such consumptives as have no lar}Tigeal catarrh have no cough, but while patients in the incipient stage often have a cough of laryngeal origin (see Lar}Tix), Aufrecht is alone in regarding it as the only cause of the early cough. He seems to be contradicted by the fact experi- mentally determined by Nothnagel and others ('94) that irritation of the diseased pleura produces cough in the alisence of any laryngeal catarrh. Moreover, knowledge of the cough-producing effects of pleu- SUBJECTIVE SYMPTOMS 201 ritic troiiljle would lead one to anticipate a pleurogenic cough in a disease in which an apical pleurisy is such an early occurrence. Cer- tainl}^ some cough is present in a large majority of all cases, and per- sistent absence of cough, as Lindsay ('04) sa3's, points to the absence of tuberculosis. The incipient cough is often preceded for some time by a weak voice which loses its timbre, or by a so-called nervous clearing of the throat, which occurs especially with every change of the weather. In such cases there is at first only a slight " ahem," which is not very noticeable and which is often completely overlooked by the patient, though noticed by his family. Tbis occurs chiefly in the morning, and while a morning cough or clearing of the throat cannot be regarded as pathognomonic, it is always a very suspicious symptom. Such a cough is due either to a sligbt laryngeal catarrh or, as Grancher ('97) notes, to an irritation of the terminal filaments of the pneumogastric nerve in the lung, pleura, or bronchial glands. It should be distinguished from the hysterical cough, which never occurs in sleep and remains the same indefinitely. At first it is not productive of any sputum, but this is seldom long absent if carefully looked for. It is almost always a morning cough at first, Grancher being alone in considering it an evening one. Instead of developing insidiously, it often begins suddenly, in the form of a bronchitis, the patient reporting that he " caught cold," and so many patients are treated for a long time for bronchitis, that it would be wise if every cough lasting more than a month were consid- ered strongly suspicious of tuberculosis. The tuberculous cough at first disappears with warm weather, to reappear in the fall, the patient being thus led to harbor a false sense of security. However, when once well established, it does not stop in summer, though it is generally less in warm, dry weather. Nothnagel's researches have shown that the respiratory mucous membrane is more sensitive, and that its irritation more quickly pro- duces a cough in the area of supply of the superior laryngeal nerve, especially the interarytenoid space, rima glottidis, and epiglottis, and that this sensitiveness lessens lower do^Ti, temporarily increasing again at the bifurcation. In the bronchi it is slight, and tbc parenchyma is insensitive, while the pleura is only sensitive when inflamed. Krishaber found that superficial lesions cause more cough than deep ones, which corres])onds with clinical experience, pleural lesions causing more cough than any otbers except tbe laryngeal. At the same time it must be remembered that there are few more obstinate or more painful coughs than tbose of abscess of the lung, or those caused by a focus of acute softening, and unless such a cough is due to a neigliboring jileurisy or to irritation of tbe bronchi, it would 15 202 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS seem to speak for an irritability of the parenchyma when inflamed. The early cough is rarely violent, unless laryngeal or due to enlarged bronchial glands. Laryngeal cough is easily recognized by its paroxysmal nature, dry- ness, great intensity, and peculiar timbre. The cough due to enlarged bronchial glands is croupy and violently paroxysmal, and such a cough in a patient should suggest tracheo-bronchial adenopathy. The early cough does not cause pain in the chest, as the late cough often does, but the writer has noted that it can give rise to qiiite a severe neuralgic pain in the point of the shoulder on the affected side, a fact not noted anywhere except by Ruehle. While cough, as is now so generally taught, can in most cases be suppressed by will power, there is sometimes in early tuberculosis such an intolerable itching, tickling sensation in the larynx that even those of strong will find the suppression of a cough impossible. This tickling is not always in the larynx, but at times somewhere along the course of the bronchial tree, and is very commonly felt under the lower part of the sternum, so that the patient supposes this to be the seat of the trouble, but the tickling bears no relation to the site of the pul- monary lesion. Morton, quoted by Osier, long ago noted that the cough could produce vomiting, but tbe conception of an early case in his day was what to-day would be considered an advanced one, and although so good an authority as Grancher ('97) considers that the early cough of phthisis, while not producing expectoration, produces vomiting, the writer has not, in his early cases, found this to be the case. The effect on the cough of the personality of the patient is very marked. Neurotic, excitable patients, especially Hebrews, react most violently to cough stimuli, as they do to all other stimuli, and unless carefully trained will do a great deal of harmful and needless cough- ing, whereas the quieter and more phlegmatic person will, with the same degree of trouble, do much less coughing. As already noted, when the cough has once begun it practically never ceases, except for short summer remissions or intermissions, until the end or until arrest of the trouble, and in the writer's experience this has generally been the last symptom to disappear. This obstinacy and persistence is one of the most typical features and every layman knows- the evil omen of a persistent cough. There is no typical cough in tuberculosis, and in all stages there may be a loose or dry, a hard or an easy, a high-pitched or a deep cough, though in general it is fair to say that in the beginning it is slight and dry, that it gradually loosens and becomes more pronounced, and is exaggerated by each exacerbation or extension of trouble, and toward SUBJECTIVE SYMPTOMS 203 the end is usually loose, deep, and hollow. On the other hand it usu- ally lessens as the process improves, and though Cornet ('07) denies that cough hears any relation to the disease, the writer helieves he is justified in saying that steadily lessening cough almost always means improvement, and persistentl}^ increasing cough generally means the reverse. As the process advances it shows distinct morning and even- ing exacerbations. The patient at this time is not much disturbed by the cough at night, though he may waken once or twice to expectorate, but on awakening, or after rising, and sometimes not until after eating, he coughs a number of times, generally easily unless the sputum is very tenacious, and after having spat a few times and " cleared out his chest,'' he does not at first have much more cough during the day, except after eating or laughing (a prolific cause of cough) or after much talking, exertion, or excitement. At bedtime, or as soon as he lies down again, he has another attack of coughing, though at this time the expectoration is much less than in the morning, and consequently the cough is much more violent. The cough at bedtime has been explained variously. De Eenzi ('9-t) ascribes it to hyperemia of the apex, and thus explains the patient's tendency to lie on his sound side to prevent cough, also noting that lying down increases dyspnea, and that the respiratory center is always more irrital>le in dyspnea. Xagelsbuch ('04) believes it is caused by hyperemia of the larynx, and by the fact that in the recumbent position air strikes different portions of the laryngeal mucous membrane. As, however, cough on lying down is not noted in incipient cases, but onl}^ when sputum is present, it seems to be sufficiently explained by the movement of sputum to new areas or by change of position, as is also the morning cough, which is also encouraged by the returning sensibility of the mucous membrane which is lowered during sleep. As the disease progresses and cavities form, the cough becomes more or less constant, the patient coughing at more or less frequent intervals during the day and expectorating at the same time. If large cavities are present, they impart to the cough the characteristic " hollow '' qual- ity supposed to be characteristic of consumption. The constant cough of the later stages can severely affect the health by disturbing sleep, using up strength, and by affecting the nutrition by causing vomiting after meals, while it also increases the danger of hemorrhage and hastens the end through exhaustion. In this stage, and even earlier, the chief site of the trouble is severely racked by cough, which may make the lung ache and cause at times sharp pain, especially if there are pleural adhesions, and when, as is so commonly the case, such adhesions exist also at the base of the other side, the patient will U'd tlicm with ever}' cough. The abdominal 204 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS muscles at times become sore from the excessive work put on them by the cough, and advanced cases suffer considerably from this. A very severe, hai'd, dry cough comes with beginning softening, or during abscess formation in the lungs, and persists until softening is completed and the detritus or pus has been evacuated by expectora- tion. When large cavities exist the cough is usually very loose and free and may be intermittent, coming on in paroxysms until the cavity is emptied, the sputum coming up in large amounts and then ceasing until the cavity is full again. Patients with cavities are usually unable to sleep comfortably on the sound side, owing to the severe cough pro- duced by the contents of the cavity emptying toward the dependent side, but this is not the universal rule; the reverse sometimes is the case. In very sensitive people or in the old, or in those who have never been accustomed to proper ventilation in their bedrooms, cold air pro- duces considerable cough, especially if it is damp. In the young or middle-aged hygienic education and outdoor life will overcome this quite promptly, though at first every breath of good fresh air will produce a cough, largely by autosuggestion, but in the old it is often unconquer- able, and one Cannot expect them to carry out an outdoor cure con- sistently. An annoying and often obstinate s^'mptom is a crackling and rat- tling in the chest, heard with every breath, caused by tenacious mucous in the air-tubes, and which can be heard at some distance from the patient. It often is very worrying and may be the cause of bitter complaint, and while often yielding to the use of alkalin waters, ipecac, or ammonium chlorid, it at times resists every effort. Expectoration is present in almost all cases of pidmonary tuber- culosis at some time in their course, and when reported absent one can by no means be sure that it is really so, many patients unconsciously swallowing all they raise. In 4,739 cases collected from statistics of German sanatoria by Montgomery ('06), 83.1 per cent had expectora- tion, and Koupke. quoted by the same author, found it present in 77.8 per cent of 144 first-stage cases. The swallowing of sputum is uni- versal in childhood, up to at least the fifth year, and some adults, more especially women, never get over the habit, or else persist in it know- ingly from motives of false delicacy. A total absence of expectoration throughout the whole course of the disease. Mobile reported, must certainly be extremely rare, and it would be most difficult to prove that it is not apparent rather than real. Formerly a typical tuberculous sputum was described, but it is now recognized that such does not exist, though certain characteristics of the sputum point to certain physical conditions in the chest. In the very early stages, when the cough first appears, sputum is often absent; SUBJECTIVE SYMPTOMS 205 thus while 93.8 per cent of Roupke's first-stage patients coughed, only 77.8 per cent expectorated. Indeed, even considerably later we are often surprised to find that many unobserving patients do not know that they expectorate, and when it is demonstrated to them, are apt to ascribe it to a nasal catarrh, a statement which is always open to doubt until proved. In most cases, however, even if at first absent, it soon appears, Fowler and Godlee ('98) believing that "it is rarely absent when symp- toms have been present for as long a period as two months." At first there is only a little mucoid, glairy sputum, with at times dark points in it, and so full of air that it floats on the water. Every now and then some transparent, jellylike masses, usually compared to grains of boiled sago, or by Aufrecht ('05) to frogs' eggs, are brought up. These masses are composed chiefly of alveolar epithelium, either unchanged or in a stage of fatty degeneration, the result of an alveolar catarrh. The sputum slowly increases in amount, and becomes thicker and more dense and less transparent, owing to increased cellular content, and shows scattered through it yellowish-white flocculi, and while still containing enough air to float, sends dowTi into the water long processes like streamers. The increase of formed elements changes its color to a whitish-yellow or a slightly greenish tinge, or at times to a faint pink shade. As tissue necrosis begins, the mucoid portion lessens and the purulent portion increases until it is plainly mucopurulent and greenish- yellow in color, tending to sink in water and showing the nummular masses which were once considered so diagnostic of tuberculosis. These are irregularly scalloped, rounded, grayish, or greeni.sh-gray balls, which hang from floating islands of mucus and saliva by long strings, if not too purulent, or if .so, sink to the bottom to form disk-shaped, coinlike masses, which, however, do not coalesce. While nummular sputum is not pathognomonic, as it can occur in bronchiectasis, it is fair evidence of a cavit}^ in the lungs. In the late stages the sputum is an evenly purulent liquid mass containing no air, and hence sinking to the bottom of the water at once, where it makes a nasty gray-green deposit in which we can find fragments of cheesy matter. In rapidly breaking down lungs the spu- tum contains irregular cheesy fragments, Avhich Bayle likened to grains of boiled rice, and which he considered characteristic of tuberculosis, while the dirty, dark-gray sputum seen in this stage Aufrecht considers always the product of the cavity wall. At first odorless, though of salty taste, it is in the late stages of a marked sweetish, nauseating odor, and sweetish sickly taste. An offen- sive odor is not present in uncomplicated cases of tuberculosis, but it is only found when abscess, gangrene, or bronchiectasis exist. 206 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS The amount of sputum can vary witliin wide limits, but in the average case, until cavity formation, it is quite moderate and by no means so profuse as in chronic bronchitis. While it may amount to a pint or more in twenty-four hours, this is rare, one or two ounces being the average, and three or four ounces being rather unusual. A convenient measure is the commonly used folded paper sputum cup in its tin frame, and patients in the early stages rarely more than cover the bottom of one of these; patients in the second stage are apt to expectorate one third or one half a cup, unless tissue destruction is very active, while old cases will fill one, two, or even three cups in twenty-four hours. An estimate of the amount of sputum in twenty- four hours should always be made, and sudden or gradual increases or decreases should be noted. A sudden decrease usually presages a con- gestion, a marked increase a l)ioncliitis, a gradual increase a breaking down of hitherto only infiltrated areas, while a gradual decrease gen- erally speaks for lessening trouble, decreased ulceration, or the drying up of a cavity, and is of unquestionable prognostic value if it persists. As the patient improves, the sputum tends to become less purulent and more white, foamy, and mucoid, and is apt to cease entirely much sooner than the cough stops. In the case of patients with purulent sputum who take up an out- door life in a climatic resort, there is generally noted at first an increase in quantity but an improvement in quality, the sputum becoming whiter, more mucoid and foamy, and more abundant, and only after this does it decrease in quantity as well. In examining the chests of patients who have abundant sputum, we are often surprised to find few or no signs of moisture, while often patients with many rfdes have little or no sputum, but generally an increase of sputum is accompanied by an increase of signs of moisture in the chest. Ulcerative cases naturally produce much sputum of a purulent char- acter, as do those with bronchiectasis, while acute miliary cases have none, save at times at the very end ; but acute tuberculous pneumonias, while having little at first, and that mucoid, when they begin to soften and when the necrotic area is being thrown off, have an abundant spu- tum, which, if any gangrene be present, may be very offensive. In these cases the appearance of abimdant sputum is usually a good sign, as only by a throwing off of the dead tissue can the patient possibly advance to a cure. Fibroid cases are characterized by a scanty sputum throughout, and that mostly mucoid, or at most mucopurulent. In improving cases the bacilli disappear from the sputum in al)out fifty per cent, but not infrequently they will be found in every specimen until no more sputum is raised. JSTaturally those cases in which the sputum loses SUBJECTIVE SYMPTOMS 207 its bacilli before it disappears may be regarded more favorably than the latter. As to the time of day when expectoration is commonest, this, in early cases, is chiefly in the morning on rising, and during the day little or nothing will be brought up; but when the case is once well developed some sputum is brought up off and on all day, especially after eating, while in old cases most of the sputum is raised during the night, a whole cup often being filled in that time. In cases near the end no sputum may be raised, it being retained in the lung owing to extreme weakness, but if a patient is in a moderately advanced condi- tion and is raising no sputum one should carefully investigate as to whether the sputum is not being swallowed. When for any reason sputum is retained and not expectorated, it is usually soon followed by rise of temperature, which falls again when evacuation takes place. Inspection of the sputum is of little value except to discover the nummular masses, sago bodies, and necrotic particles. At times one will find calcareous masses, expectorated often with severe pain. These masses originate in calcified bronchial glands or calcified, foci in the apex, and since calcification is one of nature's conservative processes, they are generally considered to be of good omen. Tonsillar plugs may be found, and can be recognized by their fetid odor and by leaving a greasy mark when warmed on paper. Small specks of blood in the sputum or a pink tinging generally foreshadow a hemorrhage, but both may continue for weeks without any such results. Fibrin and blood- casts are seen occasionally, chiefly after hemorrhages. Microscopic Examination. — While many morphologic elements can be found in the sputum by the microscope, only two are characteristic — tubercle bacilli and elastic fibers. Eosinophile cells were at one time considered by Teichmiiller as a sign of resisting power on the part of the patient, but such a claim has been disproved by Turban and others. Polynuclear and mononuclear levicocytes are abundant, Lowen- stein saying that tuberculous sputum consists principally of pus cells. J. W. A. Wolff asserts that polynuclear leucocytes speak for more re- sisting power in the patient and mononuclear leucocytes for less, but Lowenstein denies this. In this connection, it will be remembered that Arneth considers the presence of polvTiuclear leucocytes in the blood evidence of greater strength than when mononuclears are found. Epithelial cells from the mouth and respiratory tract, alveolar epi- thelium, partly normal and partly in a state of fatty degeneration, leucocytes with pigment and myelin, which Buhl considered pathog- nomonic, will all be found. In city dwellers, or in those exposed to much smoke, pigment is abundant, and can even make the sputum 208 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS black, while after hemorrhage brown pigment will 1)0 found for some time. The sputum of patients moving from the center to the outskirts of a town will promptly lose in pigment content. Before the discovery of the tubercle bacillus clastic fibers were more commonly sought for than at present, and it is to be regretted that their presence is now so rarely determined, as they speak unfailingly for lung-tissue destruction, and, if gangrene or abscess can ])e excluded, for tuberculosis, especially if pus cells are found Avith them. Soko- lowski's work in this line in 1877 is suggestive. Of 70 cases, 19 with marked physical signs of destruction of tissue showed elastic fiber in the sputum, in 18 on the first or after repeated examinations. Of 11 cases with symptoms of destruction, but good general condition and no fever, all showed fibers. In the remaining 40, with symptoms of more or less condensation, the fibers were found in the majority. In 24 patients with only slight symptoms they were found in 8. Of the 70 patients they were present in 75 per cent. Aufrecht ('05) quotes Dettweiler and Setzer, who, in 42 cases where careful examination showed only infiltration, found fibers in 34, and in 46 with suspicion of excavation found them in 43, and in 22 with positive signs of cavity found them 22 times, or in 90 per cent of all cases. While the writer has not found elastic fibers in anything like so large a percentage of cases, it was doubtless due to lack of care and interest, and to giving greater attention to the presence of bacilli. It is important that the profession be impressed with their real diagnostic value in the sputum. They appear, to quote Fowler ('98), as single or multiple, curled, branching, elastic fibers, forming a net- work, usually with traces of alveolar arrangement, and with a pecul- iarly sharp outline, typical of such fibers. Fox ('91) Avarns against mistaking vegetable fibers for elastic fibers, and says that a conclusion as to their presence could not be drawn unless there is a well-marked group of fibers, having AvcU-defined outlines and the peculiar curves which are their chief characteristics. Osier recommends the simple method of Andrew Clark, of pressing the sputum between two glass plates when the elastic tissue shows as gray-yellow spots, which can be picked out and examined. Sokolowski recommends Fenwick's method; 2 c.c. of water and of sodium hydrate are added to an equal amount of sputum and boiled for three or four minutes. This destroys everything except the fibers, which can then easily be gathered and examined. Other methods are mentioned in detail by Czaplewski ('91). Elastic fibers at times are covered with a peculiar substance soluble in alkalies; they are then fairly thick, forked threads with an uneven granular surface, and are called coral fibers. SrBJECTI\'E SYMPTOMS 209 The tnhenle hacillus is, of courpc, the only ahsolutely diagnostic sign of the disease, but nnfortimately, Avhile a positive sign, its pres- ence being absolute proof, its absence after repeated examinations does not exclude tuberculosis. Even if all the sputum were collected, prop- erly treated, centrifuged, and then examined, and this was kept up for a long period of time, it would be impossible to deny the possible tuber- culous nature of the trouble. At the same time, while the discovery of the bacillus is necessary for absolute certainty, the physician has at his disposal many methods of physical diagnosis, and he who would wait to make his diagnosis and institute treatment until he found the organisms, would rob his patient of precious time and often throw away his only chance of cure. In cases where the sputum examination is negative and in which certainty is important, it should be repeated at very frequent intervals and with every precaution, and generally such perseverance will be rewarded. The numljer of bacilli in the sputum was at one time supposed to have great prognostic value, and Gaffky made a scale of numbers corre- sponding to the number of bacilli in the preparation, which is still much used : I, — One to four bacilli in whole preparation. II. — One bacillus on average in many fields. III. — One bacillus on average in each field. IV. — Two to three bacilli on average in each field. Y. — Four to six bacilli on average in each field. VI. — Seven to twelve bacilli on average in each field. VII. — Fairly numerous on average in each field. (Brown would here put twelve to twenty-five in each field.) VIII. — Numerous on average in many fields. (Brown would put about fifty in many fields.) IX. — Very numerous on average in many fields. (Brown would put one hundred or more.) X. — Enormous numbers. However, the substitution of mere figures for a definite statement of the numbers of germs does not tend to clearness, and it would be better while using the standard given to note the exact numbers and not simply the figures. Browm's modifications seem to be a distinct im- provement, but Gaffky makes too many classes between IV and VII, 2-5 and 5-10 and 10-25 being better. While it is useful thus to record the number of germs for future reference, the conclusions to be drawn from their number are but slight, bad cases frequently showing few germs and acute cases none at all, while at times in mild cases they may be found in large numbers. As 210 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS a general rule, however, rapidly and continually increasing numbers of bacilli in the sputum speak for rapid breaking down of the tissue, and this is, therefore, a bad sign, while a gradual and continuous decrease generally goes with an improving case. Moderate and temporary fluc- tuations are of no value at all. If, in sputum which generally shows few bacilli, there is a small caseous mass, the preparation may be a pure culture of the germ, whereas all the succeeding specimens will show few bacilli or none. Although they may be absent, bacilli are found in the sputum of the majority of patients. Lawrason Brown ('03) found them in 36 per cent of 76 incipient cases, in 73 per cent of 164 moderately ad- vanced cases, and in 94 per cent of far-advanced cases. Turban found them in 38.4 per cent of his first-stage cases, 89.8 per cent of his second- stage cases, and 98.8 per cent of his third-stage cases. No patient can be pronounced cured in whose sputum bacilli can be found, as they are the infallible evidence of an open lesion, though in a few cases patients who are clinically well will expectorate bacilli for long periods. The tinctorial qualities of the bacillus have been supposed to give us some idea of the activity and virulence of the germ (short, darkly staining germs being supposed to come from very active cases; long, thin, beaded, faintly staining ones, the so-called degeneration forms, showing weakness), but after a good many years of sputum work I have not been able to verify such a supposition further than that severe acute cases do seem to show larger numbers of short, darkly stained bacilli and no degeneration forms. Degeneration forms, however, have no significance, as they are found in the sputum of all sorts of cases. Position of Bacilli. — The germs are usually scattered through the fields between the cells, and where they are scanty they are more apt to be found in the streaks of mucus produced by the spreading. They occur either singly or in pairs or bundles, and when multiple show a marked tendency to lie parallel or at an acute angle to each other. At times they are found inside the leucocytes, as though phagocytosis were taking place, and in the writer's opinion this is found chiefly in severe cases, but the work of Lowenstein ('06) and Allen, of Saranac ('07), who kept careful records in many cases, does not support such a view. Lowenstein found phagocytosis in about eleven per cent of his cases, Allen in eighty-two per cent of his, the former agreeing much more nearly with the wTiter's experience than the latter. Lowenstein found them generally in the leucocytes with one, two, or three nuclei, which he considers the younger cells, and foiind tliem rarely in cells with four or five nuclei. He considers them commonest in very chronic cases, and in new cases tending to healing, and believes they precede a disap- SUBJECTIVE SYMPTOMS 211 pearance of the I)acilli from the sputum. Allen, on the other hand, considers them of little value in prognosis. The appearance of the sputum gives no hint as to the presence or absence of bacilli. At times a mucoid, almost salivary sputum will show numerous germs, while very commonly a profuse purulent sputum v/ill show none. Aside from tubercle bacilli one may find many other forms of bacteria, of which the pneumococcus, the streptococcus, the staphylococcus, and the influenza bacillus are the most prominent. The latter is found in the sputum in pure culture, in many cases simulating tuberculosis, Dr. F. T. Lord, of Boston ('05), having reported a num- ber of interesting cases simulating tuberculosis which were apparently dependent purely on a chronic grip infection, the influenza bacillus being found in the pure culture for long periods. The pneumococcus in isolated instances is very common in sputum, l)ut at times, in cases which have begun with pneumonia, it will be found in large numbers for a long time. A few streptococci or staphylococci are not at all uncommon, but in some cases the streptococcus will be found in such large numbers and so persistently, even when the sputum is properly collected and washed, as to suggest a diagnosis of mixed infection. That such a mixed infection exists or can be proved from the per- sistent and abundant presence of the germ in the sputum, has been both vigorously asserted and denied. The writer believes that the process in the lung is materially affected and aggravated by the coexistence of the streptococcus with the tubercle bacillus in the areas of ulceration, and that it is responsible for many of the symptoms in the third stage. Although a mixed infection can exist and affect the course of the case, too many physicians make a diagnosis of mixed infection after finding a moderate number of streptococci in the sputum. Such an opinion should not be formed unless the germ is found in large quantities and persistently in sputum which is properly collected and handled, coming from patients with clinical evidence of pyogenic infection. The dif- ficulties created in the urine by the smegma bacillus do not arise in the sputum, but the technic of staining the bacillus, while simple enough, demands the greatest neatness and precision in the work (see Diagnosis) if the results are to be reliable. While anybody can find bacilli in sputum when they are abundant, it requires great skill and experience and the most precise staining methods if they are to be found in the cases where their discovery is the most important — i. e., those cases where the germ is extremely scanty. In clinical work the chemistry of the sputum need not be dwelt upon, except that its organic part consists of glycogen, sugar, and albumi- noid bodies derived from the white cells, especially paraglobulin, lecithin, and peptones, and that it also contains phosphates and chlorids, whose 212 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS loss through the urine in this disease has been elsewhere noted (see Urinary Symptoms). Renk has demonstrated a nitrogenous loss of 0.6 gm., which equals 4.13 gni. of albumin, or 5 per cent of the total nitrogen consumption of the consumptive. This albuminous loss, which Wanner found to be only slight in bronchitic sputum, but marked in that of tuberculosis, combined with a loss of phosphorus and the ehlo- rids, is a severe drain on the system in old cases with abundant secreting cavities, and hastens denutrition and exhaustion. The reaction of the sputum is usually alkaline, unless bacterial action in the cavity has produced an acid reaction, and as the differential stain fails in acid sputum, cases where a sputum examination is negative should suggest a test of its reaction, and its correction, if acid. Hemorrhage. — So alarming a symptom as pulmonary hemorrhage compels attention, and from the days of Hippocrates has occupied a prominent place among the symptoms of this disease. The father of medicine, noticing the development of phthisis after a hemorrhage oc- curring in apparently healthy subjects, very natiirally concluded, with the methods of investigation at his disposal, that phthisis was the result of the hemorrhage, and spoke of phthisis ah hcemaptoe, and the power of authority in medicine and the slow development of medical knowl- edge is well shown when we recall that this view, promulgated be- fore the time of Christ, was generally accepted well into the last century, and although Laennec and Louis, of France, in the first half of the nineteentli century recognized and taught the error of this, it had so distinguished a defender as the great Niemeyer as late as 1870. While there are various conditions which can produce a discharge of blood from the mouth, and thus simulate a pulmonary hemorrhage, as, for exaiuple, heart disease, carcinoma, hemophilia, arteriosclerosis, vicarious menstruation, hysteria, aneurysm, bleeding gums, nasal, pha- ryngeal, laryngeal, or gastric lesions, the great majority of all hemor- rhages are dependent on tuberculosis of the lungs. In this connection the well-known statistics of Sticker as to hemorrhage in the ranks of the German army are very instructive. Of 480 cases of hemor- rhages, either without known cause or following " colds," 221 were tuberculous, 196 probably so (86.6 per cent). Of 379 cases of hemor- rhage resulting from overexertion in military maneuvers, g^'mnastics, singing, blowing wind instruments, trauma, and the like, 282, or 74.4 per cent, were tuberculous. So marked is the causal relation that See ('84) says, " aside from infectious diseases, hemophilia, and acute in- fections of the lungs (pneumonia, abscess, gangrene) ... we only know of two real causes of hemoptysis — heart disease and pulmonary tuberculosis," and with the advance of modern diagnostic and clinical SUBJECTIVE SYMPTOMS 213 methods it is dail}^ more evident that in a case of pulmonary hemorrhage the evidence must be very strong to support any other diagnosis than that of tuberculosis. The pathologic conditions antecedent to hemorrhages var}^ in early and late cases. In early cases several hypotheses have been advanced to exphrin bleedings occurring before there is destruction of tissue. A localized hyperemia of the pulmonary tissue has been suspected, and Flint ('75) cites a most suggestive case and autopsy which seems to jus- tify this as a probable cause, and Anders ('07) considers tliat the influ- ence exerted by violent or long physical exercise in the production of hemoptysis justifies this view. However, it is prol)al)le that the more ordinary cause is the weakening or erosion of small blood-vessels l)y the growth into them of tubercles, or, as is well put by See: "We must recall that the branches of the pulmonary artery are terminal branches ... if the caliber of one of these arteries is lessened as a result, for example, of a perivascular tubercle, and protrudes into the lumen, the blood-pressure is raised at the narrow part, and a rupture follows." The hemorrhage can only cease by the occlusion of the bleeding vessel by a thrombus filling the cavity, and until this is firm the hemor- rhage will continue, hence the great need of absolute rest and quiet to favor the occlusion of the l)leeding point. Early lieniorrhages are always venous, and therefore, since pulmo- nary venous blood is aerated, are bright red. In later stages hemorrhages arise from the vessels of the lung, usually a pulmonary artery, chiefly in cavities, and the blood is dark. The connective tissue of the advantitia being more resistant to the eroding effects of the destructive process, the blood-vessels, generally of moderate size, are dissected out and stand out in the walls of the cavity or cross it. On these unsupported vessels small saccular or fusiform aneurysms form, and, generally as a result of raised blood-pressure, burst, giving rise to the large and fatal hemor- rhages of late phthisis. This method of hemorrhage production being open to demonstration by autopsy is the best established of all, but in some old cavity cases it seems probable that hemorrhage can result from the oozing of the granulations which line the walls. The relation of overexertion to the occurrence of pulmonary hemorrhage justifies the belief that a large number of cases of hemorrhage are brought about by an undue rise in I)lood-pressure, and every physician can remember many cases which followed the lifting of weights, straining at stool, running upstairs, etc., but, although the condition of patients just after a hemorrhage makes it difficult to study their blood-pressure carefully at such times, a large percentage of cases will show a low-tension pulse before as well as after the hemorrhage, and Otis ('07), in 18 cases at 214 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS the Rutland Sanatorium, found the pressure normal or below normal in all but one. The frequency of hemorrhage in tuberculosis has been variously estimated between 30 per cent and 80 per cent; De Renzi ('94) gives it as one third to two thirds, Fox ('91) as 5-t per cent, Aufrecht ('05) as 26.4 per cent, Williams ('87) as 57 per cent, Walsh ('71) as 81 per cent, these various estimates depending probably on the class of patients studied by the different authors. From 40 to 60 per cent would be a fair estimate. The immediate cause of hemorrhage in early cases is not always determinable; often a man in apparently perfect health and at rest will suddenly bring up a mouthful of bright, foamy blood without warning of any sort. More commonly, however, the cause is overexertion, such as athletics, lifting weights, running upstairs, strain- ing at stool, blows on the chest, unduly hard percussion, or, in short, anything which raises blood-pressure or produces trauma. Excitement, worry, or temper can act in the same way, and the sight of one patient bleeding will not infrecpiently start a hemorrhage in another patient. Barometric or other metcorologic conditions have an undeniable etfect in producing hemorrhages, though it does not seem that this has been sufticiently dwelt on by A\Titers on the subject. It is certain that everyone who has handled numerous cases of tuberculosis has often been struck with the occurrence of several cases of hemorrhage within a day or so, and ascril)able apparently only to weather conditions. While the writer has not made a close study of meteorology, he has noticed that close, damp, hot spells with a low barometer seem to be the time when many cases of hemorrhages are apt to occur, and that this bunching is nnich less common in winter. Thus, in the practice of Dr. W. L. Dunn, in the summer of 1907, sixteen hemorrhages occurred among his patients in one week. While it is impossible at present to prove such a causal relation, it is certain that the majority of clinicians have noted such an effect of weather conditions. The premenstrual period, during which there is a systemic plethora, has a distinct effect in producing hemorrhage, and female patients of a hemorrhagic tendency come to dread this time. In patients who have ceased to menstruate, any undue susceptibility to hemorrhage has not been noted, but instances of vicarious hemorrhage as a substitute for a missed menstrual period or cured bleeding hemorrhoids are on record. In patients whose appetite is very large, and in whom a condition of plethora is created by hypernutrition and rest, not at all a rare thing in sanatoria, it has seemed that hemorrhage is more common than in others less fully nourished ; those patients who have fattened and become ruddy rapidly under outdoor treatment quite frequently show some bleeding. SUBJECTIVE SYMPTOMS 215 If sex has an}- influence on hemorrhage, as Louis taught, it is not very great, although there is a slight preponderance of hemorrhages in women. Anders (07), in 589 cases, found that liability to hemorrhage appeared at an earlier period in women than in men. There does not seem to be any special time of the day which favors the occurrence of hemorrhage, though the disturljance of the doctor's sleep by night hemorrhages is apt to cause him to think them more common in the night time. The season of the year has a distinct influence. In the writer's experience the spring months show a preponderance of hemorrhages, and as this is the time when a tuberculous patient is best nourished, it may possibly be explainable on the grounds of plethora. Thompson ('T9) considers tliem commonest in the summer heat, and Anders ('07) found them most common in the spring and summer nuiuths, and ascribed them to the enervating effects of heat and the influence of marked oscillations of heat and humidity during the spring months, but Gabrilowitsch ('99), in Finland, found hemorrhages most frequent in March and October, and none occurring between April and July. Hereditij, according to Fox ('91), ])lays some part, those of his patients who had a marked family history of tuberculosis showing a greater tendency to hemorrhage. Age has a marked influence, hemorrhages being extremely rare in infancy and uncommon in childhood, and increasing in frequency witli puberty, most common between twenty and twenty-five, and after forty- five becoming less common. They are rare in old age. Of Aufrecht's cases ('05), forty per cent were between twenty and twenty-five, and 83 of Anders's 197 cases were between twenty and thirty, and 6'2 between thirty and forty ('07). The stage of the trouble bears some relation to the frequency of hemorrhage. It may be an initial symptom, nine per cent of Reiche's cases being of this sort; in abortive cases it is often the only symp- tom. While it may occur at any time during the course of the disease, the writer has found hemorrhage most common in relatively advanced cases, and Fox ('91) agrees wath this view, but quotes the first Brompton report, in which seventy-two per cent of the hemorrhages occurred before softening, and Williams also believes that the first hem- orrhage is aj)! to occur early in the trouble. Thompson ('79) con- siders bleeding most frequent in the second stage, with ulceration, 437 out of 1,000 of his cases occurring at this time. Possibly, however, careful inquiry into the past history of the patient might reveal pre- vious slight hemorrhages in many cases seen first in a more advanced state. Fatigue is a common cause, ])ossibly because fatigue generally implies 216 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS overexertion and raised blood-pressure; certainly hemorrhages seem to be very common during or just after long railway journeys. Clinical Picture. — Quite frequently a hemorrhage is preceded by no warning symptom; the patient suddenly feels something in his throat, spits it up, and is horrified to find that it is blood. More generally, however, there is a pricking in tlie throat, a short cough, a salty taste in the mouth, a sense of weight and oppression or tightness in the chest, while not infrequentlv there will be a sore spot in the lung for a few days preceding a hemorrhage, or a feeling of tightness, pain, and oppres- sion, and many patients can predict a hemorrhage which the doctor is far from anticipating, so that physicians should never neglect any such " feelings " on the part of tlieir patients. A premonitory streaking of the sputum with traces of blood will, in moderately advanced cases, often precede the bleeding for some days, and gives us useful warning, for blistering over the site of congestion will unquestionably have good effect in some of these eases. The amount of blood lost may vary from a slight streaking of the sputum, or a faint, pinkish staining to any degree of mixed sputum and blood, up to mouthfuls of pure blood ; but a hemorrhage does not generally exceed one half to one pint, though in old cavity cases enough blood may come up to kill the patient at once by syncope. A correct estimate of the quantity is difficult, if not impossible, the patient and his friends generally being terrified, the blood often being received into water in a basin or slop jar, and increased in bulk by frotliiness and greatly magnified by alarm. However, while a single hemorrhage is rarely as large as a patient supposes, the repetitions can bring the amount lost in twenty-four hours up to a quart or more, and it is surprising what large amounts patients can continue to lose, day after day, without succumbing. Smirnow recently ('07) reported a case in which ninety-seven ounces, by careful m.easurement, were lost in three days, the patient recovering. The majority of hemorrhages are probably less than one ounce, the figure given by West ('02). The color of the blood in early cases is bright red, and is at this time generally combined witli air, so as to be foam)^ and is mixed with much saliva and sputum. In advanced cases it can come up in gurgling gulps, and is darker, since it comes from the arteries, and by clotting in the larger bronchi often produces severe dyspnea. If the hemorrhage lasts for some days the later blood is clotted and dark, but should not easily be mistaken for stomach blood. By degrees the blood clots lessen, sputum begins to reappear, although at first badly blood-stained. Grad- ually, however, it resumes its normal color, and in a few days, if the hemorrhage does not repeat itself, no more traces can be found. When pneumonia sjipervenes, there occurs, generally on the third or fourth SUBJECTIVE SYMPTOMS 217 day, a sudden extreme rise of temperature, which continues without remission until it clears up, but if dissemination follows the pneumonia, the temperature persists. T?ie temperature. gives no warning of impend- ing hemorrhage, but, except in very slight cases, rises moderately within a few hours after its occurrence. If the loss of blood is very large, there will occasionally be a drop of temperature, but within the first twelve to twenty-fours hours there will always be a rise, which, if no compli- cations develop, gradually disapi)ears. The physical signs of hemorrhage are very unsatisfactory. The most careful auscultation may fail to show the site of the bleeding, and in early hemorrhages the most thorough examination will often fail to show any signs of pulmonary trouble, so that the absence of demonstrable lesions should never lead one to declare that a hemorrhage did not come from the lungs. If the process is already known to exist in the lung, it may even then be impossible to find any signs of effused blood, though generally one will find large or medium moist rales in the sternoclavicular angle, or second or third interspace, on the affected side, gradiially diminish- ing downward and not infrequently discoverable at the base as well. This, however, does not justify a statement that the blood originated at the point where the rales are heard, as the fluidity of the blood allows it to travel rapidly, so that not infrequently one can get moisture on the sound side; but unless the hemorrhage be followed by rapid dis- semination, the moisture disappears in two or three days. In hemorrhages of any considerable size the information to be gained by physical examination is too slight to justify one in favoring a recur- rence of bleeding by the necessary manipulations of a physical examina- tion. Percussion should in no case be made, and except for a light aus- cultation of the easily accessible anterior thorax the lungs should not be examined until the sputum begins to clear up. Hemorrhages may be single and never recur, and every physician at times gets histories of such cases. These are the " abortive cases," which, until recent years, have been overlooked, but where autopsies long afterwards show old healed tuberculous foci. A gentleman, now nearly sixty years of age, while a slender boy of sixteen was rather run down and below par, and had a slight hemorrhage, for which he was sent to the country for a year, and has ever since lived in a large city in perfect health. If, however, a close study were made of many of these patients in their after life, a number would show the development of tuberculosis at a later date. Such a. case is reported Ijy See ('84). An Italian gentleman, who had a hemorrhage at twenty-one, was per- fectly well until forty-four, wlien he developed a cough and showed signs of apical tuberculosis. Unfortunately, many of these patients do 218 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS not consult a doctor, or if they do tliey are too often assured, after a superficial examination, that the bleeding was of no importance, and go away with a dangerous sense of security. Such patients may either be in perfect health at the time or be somewhat " run down and below par," with possibly a slight cough. In any case, all such should be considered tentatively tuberculous, and every diagnostic measure be used to reach certainty, and if a diagnosis cannot be made, the after course of the patient should be followed with care. Tliere is another class of patients in which but one hemorrhage occurs, where one large hemorrhage is followed by the development of an acute bronchopneumonic phthisis from a general dissemination of bacilli through the lung by the blood, which at times shows the germ abundantly. Such are the cases developing unexpectedly in unusually athletic young men, in tlie midst of perfect health, and usually going on to a rapidly fatal ending. The large majority of tuberculous hemor- rhages, however, are sure to recur at some more or less remote time, though if one could get statistics of all the cases referred to above in which there was one hemorrhage, the trouble then aborting, this majority would doubtless be greatly reduced. After a hemorrhage begins most patients will have several l)lood- spittings during the next few da3's, and in not too incipient cases the blood-spitting may occur several times a day for as much as six weeks, and yet be followed by improvement, and it is surprising to see what large amounts of blood a patient can lose without suffering more than a slight anemia, and with final recovery. The nervous system, even in the most phlegmatic, undergoes a great shock at the first one or two hemorrhages, but familiarity breeds con- tempt, and after a few recurrences a patient looks upon a hemorrhage with remarkable coolness. Recurrences may be either at long intervals, generally accompanied by a relatively favorable condition in the interim, or there may be a rapidly repeating series of hemorrhages producing an acute dissemina- tion, hastening a fatal termination, or producing a severe and fatal anemia. Such patients continue to bleed, with short intermissions of a day or so, for two months, gradually losing strength, becoming anemic, and wasting till life is ended. In these cases it is impossible to decide, if there are no great signs of spread of the trouble, whether the patient can finally check the bleeding and recover or not, and the doctor and family are kept alternately between hope and despair for weeks. Where large cavities do not exist, frequently recurring hemorrhages speak for a rapidly disseminating process in the lungs, with the forma- tion of tubercle and destruction of tissue. In old cavity cases there may be long periods in which the patient brings up gray cavity sputum, SUBJECTIVE SYMPTOMS 219 evenly stained pink, owing to the oozing of blood from the granulations lining the cavity, and such pink sputum often precedes a hemorrhage. The results of hemorrhage are much less severe than the alarming nature of the symptoms would lead one to expect. In early cases the immediate results are generally negative, the patient feeling no change of any sort in his condition, barring the nervous shock. In rather more advanced cases the patient, relieved of a sense of tiglitness and oppres- sion in his chest, the pain removed, and his trying dry cough changed to an easy, loose one, feels in ewry way much better, and not a few such cases are not only thus subjectively improved, but date their recov- ery from the beginning of the hemorrhage. Whether this is due to a germicidal or antitoxic effect of the blood senmi which floods the lung, or not, is unknown, but apparently the local action of the blood on the lung can be favorable, unless it serves to spread bacteria through its tissues.. At one time it was held by Niemeyer that the blood, by its presence in the lungs, produced an inflammation harmful in itself, and precedent to tuberculosis, but experiments (See) have shown that pure blood, free from germs, can be injected into the lung and absorbed there Avithout any inflammatory effects. Flint ('75) noted more recoveries in his hemorrhagic cases than in those not having hemorrhages, and believed that in tlie majority of cases their effect was good. This can, in some degree, be ascribed to the fact that so alarming a symptom is apt to make even the most heedless patient careful and obedient so that better results can be gotten from his case. In very advanced cavity cases, liowever, the effects of hemorrhage are generally disastrous, even where tlie bleeding is not sufficient to kill at once, which is the end in a certain number of cases. Cornet ('07) quotes Brehmer, Wolff, and Strieker, who found 0.15 per cent of such sudden deaths in pulmonary hemorrhage. A typical instance was that of a middle-aged lady, who had advanced and incurable plithisis, with a large excavation in the left lung, and who Avintered in Asheville for several years with great comfort, though without any prospect of cure. AVithout having had premonitory symp- toms of any kind, she awoke one morning at the usual hour, sat up in bed, and began to speak to her sister across the room, when suddenly a flood of blood burst from her mouth and she fell back dead, doubtless from cerebral anemia and syncope. Such an end is painless and instan- taneous; but, on the otlier hand, death by suffocation from a large hem- orrhage is very painful ; the air hunger, the gurgling blood in the throat, the spasmodic efforts at breathing, and blood over everything, making a terrible and never-to-l)c-forgotten picture, which, fortunately, is not common. At times only a little blood appears at the lips, most of it being retained in the cavity and the l)ronchi. The result, however, is 220 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS equally fatal. While sudden death of this type is rare, the more remote dangers, exsanguination, exhaustion, and pneumonia, with or without acute softening and dissemination of the process, are more common. The following case is a good example of pneumonia, with rapid dissemination : A gentleman of middle age, with a very small cavity, nearly dry and shrinking, who apparently was going on toward a satisfactory arrest of his trouhle, and who had almost no symptoms of any sort, hegan to show slight hlood streakings in his sputum, which rapidly increased to copious discharges, continuing for several days, and due i)rohahly to the erosion of a small miliary aneurysm. Suddenly the temperature went up, pneumonia developed, followed by rapid acute softening, and the man was dead in ton days. In all hemorrhagic cases a sudden, undue rise of temperature on the second or third day should excite suspicion of pneumonia. If pneu- monia develops, the temperature will continue high, pains in the side, though not always present, will generally develop, and physical signs appear. Such a pneumonia may be either a broncliopneumonia or a lobar pneumonia due to the pneumococcus which is present in the lungs, and which is probably stimulated to grow by the blood serum thrown out, and from these the patient often recovers very well; or it may be an acute tuberculous pneumonia, due to the l)acillus, which has a uni- formly fatal termination. Again, the fatal result may be due to exhaus- tion and to exsanguination. Such a case was that of a young man recently brought from Colorado Springs to Asheville on account of fre- quently recurring hemorrhages. He at first seemed to improve a little, but after a few weeks the hemorrhages began to recur again, and he would have a nund^er of small or moderate-sized ones during several days, with free intervals of several days between. No marked dissem- ination occurj'ed, but although he lost no very large quantity of blood at any one time, the steady drain on his blood-making organs and on his vitality was too great ; he grew paler and paler, and more and more exhausted, and finally died from these causes alone. Quite a frequent result of hemorrhage is a moderate degree of dis- semination of trouble into hitherto healthy surrounding areas, and it is, therefore, necessary to make a most careful examination when the patient has recovered from the bleeding to see if any such dissemination has occurred. The diagnosis in most cases is easy, but at times is accompanied by considerable difficulty. It is too commonly the habit of the profession to say that a slight hemorrhage came from the nose or the throat in order to quiet anxiety, a practice that cannot be condemned too emphatically. Even the most nervous patient can tactfully be made to realize to what SUBJECTIVE SYMPTOMS 221 the hemorrhage is due without heing unduly ahirmed ; and even were it impossible not to alarm the patient, it would be much more desirable to do so than to keep him in ignorance of the truth, when that igno- rance so often means loss of the best chance of recovery. In certain j)atients the possibility of hysterical blood-spitting must be kept in mind, and one should be certain that the patient is not pro- ducing blood in order to create sympathy. A few people can uncon- sciously, in their sleep, suck their gums, and if these are unhealthy they can Avake up to find bloody saliva in their mouths, but here, again, care- ful examination should remove any difficulty. In doubtful cases, the nose, mouth, throat, and larynx sbould be examined carefully under the most favorable conditions to exclude possible broken blood-vessels in these regions; the heart should be gone over carefully to exclude mitral stenosis or any other cardiac conditions antecedent to hemor- rhage. Babeock would distinguish blood coming from above the glottis by tbe fact tliat it is not accompanied by cough, while he believes that pulmonary hemorrhage invariably is accomjjanied by cough. If there is any dou])t as to a possible hematemesis, tbe expectorated blood should be examined ocularly and microscopically and as to its reaction, especially as quite often after hemorrhage patients will vomit blood which came from tbe lungs and was swallowed. But hematemesis can at times present insuperable difficulties of diagnosis, so keen an observer as Graves having said : " You are told gravely that you can distinguish blood discharged from the stomach from that which is discharged from the lungs by the differences of its color and con- sistence, and the presence or absence of air buljbles. No, gentlemen, you cannot." In some cases it is possible to get a previous history of tender spots in the stomach, hyperchlorhydi'ia, d3'^spepsia, etc., but where blood comes from a gastric varix, or from an aneurysm of the ])ulmonarv arterv, a diagnosis is impossil)le. Theoreticallv, stomach blood sliould be unmixed with air, and acid in reaction, if not too aljundant; one should also be able to find food remains, and it should be followed by tarry stools, etc., but such distinctions, while very easy to note, are by no means alwaAS as easy to discover clinically. The brightness of color of the blood is of no assistance, blood from the lungs, if from a ])ulnionary vein or bronchial artery, being bright red instead of dai'k. Hemorrhage due to heart disease should not give trouble to anyone habiiuated to carefully going over every detail of his case, ])ut not infre- (luently a diagnosis of tubei'culosis of the lungs is made when mitral stenosis alone exists. Hemorrhage from a nontul)erculous lung — a vicarious menstruation — is on record. The writer has never seen such a case, nor a pui'ely 222 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS hysterical liemorrliage, although several authentic cases are on record. It must present great difficulties of diagnosis. However, it cannot too often be insisted on that while one should not jump to the conclusion that every hemorrhage is an evidence of pulmonary tuberculosis, he should be very slow to make a diagnosis of nontuberculous hemor- rhage, and should use every possible means at his disposal before accepting it. Pain. — Pain, while not a very valuable symptom in plithisis, is often a very early one. De Eenzi ('94) claims that it is present in two thirds of all early cases, and Peter considered it a valuable early diagnostic sign. The writer does not consider it a sign of great value, nor has he found it present in so large a percentage of cases, but it is fairly fre- quent, and combined with other findings can at times be an aid in diagnosis. As a rule, the pain is not very intense, but it is fairly con- stant, is a])t to be increased by cougliing, and later in the disease gen- erally disap]jears. It is usually a dull aching or boring pain, most common in the supi'aclavicular fossa or in the supraspinous fossa, in which last location it often is manifested as a burning spot, which is probably due to an apical pleurisy with adhesions forming. At times quite a sharp neuralgic ])ain will be felt in the point of the shoulder, in front, with each cough or with much motion of the arm. When in the shoulder the pain is often mistaken for rheumatism, and patients have been known to visit a well-known hydropathic institution to be treated for some time on a diagnosis of rheumatism, the real trouble not being discovered until the patient left tlie institution. This early apical jjain can be relieved by the application of small fly blisters. It may precede for months the appearance of a demonstrable lesion. The writer has known one of the best diagnosticians of this trouble in the country to be unable, on the most thorough examination, to find any trouble at the site of such a pain, although considerably later a lesion appeared there. Therefore, even in the absence of physical signs, such pain, if persistent, can be regarded as very suspicious and should cause one to follow the case with care. At this stage pain on pressure or percussion is not common, but a little later, when the process is more pronounced, pain on percussion, especially above the spine of the scapula, and between it and the ver- tebrge, or over the site of congestions or cavities, is very common, and over cavities will generally persist. An infiltrated apex will often pro- duce a general sense of soreness and aching in the upper part of one side of the chest which may be \evy trying. Again, very often active motion will produce severe lancinating pains in the apex, due to trac- tion on apical adhesions, and violent exercise, such as riding a hard trotting horse, may produce very severe paroxysms of such pain. SUBJECTIVE SYMPTOMS 223 As a rule, the pain in the lungs in tuherculosis, even if it persists, is not constant, being present only at intervals, especially when the patient has overexerted himself in some way. A dull aching pain be- tween tlie shoulder blades is common and very fatiguing, but the writer has never seen the severe insistent and intolerable pain in this region, demanding morphin for its relief, referred to by Aufrecht ('05). More common in this stage is a general aching of a large area of the affected lung, with a drawn, tight feeling. The patient is aware that he has a lung, and feels that it is bound down and cannot expand. Localized pleurisies generally manifest themselves by sharp, sticking pains, increased by pressure in the intercostal spaces; but it is strange how seldom in tuberculosis one finds frictions over the site of undoubted pleuritic pains, while very often large areas of plain pleuritic friction with no pain at all are discovered. The distinction of pleuritic pains from intercostal neuralgia is at times difficult, but generally the latter can be demonstrated by follow- ing the intercostal space to the spine, finding tenderness all along, and especially tenderness over the nerve root. Pleurisy of the lower anterior chest will manifest itself at times by referred pain in the abdomen, and thus subdiaphragmatic pain in the tuberculous should call for careful examination of the lower thorax, as Fowler ('98) points out. Xot infrequently patients will complain of pain in the heart region, which is due to pericardial ])leural adhesions. In the later stages of tubercu- losis pain is not so common, except on percussion, and it is apt to be in the lower portions of the lungs, owing to spread of superficial pleu- risy, which is accompanied by pain at the base of the lungs and a feeling of constriction. In advanced cases, with severe coughing, the abdominal muscles and the insertion of the diaphragm may become exceedingly tender, so as to cause the patient a great deal of suffering. Very usually in such cases the sites of cavities are tender on jjressure, and quite frequently, pre- ceding a hemorrhage, patients will complain of a dull ache in these spots. In speaking of the nervous manifestations of tuberculosis, reference has already been made to the gi'eat frequency in neurotic, and more especially Jewish, patients of fleeting thoracic pains, of nervous origin, ap])earing and disappearing irregularly in various parts of the chest, but I have never l)een able to determine any connection between them and any pulmonary change, or that they have any bearing, favorable or unfavorable, on the course of ilie disease. The severest pain in phthisis is that accompanying .iiid rollowiiig the occurrence of a juieumothorax. This can be so severe and agonizing as scarcely to yield to morphin, and lasts for a number of days. 224 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS OBJECTIVE SIGNS Inspection. — Form of Chest. — Tn incipient cases the chest does not usually show any marked changes from the normal, and many, if not a majority, of such patients have a good general huild and a well-shaped chest, the paralytic thorax once considered so typical being found in only a very few incipient cases whose develoj^ment it antedates, though it is common in the advanced stages of the disease. Aufrecht ('05), however, notes that the real paralytic thorax differs from the thorax seen in cases of advanced tiiljerculosis in that in the latter the chest falls in, while in the former it sinks down. The frequency of well-formed chests in early cases will be recognized when it is recalled that Alison ('61), after the examination of 6,000 chests at the Consumption Hospital at Brompton, found " comparatively few dis- torted chests among phthisical patients — not more, in proportion, than are found in persons not suffering from phthisis," and that Brown and Pope ('04 B) found 83 per cent of well-formed chests in 193 incipient cases, while Serailler (Herard, etc., '88, p. 497) in 60 cases of all stages found 28 normal chests, and concluded that " more than one half of all the phthisical have a regularly formed chest." The paralytic thorax, when seen, speaks for a pronounced hereditary taint, and in this stage undoubtedly antedates tuberculosis and is not a result of it. The chest is long, narrow, and apparently flat, the ster- num flat, the clavicles and.scapuhv prominent, the angle narrow, the ribs oblique and their interspaces wide, the skin delicate and semi- transparent, the hair fine and silky and often red blonde (Figs. 36 to 3S). Woods Hutchinson ('03) maintains that the shape of the tuberculous thorax is not always really flat, but often only apparently so, and as a result of his studies he claims that instead of being generally flat, as was formerly thought, it is unusually round, the antero-posterior diameter being about 80 per cent of the transverse instead of 68 per cent, which he considers the normal thoracic index. This he believes to be a persistence of the infantile typo of thorax, and the discovery of an index of 80 or moi-e in a person over eighteen years of age he believes raises a strong suspicion of tuberculosis. Bessensen ('05) accepts these views and considers that phthisical chests show an arrest of the development of the transverse diameter which should follow puberty. Brown and Pope ('04 B), in a careful review of the sub- ject, and as a result of the study of a large series of cases from vari- ous sources come to different conclusions. They found the normal in- OBJECTIVE SIGNS 225 dex to be 73, that in early tu- berculosis 72, and in advanced cases 70, and while they be- lieved that the advance of the disease tends to increase the index, they consider that this needs confirmation. They found that these cases tended to show two types, one with a flat chest, with a low index of 68 to 70, and one, deep and round, with an index of 78 to 80, but both reduced in size. This agrees with the conclu- FiG. 36. Fig. 37. there should be 8 sq. cm. f)f thoracic section for each kilo of body weight. Bezangon also ('06) concludes that the trans- verse diameter is more devel- oped than the antero-postcrior, which is generally lessened, and considers that there are two types — the flattened chest, which he connects with the usual form of chronic tuber- culosis, and the globular, which he considers common- est in tubercvdosis with em- ])hysema. 10 Figs. 36 to 38. — Rapidly De- structive Process of but Six Weeks' Duration, but Resembling an Advanced Chronic Case. Note typical lateral view. Note change of left apical resonant area. Ex- tensive cavities in both lungs. sions of Joifres and Maurel ('05), who consider the index variable, but the perimeter and thoracic section always lessened. According to these authors Fig. 38. 226 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS The writer has for a number of 3'ears taken cyrtometer tracings of the chests of all his patients at the level of the fourth costal cartilage at the sternum in front and of the eighth dorsal spine behind, and while he has not estimated the index of all of these outlines, he, like the authors quoted, has not noted any such preponderance of narrow, deep chests as Hutchinson reports, and, indeed, in the very advanced cases he has found a large number of very fiat, broad chests, with an outline sug- gesting that of a kidney bean, which agrees with tracings given by Kuhn ('99). Since, however, as Brown ('04 A) has shown very slight differences in level make great differences in the index, this question cannot be finally settled until all observers agree on and use the same points in taking their measurements. The writer is certain, as a result of the study of very many tracings, that the unduly flat chest is rare in early tuberculosis, but common in late cases, and that as the disease improves, the thorax, with few exceptions, becomes deeper as well as wider, and that if the patient does badly the opposite tends to occur. As to the relation of the perimeter to the height of the patient, all observers agree that it tends to be less than one half, and that a thorax showing such a decreased perimeter measurement is suspicious. At times one finds patients who present a typical barrel-shaped emphysematous chest, chiefly middle-aged or old men, the emphysema antedating the tuberculosis for years. In these cases the course is usu- ally favoral)le, Init the diagnosis is a])t to be rendered difficult by the emphysema of the lung tissue, the shape of the thorax, and the asth- matic breath sounds so often present in such cases which mask the signs of tuberculosis. While tlie ])resence of tuberculosis in the chest produces in the be- ginning but slight changes in the general form of the thorax, it is responsible for various small alterations which can be found on care- ful inspection and which are of great value in the diagnosis of the disease. The most important of these early changes are alterations, first in tlie outline in the upper border of the chest between the neck and tip of the shoulder, and then in the supraclavicular fossa and clavicle. These depend on a lessened functional activity of the lungs, with the accompanying lessened volume of the organ, and, somewhat later, on retraction of the apex and wasting of the shoulder- girdle muscles. These changes are: first, a slight shoulder droop, the point of the shoulder on the affected side being from half an inch to an inch lower than that on the good side; second, a slight flattening or a very slight hollowing of the supraclavicular fossa; third, a retardation or limitation of the motion of the affected side; and fourth, a slight flattening of the OBJECTIVE SIGNS 227 muscular outline of the shoul- der, owing to a wasting of the trapezius. The shoulder droop is found very early, and is present in a majority of cases, hut in those who, like clerks, have worked much at desks, it can be simulated by the lifting of one shoulder wliich this ])ro- duces and which leads to the belief that the other shoulder is lowered. The acromial end Fig. 40. which in health is usually slightly convex, is flattened or even very slightly hollowed, and the clavicle is usually slightly more prominent on the affected side, and rarely, except in those who have been used to hard manual labor, is there any prominence on the good side such as Brown ('04 A) has noted. The (lal- tening of the supraclavicular fossa at this time is duo solely Fig. 39. Figs. 39 to 41. — Shows Chest Outlines and Limitations of Resonant Area, Right Shoul- der Droop. Prominence of right clavicle and hollowing be- low it. of the clavicle is likewise low- ered, a point on which Auf- recht ('05) lays especial stress, but which has the same signifi- cance as the shoulder droop, and goes hand in hand with it. The supraclavicular fossa. Fig. 41. 228 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS to the slii'inkafi^e of the lung wliieh comes with tlie lessened function produced ])y tiie disease, the lung having heen shown to change in vol- ume quite ra|)idly, with increased or decreased functional activity (Le Grange). 8uch flattening in very early cases is not due to fibrosis or to the shrinkage of pleural adhesions which in later cases if responsible for it. This early flattening or hollowing the writer has again and again found to disappear if the process is arrested and cured, while in advanced cases the greater hollowings wliich occur can be compen- sated for or replaced by an actual convexity, if much emphysema develops. The infraclavicular fossa does not usually show much hol- lowing in the early cases, though sometimes the hollowing will be here and not above the clavicle. Motility of Chest. — Retardation or limitation of motion are very early signs, and cond)ined with shoulder droop and supraclavicular flat- tening justify a strong suspicion of apical involvement. In retardation the lung starts to expand and the shoulder to rise more slowly than the other, it seems to move in jerks, and does not reach its full expan- sion and elevation as soon as the other. In limitation of motion, on the contrary, while not starting later, it never expands fully, and such limitation can vary from a very slight degree in early cases to absolute immol)ility in cases of extensive trouble. Brown ('04 A) finds limitation of motion at the apex often accompanied by exaggerated motion at the base. In looking for changes of motion, one should distinguish between the vertical raising of the chest, which is best seen by watching the shoulders and clavicles or scapulte from in front or behind the patient, and the expansion of the chest, which takes place from behind forward, and is best observed from behind and above the patient, with head bent forward, looking down the front of the two sides of the chest. Some limitation or retardati(m of motion will be noticed in a large majority of all early cases, and when it is not made out by inspection it can often be found by palpation. However, in cases with a healed lesion at one apex and a new ])rocess developing at the other, any of these signs may be more pronounced on the side of the old lesion and thus deceive. Occasionally there is retardation on the apparently unaffected side, but where this condition exists, one should examine very carefully for signs of an old healed lesion and for a history of past trouble on that side. As the process advances, these signs all become more pronounced, the infraclavicular and supraclavicular fossa show marked hollowing, the clavicle stands out like an arch, the shoulder droop becomes very pronounced, the shoulder muscles waste, and respiratory motion becomes more and more limited. The angle of Louis, between the manubrium OBJECTIVE SIGNS 229 and the gladiolus, tends to obliterate, decreasing from a normal of IG degrees to anything between 8 and degrees. As Alison ('Gl) says: " The sternum, instead of presenting a projecting line as it descends, tends to become perpendicular, or it may even incline inward as it passes down." D. Eoths- child ("07) has pointed out that this flattening can at times be hidden by the formation of an exostosis at this point running transversely across the bone and simulating a promi- nent anffle. At times enlarged bronchial glands can cause a buckling forward of the upper sternum at the junction of the body and the manubrium, and in one case, presumably cancer of these glands, the writer has seen this occur very rapidly and jjroduce great deformity. Fig. 42. With a sinking of the ster- num, the angle which tlie ribs make with the vertical line becomes more acute. The af- fected side begins to flatten, at first in its upper third and then more generally, and loses its normal convexity, and this may increase until all of one side of the chest is flat and smaller than tlie other, with inward dislocation of the nip- ple in front and of the angle of the scapula behind. Distortion of the thorax, wliicli is unusual in incipiciit cases, is quite commonly met with in the chronic forms of advanced tuberculosis, but acute cases run their whole course without any change! occurring in the shape of the chest, and in these cases one is frc(]uently struck with the finely shaped chests one sees in people with severe trouble and hopeless outlook. Fig. 43. Figs. 42 and 43. — Prominent Angle of Louis and Funnel Below It. 230 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS The distortions of advanced cases are of two sorts, local and general. Local distortions are either manifestations of alterations in the under- lying lung, such as fd^rosis, pleural adhesions, or cavitation, or of scoli- osis or rachitis. In marked fihrosis the shrinkage can cause numerous variations in the shape of the chest, more commonly manifested as bulg- ings of the ribs at the costochondral junctions, especially of the second and third ribs on the right. An old pleurisy may cause severe contrac- tions which may draw the whole trunk over to the affected side, shorten- ing that side of the chest. Over old superficial cavities in the upper third of the chest, saucerlike depressions are often seen, and since cavities are commonest in the upjier third of the left lung, these hollows are usually seen to the left of the u])})er portion of the sternum. Scoliosis, if looked for carefully, will be found present in slight degree in a considerable number of early cases (Brown found it in 23 of 10,3 cases). It causes, if marked, a bulging of the posterolateral as- pect of the ribs on the side of the convexity. This bulging is especially well demonstrated by the cyrtometer, and if not recognized may confuse the percussion findings, such bulgings producing relative dullness. Such scolioses are generally single and usually in the lower dorsal regions, but they are at times double in the dorsal and lumbar regions. If the patient does well they will disappear as health returns. Kyphosis is seen but rarely. Eickets is responsible for alterations in the shape of the lower por- tion of the thorax, chiefly along the insertion of the diaphragm, where its results are seen as Harrison's groove, a transvei'se hollow across the chest at this level. The intercostal angle, which shoidd be nearly a right angle, is often more acute than normal, and in those with a paralytic thorax and in old cases of tuberculosis, may become so narrow that the free borders of the ribs are parallel with each other and almost touching for two or three inches downward from the ensiform cartilage. The funnel chest (" Trichterbrust " or " Schusterbrust ") is seen quite commonly in moderately advanced and advanced cases, but pro- nounced degrees are rare. In this deformity the sternum and neigh- boring costal cartilages are drawn inward to form a somewhat funnel- shaped depression in the center of the chest, this depression being commonest between the fourth rib and the ensiform, though it may oc- cur at any portion of the sternum. In extreme cases the costal angle is drawn inward along with the ensiform. These funnel-shaped depres- sions are probably the result of obstruction to the entrance of air into the larynx in childhood, while the bones are soft by reason of rickets, but may be congenital. The writer has seen an identical deformity of this sort in a brother and sister, the thorax of one being an exact repro- duction of that of the other (Fig. 42). OBJECTIVE SIGNS 231 The scapiilce show no change of position until the process is well pronounced, except the dislocation inward which, as already noted, occurs when the side is shrunken, hut after this time there is apt to develop a slight degree of prominence of the angle on the affected side, and as the disease advances this hecomes more and more marked, the angle rotating outward and getting more and more prominent until it looks like a wing, hence the term " alar." Except for those slight changes in the shoulder-girdle muscles spoken of earlier, there is no alteration in the muscles until the process is far enough advanced for atrophy to occur, though in patients with a paralytic thorax the mus- cles are apt to be relaxed and tlal)by. In cases with much activity there may be a local wasting of the muscles over the focus of the trouble or over a cavity, and Desplatz (De Renzi, "94) even considers most of the deformities of the chest due to the wasting of the muscles. The skin of the chest, in rapidly advancing cases or where there is much wasting, shares in the general malnutrition and is pale and atrophic; in the incipient cases it may not offer any unusual aspect. The dilated superficial veins seen on some chests, S. West ('02) con- siders evidence of pleural adhesions, a view shared by K. Francke ('07), who attributes to the fine vascular areas over the apices diagnostic sig- nificance in early tuberculosis. In women the breast on the side of the trouble is apt to be smaller than that of the other, but the difference in the size of the areola, noted by some Italian observers, the writer has not seen. The apex beat, if fibrosis is marked, is dislocated, and when the upper portion of the left lung is retracted from this cause pulsation can be seen over the pulmonary valve. The fades is unaltered in early cases, except that the cheek of the affected side flushes on exertion or excitement, which foreruns the development of a more pronounced hectic flush. The pupil of one side or the other is frequently dilated, but not always on the side of the lesion, as has been asserted. In cases of young people with severe trouble of an active nature, the writer has frequently noted a dilatation of both pupils, and has found it to be of a bad prognostic significance. The inspection of the mouths of patients should not be omitted, as good teeth are necessary to good digestion, and the teeth of the tuber- culous are often in very bad shape, and are a handicap to progress. Thompson's red line along the gums is not present in many early cases, though often in advanced ones. The tongue, as is natural in a disease where dyspepsia is so often present, often shows some slight degree of coating and it is pale and flabby, while in old eases with intestinal lesions or severe gastritis it is fiery red and shiny. Ulcers of the tongue are rare. 232 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS Follicular pharyngitis, or pharyngitis sicca, is quite common, the lat- ter chiefly in old cases. Palpation. — Although not of tlu' greatest value, palpation at times gives useful information, so that it should not he omitted. It gives evidence of respiratory expansion, of alterations in the conducting jiower of the lung tissue hy vocal fremitus, demonstrates frictions, re- veals painful pressure points, the location of the heart beat, and enlarged cervical or abdominal glands. As a method of determining respiratory motion, it is frequently superior to inspection. The finger tips, laid over the apices or sides of the lung, will note very slight differences in expansion, and inspection findings, if uncertain, should always be tested by this method. The determination of vocal fremitus has only a restricted value; useless in incipiency and too varied to be interpreted in the third stage, it is only in the end of the first and in the second stage that it is of iise. The vibrations of the u])pcr riglit lung being normally much stronger than that of the left, an increase at the right apex must be very pronounced to make certain that it is pathologic, although such an increase at the left apex is suggestive. Slight changes at the left can ])e assumed when one finds the fremitus over the left apex equal to that over the right. As Lindsay (04) says: "If the fremitus be equal on the two sides and marked, suspect a lesion of the left apex. If it be equal on the two sides and ill marked, suspect the right side."' Diminished fremitus should suggest emphysema, thickened pleura, occlusion of a bronchus, or fluid, the first and second being by far the most common causes. However, lessened fremitus is not common. Monneret (Grancher, '90) insists that the variations in the fremitus must not only be taken between the two sides, but relatively on each side alone. The location of the maximum fremitus in the lung depends on the pitch of the voice, it being higher up in proportion as the pitch is higher, so that in women and children it is strongest in the upper part and nearly absent below, while in men with strong voices it is strongest at the base. Thus, in a doubtful case in a man with a low- pitched, resonant voice, where the comparative fremitus between sides is normal, the discovery that the fremitus at the apex is equal to that at the base would greatly strengthen suspicions of apical consolidation. In advanced cases with multiple lesions palpation is valueless. It should not be forgotten that a narrow band of adhesions can conduct fremitus strongly under certain conditions, so that at times it can be carried to distant parts, as, for instance, in pneumothorax or pleurisy. Palpation for frictions or for ronchi is of no importance, and may be neglected. Pain on palpation is present in a fair number of the early cases over the apex in front or behind. It is commonest behind, between OBJECTIVE SIGNS • 233 tlie spine of tlio scajnila and tlie spinal column. Eibard (quoted by Cornet, "U7, p. G57) ascribes Ibis to enbiri^'-ed bronchial «);lands. Head's painful points, while they may at times be discovered, have given the writer no aid in the study of his cases, and, according to Fowler and Godlee (*98), to connect them with lesions of special portions of the lungs "is a work of some difficulty/' It is surprising how seldom enlarged cervical glands are found. When present they are commonest on the side of the lesion in the lung. Tlie necessity of palpating for the apex beat need scarcely be noted. When determined, the point should be marked with a blue skin pencil, so as to be used later in mensuration. Displacement of the apex beat to any marked degree suggests fibrosis, except where it is due to pleuritic effusion or pneumothorax. The heart beat can be felt very distinctly as well as seen over the pulmonary valve in filiroid cases, owing to re- traction of the lung, though Cornet ascribes this to infiltration of the anterior l)order of tlie upjier lol)e. Mensuration. — Tlu' full circumference of the chest should be at least one half the height of the patient, chests under this proportion suggesting a weak constitution. This circumference should be measured at the level of the fourth rib at the sternum in front and the eighth dorsal spine behind, the chest being at rest, but Loomis ('98) advises the average of extreme inspiration and expiration. Brown ('04 A) found the circumference less than half the height in 45 per cent of 80 male cases and in 75 per cent of 1)5 female cases, which led him to suggest that the standard was probably formed from the measurement of males. The expansion of the chest, according to Fetzer (Yierordt, \Sfl), is from l.G inches to 4.8 inches, which does not ditfer much from the figures of Draper, who gives it as fiom 2 to 5 inches, and this is much nearer the truth than the considerably smaller figures given by other authors. With such wide normal limits of variation, it is evident that in early cases its determination is of little value, and the writer has frequently seen such patients with an expansion of 4 inches or over, but the loss of expansion during the advance of the disease and its increase during its improvement is so usual that if taken at successive examinations its determination can throw some light on the progress of the case. While a knowledge of the total circumference of the chest, except as suggesting a weak resisting power, is of little value, a knowl- edge of the two semicircumferences is of considerable value and should always be sought. Despite the contrary view of Waldenburg (*80), a marked lessening of the right side of the chest in right-handed people, or of I be left side in left-handed ones, is good evidence of the existence of a lesi(m on that side, while a ])rogressive shrinkage of the affected 17 234 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS side very imiforml}' goes with an advancing process and a reexpansion with an improving one. Asymmetry of the chest can be demonstrated by the use of the tape between symmetrical points, but the trained eye is more vakiable than the tape in determining asymmetry. The calipers are useful in giving the Fig. 44. — Cyrtometer Tracing of In- Fig. 45.^ — Case in I. Stage (R). Re- cipient Case (I). Note shrinkage of R. side. Continuous hne Dec, broken line April, 190L Patient right handed. (Disease arrested.) Index 65. expansion After Five Months (Broken Line). Disease arrested for some years. Index 63. depth imd breadth of the chest and the depth of corresponding parts of the thorax, especially in ils upper portion, which can otherwise only be estimated by inspection ; thus the depth of the apex can be measured from Fig. 46. — Active Recent Disease on Left Side, Arrest, and Final Cure. Index 76. Fig. 47.^ — Marked Shrinkage in In- cipient Left-sided Case (I). Re- expansion very rapid. Two months between two tracings. Index 61. just below the center of the clavicle to the spine of the scapulae, or one of the dorsal spines, as advised by Walsh ('43). The distance of the heart apex from the center of the sternum should always be measured as it gives evidence of alterations in size or of dislo- cations. Cunningham ('03) gives the normal distance of the apex from the midline as 3^ inches. In his tuberculous patients, the writer has found OBJECTIVE SIGNS 235 it to be rather less than the normal, as an average, varying between 2^- and 3^ inches in men, and from 2 to 3 inches in Vv'oraen. The lead tape cyrtometer gives the thoracic perimeter at any given level, and makes visible slight alterations of size of one side of the chest, which could not otherwise be recognized, and more especially gives most graphic ocular evidence of changes in shape during the course of the disease. It is of great diagnostic and prognostic value and it is regret- table that it is not more generallj- used. The writer has used it on all cases for a number of years and through it has been able to demonstrate a slight shrinkage of the affected side in most cases early in the trouble. A slight shrinkage of the left side, except in left-handed people, is, of course, of no value, but such a decrease on the right side is of value as suggesting trouble in the contracted lung. Used in successive examinations, there is no method which will give such beautiful demonstrations of that shrinkage or reexpansion of the thorax which so uniformly follows ad- vancing trouble or improvement. Fig. 48. — Fibroid Disease, Continu- ally I.MPROVING. Showing; shrinkage of perimeter. In this case indicating improvement. Tracings ten months apart. Index 69. Fig. 49. — Stage III. Patient Failing. Decrease in perimeter. Index 71. It is interesting here to note that, as a rule, the increase of perimeter takes place first on the unaffected side, which is doubtless due to a com- pensatory increase of the good lung, and that the increase of the affected side generally follows this increase on the good side. The increase can be in breadth or in depth or both, though more commonly in breadth than in depth, but since the former is somewhat affected by increase of muscle and fat, it is not, if moderate, as reliable as an increase in depth which, being between bony points, the sternum in front and the spine of the vertebra behind, is positive. The use of tlie spirometer is at present largely neglected. While not of as great diagnostic value as Hutchinson, its chief advocate, be- lieved, it is useful, especially in watching the course of a case, although 236 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS the patient must be taught to use it properly, and it should not be used in any case where there is a tendency to hemorrhage. Even at a first examination a high reading is not positive evidence of a normal lung, since one at times sees patients with considerable trouble who can give a high reading. An unduly low reading in a patient who has been taught to use the instrument properly, always speaks for a limi- tation of available lung and suggests tuberculosis, while a high reading, persisting at subsequent examinations and coml)ined with other good findings, increases the assurance with which one can make a good prog- nosis. Steady increase of reading at each examination is a uniformly good sign, and a steady decrease a bad one, slight fluctuations being of no value. Tlie value of this instrument is well expressed by Waldenl)urg ('80). He says : " The spirometer is for general diagnosis of moderate value, but is an invaluable means for founding an individual diagnosis, either as to Fig. f>(). — Round Type of Chest. Incipient disease on right side (I). Index 80. Fig. 51. — "Pigeon Chest", Case in Stage III. Index 68. the degree of tlie involvement or to found a prognosis for observing the course of the disease, and finally for noting the effectiveness or useless- ness of every given treatment." The scales need scarcely be mentioned, as they have been treated of under the subject of emaciation. Diagnostically as well as prog- nostically they are of great use and should be placed in every examining room. Corpulence is the relation of weight to height; according to Loomis ('98), the former in pounds, divided by the latter in feet, should be 26 in normal men and 23 in women, or, according to Papillon ('97), the weight in hectogrammes and tlie height in centimeters should be 3 in women. It ought to he of value in determining the resisting power of patients. OBJECTIVE SIGNS 237 Fig. 52. — Fl.a.t Type of Che.st. Ex- pansion in one year, coincident with ■ marked improvement. Stage III. Patient for seven years with Hmited working capacity. Index 59. Percussion. — Although the cUiini of Aufrecht ('05) that percussion "offers positive findings much sooner . . . than auscultation," is per- hajis not conceded by the majority of observers, it must be admitted that if properly performed, espe- cially over the apices, it is of great value as a means of early diag- nosis. It is to be regretted that its technie is so frequently imperfectly mastered, as in percussion, more than in any other diagnostic pro- cedure, a good result depends on a perfect technie, and careful and delicate percussion will yield re- sults which cannot be hoped for if it is heavy and improperly directed. When it is recalled how slight are the lesions in early tubercu- losis, a few small, scattered or con- glomerate tubercles in an apex, with some consequent relaxation of the parenchyma, it is evident that only in an apex could one ordinarily expect to determine early changes by percussion at all, and that even then one cannot expect to find early in the disease any marked percussion changes, such as pro- nounced dullness or flatness. On the contrary, there is usually only a slight " shortness " of note, the duration of the note being less than on the good side and slightly elevated in pitch, or at most an impaired resonance or very slight dullness, often accom])anied by a slight tympanitic overnote, due to relaxation of the surrounding lung tissue (Sahli, '02). Instead of this, slight tympany or hyperresonance will at times be found, as first noted by Andral, but the commonest early percussion change is a short, high-pitched note or a slight impairment of resonance, both of which Fig. 53. — Bulging B.\ck"v\^\rd on Ac- count OF Scoliosis. Correction of scoliosis. Index 54. Fig. 54. — Marked Shrinkage of Left Side, Due to Post-Pneumonic Emphyse.ma. Restoration of normal l)erimeter in three months Ijy exer- cises. Index 6(3. 238 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS are more common and more certainly determinable than tympany or hyperresonance. Aufrecht ('05) considers an even earlier sign to be the difference between the percussion note on inspiration and expira- tion. Da Costa ('75) pointed out that in the normal lung there was a difference in the note on percussion in inspiration from that in ex- piration, the former being duller, the latter clearer. Aufrecht considers that in the very early lesions in an apex this is reversed, inspiration being clearer and expiration duller. In view of this respiratory variation, it is wdse in doubtful incipient cases that the percussion blow should be delivered over each apex during the same phase of respiration, and in percussing one spot to compare the note during inspiration with that during expiration. The slight retraction of tbe inner border of the apex, with a lowering of its height, first pointed out by Ziemssen and later more fully studied by Kroenig and Oestreich, is a valuable early sign of a lesion in the apex, and careful percussion will demonstrate a slight degree of such retraction in many early cases. As stated elsewhere (Minor, '06), the slight retraction found at this stage is due not to fibrosis, which is not yet present, but to lessened functional activity, and, if the case is soon cured, it can disappear. It need hardly be emphasized again that these slight incipient changes demand for their detection the most delicate, light, resilient percussion possible, using one finger only, and using the little finger as a pleximeter. When there are beginning lesions in both apices, it will at times be impossible to determine any change, and other methods will have to be relied on. The slight decrease of resonance, normal at the right apex, which was noted by Flint long ago ('75), renders slight impairment at the left apex of more value than at the right, but slight alterations at the right are too often ascribed to this normal difference. Where hyperresonance is present over an apex, one may be deceived into regarding the other apex as being impaired, and this accounts for the fact, noted both by Turban and Sokolowski, that different competent examiners, examining the same case in the same day, may locate the lesion in different apices. Again, impaired resonance over the anterior aspect of an apex may be accompanied by hyperresonance on the posterior aspect (Fox, '91) from relaxation of adjacent lung, hence if hyperresonance is noted, the other aspect of the lung tissue should be carefully searched for dullness. At times the remains of an old pleurisy or a healed focus at one apex may produce slight dullness there and obscure the slight signs at the other side where a new process is beginning, but, while such cases may be puzzling, a careful study of the results of the other steps of the examination will suffice to clear up the trouble. OBJECTIVE SIGNS 239 Distinct dullness cannot be regarded as an early sign, but speaks for more pronounced trouble and the coalescence of the scattered tubercles into a solid mass of some extent with little air-containing tissue between. Piorry taught that even superficial lesions to produce discernible dull- ness must be from 4 to 6 cm. in width and 5 cm. in thickness. Alison ('Gl) noted that a superficially located spot, one half a square inch in size and one half an inch deep, located in the apex, could produce unquestionable dullness. Oestreich ('98), as a result of autopsies, be- lieves that a consolidated area the size of a cherry can produce dullness with tympanitic overnote; and Flint ('75) reported an interesting case where a mass the size of a hazelnut was discovered. The note over the apex is not uniform, the outer portion being slightly impaired by the underlying muscles, the inner slightly tym- panitic from the neighljorhood of the trachea, while the central portion alone gives a clear sound, and in early cases this must be kept in mind and each of these portions of the apex studied separately. Observers differ as to the commonest seat of the dullness produced by apical lesions. C. J. B. Williams ('87) and Babcock ('07) consider it commonest in the suprascapular fossa, but while, as Fowler points out ('98),- lesions commonly tend to spread backward, the structure of the overlying soft parts renders small foci less accessible to percussion here than in front, and dullness is most generally first found in the inner part of the supraclavicular fossa and in the inner third of the infraclavicular region. This agrees with the fluoroscopic findings in early cases, which show that a shadow in the sternoclavicular angle or above the clavicle is very much commoner than a shadow behind. W. Walsh ('71) and Alison ('61) also consider that this region is usually the first site of dullness. With bilateral apical lesions crossed dullness is often found, the apex on one side being dull in front, that on the other side behind. At times the first lesion will develop directly under the clavicle, and the first spot of dullness will be found by percussion on this bone and not above or *below it, a point noted first by Laennec ('19) and also by Stokes ("82), but we must be sure that an unduly arched clavicle or the thickening from an old fracture is not responsible for the dull- ness. The writer has never felt safe in laying much weight on dullness limited to this bone. The condition of the soft parts and of the bony thorax can have a marked modifying effect on percussion, especially in the early stages. The strong muscles of a laborer or a thick layer of fat may render per- cussion useless, and even the difference between a normal, well-nourished, ejastic skin and a thin, loose, and relaxed one can cause a difference in note. 240 SY.MPTOMATOLOGY OF PULMONARY TUBERCULOSIS Local prominences of individual ribs, or of many riljs, as a result of scoliosis, can simulate dullness, and the unyielding ossified thorax of an old j^erson gives a rather dull note, whereas the elastic chest of a young person gives a sonorous, h3q)erresonant one. Slight areas of impaired resonance can be mapped out better when approaclied from the normal resonant lung, and therefore percussion from Ijclow npward to a suspected apex is often better than the customary method of per- cussing from the impaired area downward to the noruuil. As the disease advances, these early signs are replaced by easily demonstrable dullness, at times accompanied by a tympanitic overnote (tympanitiscJier Beiklang), indicating at this stage not a cavity, as some have erroneously supposed, l)ut a mass of consolidated lung sur- rounded by relaxed tissue. Aufrecht ('05) expresses this well. He says: "To conclude from a tympanitic note alone that there is already a destruction of tissue in the apex with cavitation, would be incorrect. We know that in the neighborliood of a pneumonically infiltrated lobe the percussion note is tympanitic, and that the same can occur over an apex with normal tissue in llie neighborhood of a considerable area of condensation." This tympany can be distinguished from the tympany due to a cavity by the absence of change of pitch (Wintrich's Schall Wechsel), and one should be very careful before diagnosing a cavity on the strength of dullness accompanied by tympany, though marked tympany surrounded by a wall of dullness is a very reliable cavity sign. Where unduly hard percussion is used a tympanitic note can frequently be obtained over the apex by transmission from underlying bronchi, but as very hard percussion should never be used over the apex, such an error is easily avoided. When condensatioft has advanced sufficiently to produce marked dullness, there will frequently be found increased resistance to the finger on percussion, especially in the suprascapular regions. The dislocation of the apex outline, which is present in a slight degree in the early stage, now becomes more marked. The writer has found that either the inner or the outer borders can be altered from their normal position, the outer coming inward, the inner moving outward, though Oestreich — quoted by Aufrecht ('05) — denies that the outer border moves, Plowever, after having percussed out the apical borders very carefully in all patients for a number of years, the writer is positive of the cor- nx-tness of his statement, Avhich agrees also with the views of Kroenig. The inner border is usually affected earlier, but dislocation of the outer is often plainly marked. (For fuller details of the exact outlines and the methods, see Diagnosis.) While (ioldscheider's statement ('07) that the outlines as laid out by Kroenig do not correspond to the exact ana- OBJECTIVE SIGNS 241 tomic apex is correct, Ivrocnig's lines being only a projection of the underlying resonant area on tlie skin of the shoulder, this does not in any way affect their diagnostic value, which, since changes in this pro- jection occur very early aud very regularly in tuberculosis, is consid- erable. Retraction of the base, which is not found in the early stage, is quite common in the second stage, combined with limitation of motion, as can easily be demonstrated if the outlines of the base at rest and on extreme inspiration are marked out by the skin pencil in all cases, and the information as to the mobility of the base yielded by this method and by the tluoroscope is so satisfactory that the writer has not made use of Littcns diaphragmatic phenomenon for this purpose. When dullness becomes pronounced the impaired resonance generally reaches below the clavicle, and the advancing border of dullness will be found very often to run obliquely downward from the outer end or middle of the clavicle to the sternum at the second or third rib, while posteriorly a similar obliquity will often be found, though not as com- monly as in front, the dullness running from the middle of the spine of the scapula downward and inward to the vertebrae. The frequency of this oblique position of the dullness can be verified with the fiuoroscope. In examining the upper portion of the lungs by percussion, one should be careful always to percuss the axilla up to its apex, as freciuently there will be found a spot of trouble here and not elsewhere. The area of lung below dullness is usually hj'perresonant, probably from relaxation, or, as Skoda ('64) suggests, from hyperf unction, but it must be remembered that the anterolateral aspect of the lung is nor- mally hyperresonant. Where there is extensive involvement of one lung, the other lung is apt to be hyperresonant through increase of function. Absolute dense dullness over the upper third of the lung is rare, owing to the presence of the large bronchi, and dullness here often has a tympanitic overnote, as already stated. In the second stage, dullness will practically never be found at the base, except in tlio rare cases where the process begins in this region or where there is a basal dry pleurisy with thickening. Flat- ness, except over fluid, is not found. Basal dry pleurisy should always be looked for carefully, and in many cases with beginning apical trouble on one side slight dullness can be found at the anterior base of the other lung, or the posterior base of the affected lung, owing to it. A very usual location for outlying areas of dullness on the anterior aspect of the chest is the fourth interspace, on the left near the axilhiry fold, where percussion and (he fiuoroscope will often sliow small foci of trouble, separated from the main focus above or lying to the outer 242 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS side and slightly above the heart. In view, however, of the thickness of the pectoralis major in this region and the greater arching of the ribs at this point, one must be very careful that this does not deceive. Posteriorly outlying areas of dullness are apt to appear just above or at the angle of the scapula, especially on the left side, while the main process is still confined to the other apex. Another important area of dullness is between the spines of the scapula and the vertebral column, dullness here being a good evidence of tracheobronchial adenopathy. However, this can be simulated by an unvisual muscular development. Anteriorly such enlarged glands can produce areas of dullness, usually more or less semicircular in outline, on one or both sides of the sternum, at the level of the second and third ribs, or over the manubrium. Fig. 55. — Tuberculosis of Tracheobronchial Lymph Glands in Child Four Months Old. Principal symptom: severe, dry cough, almost constant. Treat- ment without effect. Pathologically: small tuberculous deposition in both lungs, with area of caseous pneumonia in right middle lobe. In other organs scattered miliary tubercles. (From Holt, " Diseases of Infancy and Childhood.") Enlarged hroncliial glands are, however, more often missed by the physician than found, as can be shown by the fluoroscope, which has demonstrated them in many cases where they were entirely undiscover- able by percussion. Ordinarily they lie too deep to be found, until they OBJECTI\'E SIGNS 243 have readied a very considerable size (Fig. 55). When perceivable, they cause dullness in front much oftener than behind, and Barety ('74) ascribes it to their position nearer the front than the back. Anteriorly they should be percussed for by moving the finger slowly inward along the second and third interspaces. If they are much enlarged the dull- ness will also be found over the manubrium. When the process reaches the third stage the percussion findings are usually more varied, less definite and less satisfactory than in the earlier stages. The upper portion of the lung is usually veiy dull but not flat, flatness, if present at all, being generally found in the middle or the lower half of the lung behind. The lower portion of the lung in front, especially in the axillary line, generally shows some resonance even in very advanced cases, and this area on the fluorescent screen generally retains some degree of translucence, even in very advanced cases, unless there is fluid or a very thick pleura. As is natural, in view of the commonness of cavitation in that region, marked tympany, or even cracked-pot resonance, when found, is usually in the upper third or half of the lung, though if the cavities are extensive tympany may extend over almost the whole anterior surface of the lung. Posteriorly, t3'mj)any is less common than in front, and cracked-pot resonance very rare; and in the writer's experience signs of cavitation of any sort are rarely found behind below the spine of the scapula, and while autopsies reveal in old cases cavities in the lower portions of the lungs, these W'Ould rarely have time to enlarge suffi- ciently to be easily determinable. In the apex, on the contrary, they can scarcely be overlooked when they reach any considerable size. The retraction of the apex in the third stage is extreme, the inner and outer borders meeting at an angle whose apex lies below the free border of the trapezius, or the dullness may be so marked that they cannot be mapped out at all. The base is also often greatly retracted, especially if there is much fibrosis, and the liver can be drawn upward and back- ward into the thorax, tympany occupying the normal location of this organ, so that by percussing downward over the fifth, sixth, and seventh ribs there is a transition from normal or moderately impaired resonance to marked abdominal tym])any. Such tympany in the site of liver dull- ness should, therefore, always suggest fibrosis, with liver dislocation. In this stage also the other lung is always involved to a greater or lesser degree. While some degree of excavation occurs before this stage is reached, and while its determination at an earlier period is more important than at this time, it is in this stage that one can best study the tyj)ical signs of cavity. These vary greatly according to the condition of fullness or emptiness, presence or absence of connection with the air, the condition 244 SYMrTOMATOLOGY OF PULMONARY TUBERCULOSIS of tlie walls — such as smootlmess, elasticity, and regularity — the condi- tion of the surrounding lung tissue as to condensation or aeration, and es^iecially according to the size of the cavity. Cavities of less than the size of a walnut cannot be diagnosed, and even such must be super- iicial if they are to be found, location, as Landis ('06) found, being more important than size in their discovery. No one has followed to the autopsy table cases of tuberculosis without being convinced that cavi- tation, in some degree, exists very much earlier than is usually supposed or than jihysical signs can determine, and that many cavities entirely escape notice. The percussion note over a cavity, if the latter is super- ficial enough and not too small (4 cm.), may be tympanitic, amphoric, or cracked-pot; but if the walls of the cavity are thick, or overlaid with condensed lung or much thickened pleura, there may be only more or less dullness, with or without a tympanitic overnote, and if the cavity is deep enough, there may even be normal resonance over it. A tympanitic note, while the commonest percussion finding over a cavity, is in itself by no means diagnostic; but a clear amphoric note, if pneumothorax can be excluded, is a positive sign of cavity. A cavity which can give tympany when empty can give dullness Avhen full of secretion, and such a variation between dullness and tympany is an excellent diagnostic sign. Some assistance in recognizing a cavity can be obtained from the variation of pitch on percussion produced by changes of condition or position, this being the Schall WecJisel of the Germans. Various tojie changes have been distinguished. The simplest is the change in percussion note according to the fullness or emptiness of the cavity, and has been referred to above. The next is Friedrich's tone change, in which the note becomes higher on full inspiration and lower on full expiration. The only important changes, however, are those which bear the names of Wintrich and Gerhardt. The former is obtained by opening or closing the mouth, the note being higher with the mouth open and lower with it closed. When this change occurs only in the recumbent or the erect position of the body (intermittent AVintrich's tone change), it is good evidence of a cavity, and depends on the fact that change of position occludes or opens the opening of the cavity to the air. The simple Wintrich's change of pitch is of but slight value in the diagnosis of a cavity, but may be of value in distin- guishing cavity tympany from tympany due to pulmonary relaxation. Gerhardt's change of pitch is the one produced over a cavity contain- ing fluid, and is brought about by an alteration of position of that fluid by a change of position, usually sitting up and lying down. Since most cavities have their longest axis vertical, the note is usually lower pitched on reclining and higher pitched on sitting up; but where the long axis OBJECTIVE SIGNS 245 of the cavity is transverse this may be reversed. De Renzi ('94) insists on the importance of holding the head straight in trying for Gerhardt's tone change, as changes of position of the head alter the dimensions of the pharyngeal cavity. While this last tone change is a valualjle sign, Leube ('91) considering it final if the pitch lowers on sitting up, or if we have intermittent Wintrich's tone change, which, after all, is only a modification of Gerhardt's, the necessary conditions are combined too rarely to make it of great practical value. Cracked-pot resonance is that peculiar sound produced by firm per- cussion, without rebound of the fingers, over a cavity which communi- cates freely with the air when its contents are suddenly compressed and expelled by the percussion stroke. For its production the mouth must be open, but it should be noted that false cracked-pot resonance obtain- able over the chests of children, or over other very thin, elastic chests, can be obtained while the mouth is closed, and that at times large, super- ficial, thin-walled cavities give cracked-pot resonance with the mouth closed. The sound can best be imitated by striking the back of the clasped and concave hands on the knee, wdiich drives the air out sud- denly from between the fingers. Skoda explained it as due to a sudden compression and expulsion of the air, and while Wintrich has given another explanation, the former is generally accepted as satisfactory. Not only must the cavity communicate freely with the air, but the walls must be thin and elastic so as to be capable of sudden compression. Grancher and Corn 11 ('90) have noted that when it cannot be ob- tained otherwise, cracked-])ot resonance can be gotten if percussion is practiced during expiration. Unfortunately, cracked-pot resonance is oftener absent over cavities than present (T^andis, '06), and is not con- fined to excavations, but it may be obtained in the area above consol- idations, or more especially effusions, as well as in children or others with thin, weak chest walls; nevertheless, if it occurs sharply defined and surrounded by an area of dullness, it is pathognomonic, especially if, as Leube ('91) notes, it is accompanied by a metallic tone. In the third stage there are very marked dislocations of the heart, due to fibrosis in the right lung, drawing the heart into that side of the chest, while a similar condition in the left lung can pull the apex upward and outward into the left axilla. Collections of fuid in the chest in pulmonary tuberculosis are not as frequent as one would expect, and owing to the very varied findings in the third stage are often overlooked until at autopsy. Eittjtinisrma is found associated with tuberculosis of the lungs quite frequently, desj)ite the sup])osed antagonism of the diseases (Grancher, '90). The writer's cases which have presented marked signs of a prece- dent empln'sema have usually done very well. It may be either a pre- 246 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS existing condition, in whicli case there is- a typical barrel-sliaped thorax, with hyperresonant or boxlike note, with decrease of the area of cardiac dullness and increase of extension of the lower borders of the lungs and loss of motion of the bases, or it may be the result of fibroid shrinkage, with consequent narrowing of bronchi and resistance to expiration, this usually being found in old third-stage cases, and scattered here and there in the lung, so that its diagnosis is very difficult; or it may sur- round healed apical lesions, partly or even entirely masking tlie dullness they produce, or rejjlacing it by a nearly or quite normal percussion note. The percussion in cases which are improving shows a gradual lessen- ing of extent in tlie areas of impaired or modified resonance, with less- ening or, in very incipient cases, disa])])earance of dullness or impair- ment and reexpansion of dislocated apical outlines, but pronounced areas of dullness never return to a nonual percussion note, and some dullness and dislocation can be found long after all symptoms have entirely ceased. The limitation of motion of the base can greatly lessen, but does not often disappear entirely. Over healing cavities tympany may gradually lessen, and finally disappear if the cavities are small enough and shrinkage is very com])lete. AuscvUatory percussion the writer has not found of value, and he has secured from the more usual methods all the information it can offer. In a careful review of tlie various modifications of auscultatory percussion by Kantorowicz ('OC), he comes to similar conclusions, and it can safely be stated that in the examination of the lungs in pulmonary tuberculosis it can be neglected. Auscultation is the most delicate and acute means of recognizing the presence of tubercle in the lung, but it is to be regretted that as a consequence, and because its technic is more easily mastered than that of percussion, the other steps of a pliysical examination are too often hurried through in a perfunctory way, while all attention is placed on auscultation. Tliis very common error deprives the physician of many invaluable aids and hints given by the earlier steps of a regular exam- ination. A correct diagnosis may, it is true, often l)e arrived at by auscultation alone, but a complete one can only be reached by a careful synthesis of all the facts yielded by each step in the examination, and a neglect of any one of them can only lessen the accuracy of the result, and while such an incomplete examination may enable one to make a correct diagnosis of a fairly advanced case, it is unreliable in those early cases where certainty is most needed. In the majority of cases each new step of the examination will develop some slight or more marked devia- tion from the normal standard which is often most suggestive, and a summation of all these slight alterations Avill generally enable one, before auscultation has been reached, to get a fair idea of the seat and nature OBJECTIVE SIGNS 247 of the trouble, which this last and most delicate step will confirm and increase. Cases in which every step except auscultation yields absolutely nega- tive results will be found, but only very rarely, and among the most incipient cases. Eemembering the patliology of early tubercle of the lung, the few scattered foci of peribronchial infiltration in the apex involving the vestibule of the alveolus and surrounded by much normal lung tissue, it Avill be evident that marked changes in the respiratory nnirmur in inci])ient cases will not be found. At this time the apex, supra- and infraclavicular fossfe, superspinous fossae, and interscapular regions will alone give any auscultatory changes. The alterations physically determinable in the breath sounds in early tuljerculosis consist of slight modifications of the normal pitch, intensity, duration, and rhythm of the inspiratory, and a little later of the expir- atory murmur over the apices, rales in the very incipiency of tubercu- losis being generally absent. To recognize these early changes it is essential first to study each phase of respiration, the inspiratory and expiratory, separately, concentrating attention on the one to the exclu- sion of the other, comparing that of one side with that of the other, and then comparing inspiration with expiration on the same side. This I would call single-phase auscuUation; it was developed by CTrancher, one of the greatest of auscultators, and a thorough experience with it has convinced the writer of its importance and of its great superiority over other methods in the recognition of early changes in tuberculosis. Such single-phase auscultation will demonstrate that the earliest changes are inspiratory, a fact which until recently was totally over- looked by the best authorities, as a reference to the works of Skoda, Walsh, Flint, Barth et Roger, Euehle, Vierordt, Leube, and others will demonstrate. Those expiratory changes which were long regarded as the earliest signs (Euehle, '87) follow with the increase of involvement, and as consolidation appears merge into bronchovesicular and bronchial breathing. However, thanks to the work of Grancher, the more recent authors now recognize the priority of inspiratory changes (Turban, Sokolowski, Sahli, Fraenkel, de Renzi, Babcock, etc.). It should be noted here that there is no auscultatory phenomenon which of itself is pathognomonic of pulmonai^y tuberculosis, and the alterations found speak for certain changes in the pulmonary tissue, which may or may not 1)0 due to tuberculosis, and only by their locality, persistence, and association icith other symptoms do they acquire diagnostic value, and that, as W. Walsh ('71) says: "The value of these states of respiration is directly as the limitation of the area in which they are discernible." Auscultation of the First St.^ge. — The earliest change is the " rough " vesicular respiration, or, since it is more descriptive, granu- 248 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS lar respiration, the term used by Woillez. This is the respiration rude et grave of G rancher and other Frencli authors and tiie raulies Athmen of Dettweiler and Turban. Until (juile recently it has been confounded with harsh, sharp, or puerile respiration, with which it has nothing to do (Sahli, '02). It is related to interrupted respiration and pr(jl)ably due to sligiit narrowing or uneven surface of the bronchioles (Ijy tutjer- cles here located), into which the alveoli open and where the normal vesicular murmur is formed in health ((irancher, 'DO), or, accoi'ding to Turban ('99), to a rapidly interrupted entry of air into the alve- oli surrounding the tuberculous deposits. Thus it is always an evi- dence of parenchymatous troul)le. The respiratory murmur is rough and low-pitched, and it is nuide up of a succession of very sliort sounds, as though snuill, soft granules of fine, wet sago were being rolled over each other. When the sounds become larger and separated from each other by distinguishable intervals, tlie ear ])erceives them as interrupted respira- tion or as numerous fine moist rales. As there is always difficulty in conveying by words a correct impres- sion of a given sound, and as a good understanding of it is essential to its recognition, and as it is not described in many of the current text- books, or is confounded with other types of breathing, it may be well to quote a few descriptions of it by other authors. Grancher ('90, p. 98), who, while not the father of the term, is the one who has done most to develop the iniportanee of this type of breathing, says: "The ear gets the impression of a column of air which glides (f/lisse) with rubbing over an irregular and narrowed (rcfrecie) surface." Turban ('99), who was one of the first Germans to recognize it, describes it as " a series of short, qviickly recurring sounds," and adds, " it depends on their rapidity and strength whether the ear can differentiate them into rales or not," and further notes that they recall to him the rapid vibrations of the hammer of an induction coil. Sahli ('02) speaks of it as " an im- pure, slightly uneven {holperiges) vesicular sound, which now and then gives the impression as if adventitious sounds were mixed with the vesicu- lar sounds," and adds, " if these adventitious sounds can be plainly dis- tinguished from the respiratory murmur we have rales," and ascribes it either to uneven respiratory excursions, to a plugged bronchus, or to the presence of secretion in the bronchioles. Cassaet ('06) says: "The air seems to be constantly passing over slightly elevated obstacles by which it is constantly broken, and this sensation of obstructed progress gives the idea of a rough unpolished surface." De Renzi ('94) describes it as " an abnormal respiration consisting of successive small irregular impulses, and corresponding to the tactile impression one gets when one rubs the beads of a rosary together with the fingers (ircnn man die Gliedcr eines Rosen- kranzes mil den Fingern aneinander reibt)." Mannheimer ('06) says: OBJECTIVE SIGNS 249 " Instead of being heard as a continuous breezy sound it will be perceived to consist of a series of short puffs following each other in rapid suc- cession." This type of respiration is most common in the supras])inous fossa, in the claviculo-sternal angle, and in tlic supraclavicular fossa, in the order named, Init it can often he found farther down in the lung on the advancing border of the disease, and its appearance in isolated spots often gives early warning of the development of a new focus. Grancher considers it most common in the left infraclavicular space, but in the writer's cases it has been commoner on the right. While, like all other auscultatory signs, it is not in itself absolutely pathogno- monic of tubercle, it is, when limited to the apex, fixed and not transi- tory, slowly increasing in intensity until expiration is involved as well as inspiration, and in conjunction with other symjitoms a sure sign of beginning tuberculous involvement. Grancher believes that where it is found at the apex, one will often also find it at the base of the same lung, an observation the writer has not been able to verify. Next in earliness of a])pearance, but not in diagnostic value, is feeble breathing, a lessening of the intensity of the sounds both on inspiration and expiration. It may be either vesicular or slightly rough, and inspi- ration is feebler than expiration (Herard, C'ornil, and Ilanot, '88). It is due to obstruction to the flow of air l)y tubercles or mucus. The writer has found it, in the small areas in which alone it is of value, commonest in the left lung above the clavicle. It can, however, be pro- duced by so many conditions (by limited functional activity, as in adhe- sive pleurisy, pain, emphysema, obstruction or nar^-owing of ])ronchi ; or by imperfect conduction of sound, as from thick pleura, fat, or muscle) that it needs to be limited strictly to the apex and persistent after cough, but if these conditions are satisfied it is suggestive of tuberculization. At the base behind it suggests a thickened pleura. Interrupted hreathing (wavy, jerking, cog-wheel l)rcathing, respira- tion saccadl'e of the French, saccardirtes Atlimcn of the Germans) is a form of respiration in which, instead of the smooth, even sound of the normal respiratoiy muiiiiur, the inspiratory, and much more rarely the expiratory sound, is divided by short pauses into successive periods, which give the impression as though the column of air were alternately arrested and freed, and, according to Sahli ('02), it is due to a valve- like action of swollen mucous membrane or secretion in the smaller tubes; or, according to others, to the uneven contraction of the lung from the presence of tubercles; or, as Kuehle ('87) thinks, to the rub- bing of subpleural tubercles. While it lias been considered by nuiny, notably Peter, as a very early 250 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS sign, the writer does not believe that an early diagnosis will often depend on the discovery of this type of respiration, and he has not found it as commonly over the apex as in the claviculo-sternal angle and at the right base behind, or on the advancing border of evident lesions. It is very frequent behind, between the angle of the scapula and the base. It is best auscultated during quiet breathing, as deep breathing has sufficient force to overcome the obstruction it produces and thus remove it (Vie- rordt, '8!)). Interruptions in the respiratory jhythm may be produced and real interrupted breathing simulated by several other conditions. The most deceptive of these is irregular muscle contractions in nerv- ous, timid, or chilly subjects, in whom it is common. In such cases it will be heard very extensively, especially in front. Adhesive pleurisy or pain, by causing irregular expansion of the lung, may also cause it, but the interrupted breathing so caused can easily be distinguished from the genuine. The heart action may also simulate it in inspiration, but will not deceive the careful auscultator. Grancher ('!><)) thinks real interrupted breathing can be distin- guished from all these forms by the fact that in them the vesicular murmur is normal, while in tuberculosis it is generally rough or weak, but See ('84) considers that it can be pure in tuberculosis, a fact which the writer has noted. Like feeble breathing, its strict localization to a small area is essential; heard over large areas it is certainly false. Harsh respiration {verschdrft vesicular), as already noted, is very often confounded with rough respiration, so that it is well to define it. According to W. Walsh ('71), "both sounds have lost their natural softness, a peculiar dryness accompanies them, the breezy character of health is exchanged for one sharper and more blowing, which is gen- erally more marked in expiration than in inspiration. The intensity of the respiratory sound ai)})ears augmented from the superadded char- acter and its duration is increased. Both these latter properties may be, and commonly are, unaffected in the inspiratory sound. ... In harsh respiration tlie expiratory sound commonly alone suffers clumge of quality." Until recent years harsh respiration with prolonged expiration was considered the commonest early sign of tuberculosis of the apex, as a reference to any standard text-book of fifteen years back will show (Euehle, '87), a view first advanced in 1833 by Jackson, of Boston (Flint, '5G) ; but such have been the advances in knowledge of the early pathology' and diagnosis of tuberculosis that it is now recognized that harsh respiration is not as early as rough, feeble, or interrupted respiration. Grancher ('90), who distinguishes a stage of germination, considers that the appearance of this type of breathing marks the end of this stage, and is accompanied by dullness on jjercussion, and that OBJECTIVE SIGNS 251 it succeeds rough, low inspiration, and tends to pass gradually into bronchovesicular and bronchial breathing, with harsh inspiration and expiration. Nevertheless, since few patients are seen in the very incipiency of the trouble, harsh respiration, esjaecially in the expiratory phase, will be the change ordinarily found by the physician at his first examination in the majority of incipient cases, and if it is confined to one apex, and heard on quiet hrcalhiiig, it has great value in diagnosis, and Sokolow- ski ('06) believes that in this location it is only heard in tuberculosis. However, the writer would note two exceptions to this statement; he has found it quite often at the apex after grippe pneumonias, especially in children, where it may be quite persistent for some weeks, arousing fears as to the possible development of post-grippal tuberculosis, but finally clearing up completely.^ The harshness is due to narrowing of the bronchi and condensation of lung tissue, and demands, therefore, a relatively extensive lesion for its production, so that when it is found the case is no longer incipient in the strictest sense. Unlike rough, feeble, or interrupted breathing, it is heard most often at the extreme apex in front, and to a less degree at the extreme apex behind, or in the clavieulo-sternal angle. While commonest at the right apex, the examiner must never forget that such a type of breathing is said to be normally found in a slight degree at this point, especially in anemic young girls, and hence that its value is greatest when found at the left apex, and in men (Walsh, '71). At the same time, since tuberculosis in young girls often begins as a chlorosis, and as the writer has seen not a few sucli girls who also had incipient right apical trouble, he would advise that not too great weight be laid on the normal appearance of this type of breathing at the right apex if it be found in a slender, pale young girl, with other- wise suspicious symptouiS, and be not too quickly passed over as normal to this region, but tliat such a one be carefully watclied and studied before a diagnosis of tuberculosis is rejected. Harsh respiration in tuberculosis, when it once appears, may be most persistent, unlike the inspiratory changes which soon alter, and it often persists for years after the disease is arrested. Prolonged expiration, or prolonged and feeble expiration, in the absence of harshness, is not of great value. Sokolowski ('06), however, considers that when strictly localized to an apex, and heard on quiet breathing, it is a valuable sign, but Walsh holds the opposite view, as • The writer has also found it along with other rational symptoms in certain cases of sy]5hilis of the apex, and persistent for long periods, and entirely undistinjruishablc from tuberculosis until the patient was placed on mixed treatment, when it cleared up rapidly and permanently. 252 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS does Flint ('75), who says: "Among cases in which a tuberculous deposit exists it is exceedingly rare that diagnosis hinges exclusively on prolonged expiration, and it would certainly be unsafe to base a posi- tive diagnosis on tliis sign alone." However, as an evidence of com- pensatory emphysema around a healing focus it is of great value. Puerile {exaggerated, supplementary) breathing. While this type of breathing will at times be found over the apex in incipient tubercu- losis, it is not a reliable early sign, and is commoner over the healthy lung as a result of compensatory action, or in the area around a focus of trouble. The increased intensity chiefly involves expiration, which is also prolonged, but it does not lose its vesicular quality nor its pitch. Finally, in speaking of early signs, one should note the undue trans- ■ntission of heart sounds to the apex (Brown, L., '04 A). When the heart sounds are distinctly audible over the right a[)ex it speaks for a con- densation of the underlying lung, and is a very valuable sign. AVhea heard at the left apex the sign is not of great value; and in any case, if the heart is beating hard, the value of this sign is greatly lessened. At times other small areas of the lung are found in which the heart sounds are unduly transmitted, especially in tiie bases behind, and will thus direct attention to spots of congestion, and probably of consolidation, which might otherwise easily be overlooked. The study of vocal resonance in the earliest stage of the disease is of little value, but when there is slight percussion dullness and harsh, prolonged expiration it is usually intensified; but here, again, as in so many other instances, its value is slight unless it is very intense or unless it is found at the left apex, owing to the noi-mal increase of vocal reso- nance over the right apex. In men with very strong voices it is value- less, and in patients with very weak voices or hoarseness it cannot be tested. Rales cannot justly be considered as signs of the incipiency of tuber- culosis, although formerly they were so considered, and -some authors still so regard them. G rancher ('90) considers them a sure sign of softening, but they will not generally be found until the first stage is well advanced, and one should under no circumstances wait until they develop before nuiking a diagnosis. At the same time, while generally a sign of more advanced trouble, certain kinds of rales, if the process is developing actively, can be found very early in the disease, while if its course is very chronic they will 7iot be heard until later. A few fine sibilant rales can frefpiently be found over the posterior aspect of the apex, or less commonly in front, at the very end of inspiration, but while they speak for a localized broncliitis, they are not of great diag- nostic value, unless i)ersistent. Isolated pleuritic friction sounds (Flint, '75) over an apex, while OBJECTIVE SIGNS 253 not common, are suggestive of a tuberculous apical pleurisy, and acquire great importance when confirmed by other slight changes. At times they may be mistaken, if fine enough, for crepitations. Of very great importance are the " dry crackles " of Walsh, the cracquements sec of the French. As there is much confusion in the use of terms descriptive of adventitious sounds, and as such dry crackles are closely related to crepitant rales, a quotation from the description given by Walsh, a master in the description of physical signs, will be of value. The dry crackle " is composed of a succession of minute, dry, short, sharp cracklings, feiu in number, rarely exceeding three or four in a respiration, coexisting exclusively, or almost exclusively, with inspi- ration, though in very rare cases most obvious in expiration . . . perma- nent (that is, not removed by cough) in the great majority of cases, after its character has once been perfectly developed, . . . passing into the moist crackle." The crepitant rtile Walsh defines as occurring " in puffs more or less pronounced, but rapidly evolved, composed of a variable, sometimes immense, number of sharp crackling sounds, all perfectly similar to each other, conveying the notion of minute-sized, dry bubbles, coexisting exclusively, except in rare cases, with inspiration, and, once so established, remaining persistent until superseded by other phenomena." Crepitant rales are not strictly dry, being probably generally pro- duced by the separation of the walls of alveoli which are stuck together by secretion (hence, sometimes heard after very deep breath in nor- mal individuals and called "atelectatic rales") or by pleural frictions (Leaming) ; but they certainly are not really moist in the sound they give to the ear, which is distinctly a dry sound. When heard, true crepitant rales speak for small areas of pneumonic infiltration. Recurring to Walsh's excellent description, which agrees with that of Flint ('56), it is evident that the "dry crackles" of Walsh, or the iracqiwments sec of Fournet and Grancher, difi^er from crepitant rales only in that the former are few in number and isolated, the latter very numerous and in salvos. It would tend to clearness in nomenclature if the former were simply spoken of as isolated crepitant rales. If, as Fox notes, tuberculosis is ushered in by hemoptysis, the first rales heard will be moist, but with this exception, although such excellent authori- ties as L. Brown ('04 A) and Babcock ('07) difl'er from the writer's opinion, he is satisfied that in the very incipiency moist rales will not be heard, the typical rale being generally a dry crackle, though if a small area of pneumonia exists there may be crepitant rfdes, an ojiinion that is supported by many of the best authorities, such as Fox ('•'!), W. Walsh ('71), Grancher ('i)O), and Flint ('of.). Limited to one spot, es])e(ially in the apex, but at times in other 254 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS areas, persistent after cougli and not transitory, dry crackles are in them- selves alone presumptive evidence of tuberculosis, and when accompanied by breath changes and rational symptoms justify such a diagnosis. In other spots than the apex they are less to be relied on, but are increas- ingly suspicious in proportion to their persistence. It mvist be recalled, however, that at first they will not be heard on quiet breathing, but only on deep breathing, or after cough, and thus it is important in all sus- picious cases to make a patient cough at the end of a deep breath, or just before one, if they are to be heard. If heard on quiet breathing. Brown considers the case no longer an incipient one. The dry crackle tends by degrees to become a moist crackle (W. Walsh, '71), the rracquement hutuidc of Fournet, and with this change it invades expiration as well as inspiration. Here, again, in the in- terest of simplicity of nomenclature, it seems that the term " moist crackle " should be given up, since a reference to Fournet or Walsh's descriptions will show that it is simply a fine moist rtde (" subcrepi- tant " rale). 'J'o (|uote Walsh: "A series of clicking sounds — a few in number — of moderate size, occurring during both respiratory move- ments, but with greater regularity and distinctness of character in inspi- ration, aiul eventually passing into, or rather superseded by, ronchi of the buljbling class." In the latter part of the first stage a few such fine moist rtlles will be found, and Fournet believed that the change from a dry to a moist sound did not occur until from twenty days to three months had passed. Lampadarios, quoted by Cornet, and Stanton, of Philadelphia (personal reference), consider that rales not otherwise dis- coverable may at times be found if the patient is reclining. Again, rales are more apt to be heard early in the morning, and if not found at the usual time of examination, it may be necessary to auscultate the patient on waking and at various times in the day. H. Anders ('07) quotes Cybulski as to (he diagnostic value of oral auscultation for fine crepitations in early cases, the physician auscul- tating in front of the patient's mouth during quiet breathing, the sounds being heard botb on expiration and inspiration. While the writer has verified this in moderately advanced cases, he has not been able to do so in very early ones. It cannot be too emphatically insisted that nlles, to have any diag- nostic value in early tuberculosis, must be strictly localized, in the majority of cases to the apex, and permanent ; transitory rales having no value at all, though rales may be absent temporarily. Auscultation of the Second Stage. — As the process spreads and consolidation appears, with beginning softening, the auscultatory find- ings intensify and multiply, the most typical being changes in expira- tion. The breath sounds become bi'oncliovesicular and finally bronchial. OBJECTIVE SIGNS 255 with the appearance of what have been very generally called subcrepitant rales, an unfortunate term for fine and medium-sized moist rales. The expiratory murmur becomes increasingly prolonged and harsh, inspira- tion begins to rise in pitch, and there is bronchovesicular respiration, so named by Flint. This type of breathing is due to the presence of consolidated areas of considerable extent in the midst of normal lung tissue, the tubular or bronchial breathing produced in the diseased bronchi and surrounding infiltrated lung being modified by being mingled Avith the normal vesicular sounds of the overlying tissue. Inspiration is less vesiciilar than in health, being a mixture of nor- mal vesicular breathing with the tubular quality of bronchial breathing. Its pitch is raised and it is not continuous with expiration, being short- ened, while the resultant inspiratory pause increases with the increase of the consolidation, and the advance toward pure bronchial or tubular quality. The name bronchovesicular is so appropriate that it is to be regretted 'that the term indeterminate {unbe^tinvmt, Skoda, '64), a most unsatisfactory and undescriptive term, has been used so largely, and the writer believes with Turban ('99) that it should be abandoned. When finer distinctions are to be made the term vesiculobronchial, as suggested by Da Costa, can be applied to the earlier stage in which the vesicular element predominates, bronchovesicular to that in which the bronchial element is most prominent. This type of breathing is of very great diagnostic value and speaks for a considerable tuberculous deposit in the apex. While slight degrees of vesiculobronchial Ijreathing may be found at the right apex in the normal lung, as noted by Flint ('56), the writer has never found distinct bronchovesicular breathing in nor- mal lungs, but if vesiculolu'onchial l)realhlng is heard at the right apex it must be pronounecd to be of significance in diagnosis. Bronchial breathing, except in acute cases (De Renzi, '94) where consolidation is rapid, never appears suddenly in tuberculosis, but de- velops out of bronchovesicular breathing, and its presence evidences considerable consolidation near the surface, connected with the air by a bronchus. In this ty))e of breathing all vesicular quality is lost, and the respiration beconu^s what the French call a sotiffie. It is harsh and loud, inspiration is high-pitched and prolonged, and the intensity of both sounds is increased, especially that of expiration, in which phase it is best heard, hut, owing to the less intense consolidation in tuber- culosis, the typical bronchial breathing of pneumonia is rarely found. When the process has gone far enough to produce bronchial breath- ing in one lung, auscultatory changes are usually found on the other side, together with exaggerated I)r(>ath sounds, weakened l)reathing, or the various signs of early tuljerculosis, or even bronchovesicular Ijreathinsr. 256 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS In tliis stage one M-ill at times find absent breath sounds, chiefly bel)in(l, Init a few strong eouglis will often remove the mucus which, by plugging a bronchus, causes it. Siljihant, wliistling inspiration, heard h)udest on eaeli side of the sternum, at tlie level of the second rib, or be- tween the scapula^ and transmitted downward and outward, is at times found in this stage, when enlarged bronchial glands exist, and speaks for pressure on the Ijronchi and is a valualde diagnostic sign of adenopath3^ Usually one will find along the Ijorder of the more marked abnormal breath sounds a zone in which the earlier breath changes can be heard; for example, bronchial breatliing merging into bronchovesicular breath- ing, and this into rough, feeble, or interrupted breatliing. The normal occurrence of bronchial breatliing between the scapula over the large bronchi must not be forgotten, as it might lead into error. The typical nlle of this stage is the small or medium-sized moist rale, due to bronchitis and softening, and which has been unfortunately called subcrepitant, a term wliich causes much confusion. Cabot ("05) advocates making no distinction between the "'subcrepitant" and crepi- tant r.lles ; but since the crepitant rale is essentially a dry rale in sound, and the "subcrepitant" rale is a moist ride, and the distinction of dry and moist rales is useful and justifiable, this is unfortunate, and the majority of recent authors distinguish them sharply. Tlie difficulty of distinguishing between the crepitant n'lle and the dry crackle has already been referred to. Fine, moist rfdes, AA'hich, unlike crepitations and dry crackles, are heard both in inspiration and expiration, appear over the apex in the end of the first or early in the second stage. They are at first limited in area and scanty, and later become more diffused and more numerous. Their prognostic significance is very great, and while at times they may be present for long periods in favorable cases and over large areas, it may, as a rule, be said that the number and size of the moist rfdes bear a fairly direct relation to the course of the trouble, lessening of the rales signifying usually improvement, increasing of the rales signi- fying increase of trouble. Often, if the patient is doing well, these rales will disappear for long periods, appearing only at intervals when congestions occur. Gen- erally the rales at the apex are medium-sized or small, and Vierordt ('89) considers large rales in this location, where there are only small bronchi, the most certain sign of cavity. At times one will find a single persistent medium-sized moist rale, which from its peculiar sticky quality has been called a mucous click, and some authors consider it of great diagnostic value. More usually one will find ten, twenty, or more fine or medium-sized rales, not pronouncedly moist and not per- manentl}' removed by coughing. As the process advances the rales be- OBJECTIVE SIGNS 257 come larger and occupy inspiration and expiration comjoleteh;, are more numerous, cover a greater area, and are apt to become resonant (con- sonant, l-Hngend) , such resonance speaking, like bronchial breathing, for cavity formation or consolidation. In this stage one will very com- monly find at the base, and chiefly at the anterior lateral base, on the side opposite the chief lesion, signs of dr}^ pleurisy, with fine or medium- sized frictions reaching up as high as the fifth rib. And when tlie fric- tions from below merge into an area of the lung showing dry or fine moist rales, it is with the greatest difficulty that one can determine positively where the friction sounds end and the rales begin. And when, as in a diffused process, rales and friction sounds coexist, the difficulty is insuperable. Leaming ('84), a brilliant physical diagnostician, was puzzled by the distinction of fine frictions from crepitant rales, and after a number of autopsies in which he found that what had apparently been typical crepitant rales were really pleural frictions, advanced the theory of the pleural origin of the crepitant rale. Most authors now admit that in this he was in part correct. Certainly a distinction is often impossible. Trousseau, recognizing the difficulty of the distinction, called such doubtful rales "friction rfdes " (fruttenwuts rciles). On reading a text-book of physical diagnosis such a differentiation might seem a simple matter. But unless the frictions are loud and un- mistakably pleuritic, which is true in only a minority of the cases, none of the rules given will serve, the distinction being one of the most difficult the auscultator has to meet. The pleural friction is said to be increased by the pressure of the stethoscope, unlike the riile, but this maneuver will often not prove of assistance. Cough should remove or modify the rale and intensify the friction, and when one can demon- strate this it is a valuable sign, but is more often absent than present. Cornet ('07) quotes Prodi to the effect that oral auscultation inten- sifies resonant rales, while pleuritic frictions are weakened or not heard. The fact that pleural sounds seem to be directl}' under the ear is more reliable, but loud superficial rales can seem equally close. Pain is as often absent as present over pleuritic frictions. Grancher ('90) says: " Wben a sound like a moist crackle or a subcrepitant rale is heard at the end only of inspiration, and continues into expiration, we can reasonably attribute it to the pleura, because the large crepitations of pulmonary or bronchial origin exist from the beginning of inspiration. Further, it is characteristic of almost all light frictions that they only commence in the second part of inspira- tion, to continue during expiration, so that the ear has a paradoxical sensation of sounds similar to mucus rales, developed a long time after the passage of air in the bronchioles." 18 258 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS On the whole tlie writer believes that the only two fairly reliable points are clinical rather than physical — the persistence of the sounds, if pleural, in stationary or improving cases, and the fact that they are often found over areas in cases where rales so extensive would almost necessitate severe constitutional symptoms, yet in which health is fair. A young man, who at the first examination showed diffused over the front of his chest on the left side numerous apparently fine moist rales, had been pronounced to be in an advanced and almost hopeless condition. The total absence of rational symptoms, sufficient to justify such signs, led the writer to suspect that they were largely pleural, but only the sub- sequent course of the case, which has been one of very good health and working efficiency for years, showed that the assumption was correct. Turban's statement that there is no certain method of distinguishing fine frictions from rales is, therefore, fully justified. At the bases posteriorly one will frequently find fine or medium- sized frictions, which point to an old pleurisy, and in this same region, even in healthy people, on coughing one can usually get one or two transitory atelectatic or unfolding rales which are of no diagnostic value. Aside from friction sounds, one can at times be misled into suspecting the presence of rales by the sounds produced by the act of swallowing, by the friction of hairs under the stethoscope, by move- ment of the stethoscope on the dry skin, and more especially by muscle sounds. The act of swallowing can produce sounds very much like medium-sized moist rales over the apex, in front and behind, and since patients will generally after a cough swallow unconsciously, the exam- iner must be on his guard when, in auscultating the apex, he asks the patient to cough and take a deep breath, for some patients will swallow between the cough and the breath, thus producing most confusing rales. Patients should be warned not to swallow after the cough when per- forming this maneuver. Their occurrence and nature can be demon- strated very easily by a trial on the patient. In the case of patients with hairy chests crepitations can be caused by frictions of the stethoscope, but these should not give much trouble, and an application of vaselin (or water) will quickly remove these frictions, and in very hairy patients such an application should be a routine procedure. In patients with a dry skin, for a similar reason, careless application of the stethoscope should be guarded against, and here also vaselin is useful, but it should be noted that with the use of the binaural stetho- scope, which is almost universal in this country, unduly hard application of the stethoscope is much less likely to occur than with the monaural. OBJECTIVE SIGNS 259 Muscle sounds, if the patient is in a proper, restful, easy position during the examination, will not generally prove troublesome, but in some patients in the suprascapular regions they are very confusing, though Walsh thinks tliem more common in the infra-axillary regions. They are caused by the vibration of tlie muscle fibers on contraction, and hence are oftenest heard on forced breathing, or in patients in a constrained attitude, or in those who are chilled and shiver. Such sounds continue when the breath is held. Cabot ('05) would distinguish them by their being less clear cut, beginning and ending less distinctly, and being less crackling or bub- bling in character, as well as by their muffled distant character. He says that probably many rales described as " crumpling," " obscure," " muffled," " distant," or " indeterminate " are in reality due to mus- cular contractions. Sahli claims that they may simulate rough breath- ing, but this is doubtful. Turban ('99) dwells especially on the transmission from one lung to another not only of sonorous rales but of moist rales. The writer has often found such a transmission in the back between the shoulder blades, but never in front, from apex to apex, as Turban reports. Such transmission can be distinguished by slowly following the sounds from one side to the other and noticing the persistence of timbre and pitch with change of intensity. Vierordt ("89) warns against mistaking bronchial rales transmitted from the hilus of the lung to the apex for evidence of apical catarrh. A little care, however, in the examinations can obviate all these sources of error except in unusual cases, and with increasing familiarity with such work such difficulties will largely disappear. Insuperable difficulties in auscultation can be created by the presence of asthma, which, despite the fact that there seems to be some antago- nism between the two processes, is frequently met with in tuberculosis. The innumerable sibilant and sonorous rales completely hide any other signs, and one will have to wait for a period of cessation of the asth- matic signs before any opinion can be given. Aphonia and hoarseness may make auscultation of the voice impossible. Perforation of the nasal septum produces a loud, harsh, high-pitched breathing which makes proper auscultation of the breath sounds difficult and useless unless the nose is held, and if a nasal examination is neglected it may prove puzzling. ■ \ In this connection it is to be noted that a large percentag u. '■^nts will produce, by faulty nasal- or mouth-breathing, abnormally . yh respiratory sounds (see Diagnosis), and tliat in such cases, which are frequent in America, where nasal obstructions are common, it is essen- tial to use quiet moulli-breathing and teach the patient how to carry 260 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS it out properly. Many patients produce an excellent imitation of bronehovesicular breathing in the nose or larynx, and the examiner should bo most careful to listen to the breathing of each patient, both during quiet and deep breathing, and if necessary teach him how to breathe correctly before proceeding to auscultation. At one time great Aveight was laid on the value of a suhdavian sys- tolic murmur in the early diagnosis of this disease. It was first dis- covered by Stokes ("82) and ascribed by him to a falling in of the subclavicular region and consolidation. He noted that hemoptysis or leeching would remove it. but did not lay any weight on it as a diag- nostic sign. W. Walsh ('71) quotes Palmer, who found it present in 103 out of 497 healthy workmen, and considers it a pressure murmur and so common in the healthy as to be of no vahie. Euehle ('87), who laid considerable weight on it as an early diagnostic sign, believed it was due to a kinking of the artery by pleural adhesions, where it crossed the apex of the lung, and considered a systolic subclavian murmur, near the end of expiration only, in the outer part of the subclavic- ular fossa, an evidence of pleural adhesions at the apex. While it is found quite often, its value in diagnosis is small, its freciuent presence in health rendering it unrelial^le as a sign of apical adhe- sions, and this seems to be the consensus of the more recent opinions on the subject. Accentuation of (he second pulmonic sound is very common in mod- erately advanced or old cases, and if much filirosis exists a pulmonary systolic murmur may be produced. A roughening of the tricuspid systolic sound is also common. Sokolowski ('06) lays great weight on the value of small areas of persistent, fine, moist rales in the lower portion of the lung without percussion or other auscultatory changes, as speaking for small foci of infection, as yet too small to give other signs, but which will sooner or later manifest themselves. In these areas the breath sounds are generally unaltered, which makes their value doubtful, but it is not safe to suppose that adventitious sounds will necessarily l)e accompanied by breath changes, as frequently this will not be the case. Auscultation of the voice, on which formerly, through the influence of Laennec, much stress was laid, has not yielded the results anticipated, and modern physical diagnosticians do not rely on it to any great extent. W. Walsh (*71) has well stated it when he says: "The signs derived from modified vocal resonance are uncertain in character and , obscii^;/in theory, and though occasionally not devoid of clinical signi- fica(nce, hold, as a rule, a very low place among physical aids to diag- nosis." Formerly great pains were taken to differentiate bronchophony from pectoriloquy, etc., but to-day it may safely be asserted that the OBJECTIVE SIGNS 261 chief thing to which attention need !)e given is the increase or decrease of vocal resonance (Flint, '56). The results of the determination of an increase of vocal resonance in the writer's experience agree very closely with those of percussion, and are of some value in verifying the latter, but one is often surprised by the lack of correspondence, between vocal fremitus and vocal resonance, though they generally roughly correspond. Increased vocal resonance, which is only a lessened degree of bron- chophony (Salili) adds nothing new to the information obtained from bronchial breathing and resonating rales, and like them speaks for consolidation or cavity formation. It is scarcely necessary to recall that the voice at the right apex is normally more resonant than at the left, so that, equally Avith vocal fremitus, an increase in this region must be very marked to have any meaning. The whispered voice gives a better impression to the ear than the spoken, since this normal exaggeration of vocal resonance at the right apex is less marked, and Babcock ('OT) considers the sound clearer and more sharply defined in whispering than in speaking. The writer has found that patches of increased vocal resonance in the posterior bases, just like areas of undue heart transmission, give useful early warning of the development of foci of trouble, and changes here are more easily determined, since vocal resonance, in w'omen at least, is normally less below than above. In the estimation of vocal resonance, however, one must take into consideration the timbre of the patient's voice and the formation of his thorax. Men and deep-voiced people, or those with firm chests, have more vocal resonance than children and women, or those with weak chests. Once established, increased vocal resonance is very persistent (Flint, '56), so much so that in a bilateral process one will at times find the vocal resonance increased on the apparently well side as the result of an old healed process, while the active trouble is in the other side. Decreased vocal resonance is found at times over pleural effusions, thick pleural membranes, emphysema, or if the bronchus leading to that portion of lung is plugged, but it is not usually of very great value. Pectoriloquy is chiefly useful as a cavity sign, hence is dwelt on under the auscultatory signs of the third stage, but it should not be forgotten that it may be found over a consolidation if the consolidated patch contains a bronchus, and that whispering pectoriloquy should never be relied on too implicitly in the diagnosis of cavity formation. Egophony, a tremulous, intermittent, bleating voice, was considered by Laennec pathognomonic of pleuritic effusion, and is usually found in that condition above, or just at, the level of the fluid, but, like pector- iloquy, it may at times be found over consolidations, but it is not com- mon in tuberculosis. 262 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS When a patient is aphonic, or hoarse, Sehrwald's plegaphonia (An- ders, H., '07), or artificial vocal resonance, is of use if it is important to test the vocal resonance. The thyroid cartilage is lightly percussed by the hammer, using a pleximeter, with the patient's mouth closed, and the resultant pulmonary sounds are auscultated. Aufrccht ('05) speaks of what he calls a "bronchial after-sound" (hronchialer Nachhauch) in cases of infiltrated lung and pneumonia. It is a rough bronchial after-sound heard at the end of the spoken word, or after it, which corresponds to the expiratory bronchial breath. He claims to have been the first to note it, but Flint referred to the same thing as a bronchial souffle, accompanying the spoken word, and quotes a case in point. Enlarged broiicliial glands are most apt to l)e found in the second stage, though the fluoroscope will at times reveal them in incipient cases. The most typical auscultatory sign of such enlarged glands is a sibilant inspiration heard on one side, or less often on both sides, of the sternum, at the level of the second or third ribs, and it is transmitted downward and outward. Less commonly it will be heard behind be- tween the scapuljfi and the spinal column. This is most suggestive, if not diagnostic. It is due to a compression of one or both main bronchi by the glands. Barety ('74) considered a blowing bronchial expiration, commonest behind, as very typical. Barthez and Eilliet ('61) noted as diagnostic a large, noisy ronchus, masking the respiratory sound, transmitted to a distance, very persistent, unlike a sibilant rale of bronchitis, and due, they believed, to tracheal com])ression. Emphysema, if in scattered foci due to phthisis, is difficult to rec- ognize, but if limited to an apex around a focus of trouble the typical prolonged feeble expiration will often serve to enlighten one. When general, it has antedated the tuberculosis, and gives all the signs on inspection, palpation, and percussion, which make it unmistakable, but in such a case it can render the auscultation of the tuberculous lesions much more dilficult. In all stages of pulmonary tuberculosis, but especially in the second stage, it is needful to remember that there always exists in the lungs much more trouble than the most acute diagnostician can discover, and that what is found are only the more sviperficial or advanced lesions, while, as innumerable autopsies have shown, there is always an advancing border of trouble which stretches well beyond the extreme limit deter- minable by physical diagnosis. While the general tendency of tuberculosis is toward a gradual spread of the disease, a few cases which, while not advancing toward a cure, will remain stationary for long periods, the signs not changing materially, and while of course one would prefer to see a gradual retro- OBJECTIVE SIGNS 263 gression, \yith clearing up of the involved areas, such cases are often very favorable and speak for the development of fibrosis. When a case is advancing toward cure, there is noted first a diminu- tion in the number, size, and quality of the rales, abundant rales becom- ing scanty, large rales becoming small, and moist rales becoming dry. With this there occurs a lessening in the intensity of the breath sounds which retrograde in somewhat the same order in which they have ad- vanced, though where there has been any but the slightest trouble, normal, pure, vesicular breathing never entirely returns, although the impure breathing may be masked greatly by the development of com- pensatory emphysema. While in the most favorable cases rales dis- appear entirely, this is not always the case, and the writer has seen patients Avho have been well for years in whom he could demonstrate small patches of fine rales, generally dry, though they sometimes seemed moist, and these are probably pleural and not parenchymatous. Auscultation of the Third Stage. — The use of the term stage of cavitation for the third or most advanced stooge of tuberculosis, has often been objected to on the ground that cavities exist at a much earlier period, as shown by the fact, demonstrated by Sokolowski, that elastic tissue can be found in the sputum within a few weeks of the discovery of early signs; but while this is ti-ue, and on anatomic and pathologic grounds the term is not correct, clinically and in the study of the phys- ical signs it corresponds very closely with the facts, and this stage is especially characterized by the signs and symjjtoms of cavitation which generally dominate the clinical picture, though, as Fox notes, signs of extensive solidification and of fibrosis are also prominent. Cabot ('05) considers these latter the most prominent. Just as the first stage is marked by slight changes in the inspiratory and expiratory murmurs and fine dry rales, the second by broncho- vesicular and bronchial breathing and medium and fine moist rales, so this stage is characterized by tubular and cavernous breathing with metallic overtone (Leube, '91) and large, moist rales and gurgles with resonating character. At the same time it should be noted that, on account of the multiplicity of lesions, the signs of the third stage are usually extremely varied, which makes its auscultation often most un- satisfactory and confusing, as can well be understood when one exam- ines the lungs of such a case at the autopsy. Thus it is much more difficult in the tliird stage to draw correct conclusions as to the exact existing physical conditions in the lungs than in the other stages. As the process so generally begins in the apical regions and advances downward, the third stage generally shows the signs of all the stages, advanced cavity fornuition above, consolidation with softening in the middle and disseminated tubercles below, so that, as a general rule, the 264 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS signs of the third stage are found ahove the fourtli I'ih, and cavities will not be discoverable in the base except in very old chronic cases of long duration. When it is recalled how many conditions must be satisfied before a cavity can be demonstrated — superficial location, considerable size, no cavity less than a walnut heing discoverable (Gerhardt, 'l)U), connection with the air, more air than secretion in its contents, etc. — and that there is no single sign which can be considered pathognomonic, it is not remarkable that autopsies show such a large number of cavities which were overlooked during life. Landis (*06), in an excellent study of 76 cavities in 515 cases in the Phipps Institute, of Philadelphia, Avhieh had been carefully observed by the staff, found that 58 had been recognized and LS overlooked, a better percentage of diagnosis than would usually be obtained. Fortunately, the determination of the pres- ence of a cavity, while important, has not the extreme importance once attached to it, for, as Sokolowski says (*0()), the presence of excavation, whose recognition is important, can be sooner and more surely deter- mined by the discovery of elastic filjers in the sputum, though of course this gives no iriformation as to its location. jMoreover, the diagnosis in this stage never depends on the physical signs, and examination is apt to be of more importance from a prognostic than a diagnostic standpoint. Broncliial or {uhiihir hrrafliinf/, as has been noted, appears in the second stage, with tlie occurrence of appreciable amounts of consoli- dation, and so in itself cannot be considered a characteristic of the third stage. It is, however, very commonly found, since areas of con- solidation are always present, and Loomis ('77) taught that in ad- vanced tuberculosis a cavity could be suspected if there was found intense bronchial breathing, localized, and accompanied by metallic moist rales. The typical respiration of the third stage is cavernous or more rarely amphoric. Most of the German writers following Skoda ('64) admit no distinction betAveen bronchial, cavernous, and amphoric breathing, Leube ("91) considering the latter to be a bronchial breath- ing with a metallic tone, but Sahli treats of them as distinct subvarie- ties, and the majority of American, English, and French authors recog- nize their distinction as independent types as valid, and it seems that either as a subvaricty or as an independent type the division should be recognized as justifiable and useful. Such a difference of opinion, how- ever, shows that there is need of great care in distinguishing them. Cavernous breathing has a low-pitched, blowing inspiration, bron- chial breathing a high-pitched one; in cavernous breathing the expira- tion is even lower pitched, in bronchial breathing higher pitched; cav- ernous respiration is weak and hollow, bronchial breathing intense and OBJECTIVE SIGNS 265 tubular. When there is a combination of solidification and cavita- tion there may be a mixture of both, which Flint ('T5) distinguishes as bronchocavernous. Cavernous breathing Ij}' itself, if not well limited, cannot be relied on to any great extent, and of it, as of so many other of the signs of tuberculosis, it may be said that it is chiefly of value if circumscribed, combined with other symptoms, and surrounded by an area of bronchial breathing, just as the percussion sign of cracked- pot resonance, to be valuable, must be sharply defined and surrounded by an area of dullness. Of course, if to this are added large moist rales or a metallic tinkle or metamorphosing breathing, etc., tlie certainty is increased, but such happy combinations of convincing signs are the exception rather than the rule, it being much easier to put together a table of such typical signs for a text-book than to find them com- bined in a patient, and in Landis's cases 29 showed cavernous ])reath- ing, 19 amphoric, and 13 bronchial. Amphoric hreatliing is so well imitated by blowing across the mouth of an empty bottle that anybody can produce for himself a perfect reproduction of it. It is metallic and blowing, and is almost unmis- takable, but for its production there is needed a cavity of at least 4 to 6 cm. diameter (A. Fraenkel, '91), with smooth, stiff walls and a con- sideral)le bronchus entering it, hence it will not be a common finding, but, if pneumothorax can be excluded, generally not difficult of diag- nosis, it is a positive sign of great value. Metamorphosing breathing, in which the first part of the inspira- tion is high-pitched and resonant, and which changes during the. larger part of inspiration to bronchial or vesicular hreatliing, is variously explained as due to partial occlusion of the bronchus leading to the cavity by mucus which the latter part of insjjiration is strong enough to remove, or to the increasing dilatation of the cavity and its opening, which changes its note, or to the entry of air into unequally diseased areas (Sahli, '02). This is a fairly sure sign, but is too rare to be of great assistance. Large moist rales are the typical nlle of this stage, and speak either for rapidly advancing softening or cavity. In the apex, where there are no laige l)ronclii, they are a very valuable cavity sign, Vierordt, as already noted, considering them the most typical sign of excavation in an apex. Lower down they can be produced in the large bronchi, and are therefore not as diagnostic, nor are they as common. When they increase in numljer and size they become gurgles, which are very numerous and very large bnljbling sounds, masking everything else, and which, on the whole, are the most certain sign of advanced and extensive excavation, Stokes ('82) hinging the diagnosis of cavity on cavernous l)reatliing and gurgles. Unfortunately, they are usually found 19 266 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS only in hopelessly advanced cases where diagnosis and prognosis have been long since settled. In the majority of cavities we find fairly numerous moist rales, with various indeterminate crackling, crumpling sounds, and in the surrounding tissue medium and fine moist or dry rales, which increase with the progress of the disease, but which, when the case improves, gradually lessen and disappear, the cavity being said to become " dry " and only presenting breath and voice changes. Naturally, such " dry- ing " of a cavity is a prognostic sign of great value and good omen. By degrees the fibroid shrinking of the surrounding lung begins, and the signs become less evident, until very often no signs remain, which in a new case would lead to a suspicion of a cavity. Such dry cavities luay persist for years, rarely remaining truly dry, but producing gen- erally a small but constant amount of mucopurulent sputum, even when all signs of moisture are absent. If the victim of such a cavity leads a healthy country life in a clean, dust-free air, it will generally remain inactive, but a return to the dust of cities, or much railroad traveling, will often reinfect them with pus organisms and cause a return of active ulceration and moisture. It is such cavities as these also which in old inactive fibroid cases may cause sudden, and at times fatal, hemorrhages in apparently cured cases, or, if it does not go as far as this, they account for the recur- rence at intervals of pink sputum, which will often follow overexertion or colds. The writer recalls such a case in which the cavity had been dry and contracted for two years, and the patient had returned to work in good health, when suddenly, probably from a small miliary aneurysm in the wall of the cavity, hemorrhage occurred with a fatal termination. While, as a usual thing, the cavities, for the reasons stated earlier, are found above the third or fourth rib, one can, at times, through the coales- cence of several cavities, see a whole lobe or more rarely a whole lung converted into a large sac, and a beautiful example of the latter condition is to be seen in the pathologic collection of the Phipps Institute at Phila- delphia. Metallic tinl-Je is a rare sign. It is not caused, as was once thought, by the dropping of secretion from the wall of a cavity into its fluid con- tents, but by the bursting of bubbles of air at the surface of the fluid in a cavity with whose note they are consonant. It is only found in pneumothorax and large cavities, and when found is a positive sign of one of these conditions. The Germans, who, as noted, do not distinguish cavernous or amphoric breathing, consider a metallic tone to bronchial breathing, moist sounds, or rales one of the best cavity signs (Gerhardt), OBJECTIVE SIGNS 267 this being ])iit another wa}' of recognizing the Vakie of what in France, England, and America is called cavernous breathing. The vocal resonance of the third stage may be varied, but, as a rule, it is strongly exaggerated. Over consolidation one can get either bronchophony, pectoriloqu}^, or amphoric voice. Laennec considered pectoriloquy pathognomonic of cavity, but it can be heard over a con- solidated lung if a large bronchus passes through the consolidation. It demands a large cavity with firm Avails, freely communicating with the bronchus, nearly empty, and superficially located. Such conditions, of course, assure its infrequence. Even whispering pectoriloquy, while a more relialjle sign, can be found over solid lung, and W. Walsh, who is su])posed to be sponsor for this sign of cavity, says ('71): "Vocal resonance should never be seriously appealed to in diagnosis of a cavity. The form of resonance most nearly distinctive of an excavation is whispering pectoriloquy; but cavities may exist without this, while resonance of the sort ma}' exist under physical conditions directly the reverse of excavation." And again : " Where the quality of the resonance is markedly hollow and ringing, and where it exists in the whis])ering forms, I long believed that it strongly indicated a cavity; l)ut I have found whispered pectoriloquy over even simple acute hepati- zation, as well as in the retraction period of pleurisy." Landis ('06), who found it in a majority of cases and believes it a valual)le sign, does not consider it pathognomonic and found it over consolidation al)Out a bronchus. It should not be relied on too implicitly. Whispering pcctoriloqny over a cavity differs from that over solidi- fication just as cavernous breathing differs from bronchial — i. e., it is low and blowing instead of high-pitched and tubular. Once more it can be said that localized, and accompanied by other signs, its value is considerable, or to quote Stokes ('82) : "Taken alone it is absolutely without value, but when in combination with other signs it strengthens the diagnosis." Amphoric voice, a cavernous voice with amphoric echo, demands a very large, thin, smooth-walled cavity, and is most typically heard in pneumothorax, and, like amphoric breathing, if pneumothorax can be excluded it is a positive sign. To recapitulate, the most reliable auscultatory signs of pulmonary excavation are cavernous breathing, large most rales or gurgles, and whispering pectoriloquy, but the filling of the cavity with pus, the occlusion'of its outlet, or its location in the middle of healthy lung tis- sue, may render its diagnosis impossible. While cases which have ad- vanced to the -third stage, with demonstrable cavitation, have a poor outlook for recovery, a small number, as autopsies have abundantly proved, may become arrested if the process is not too active and the 268 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS resisting powers sufficient, so that the system can form fibroid tissue around the lesions. In such cases the symptoms of ulceration by degrees lessen, expecto- ration becomes less and less purulent and more mucoid, rides decrease and finally disappear, symptoms lessen coincidently with an increase of general vitality and strength, and the jiatient can reach quite a fair state of health and Avorking efficiency. Such cases are, however, the exception, and may at any time, without any imprudence on the ])art of the patient, relapse; the dormant disease becomes active, or sudden hemorrhages occur. Thus if one would obtain permanent and satisfactory results, it is essential to discover and diagnose cases of tuberculosis at a time Avhen the lesion is so limited and so little destruction of tissue has occurred that the body may be able to encapsulate the process, which is, of course, impossible Avhon the disease has reached this stage. Roentgen Rays. — The discovery of the X-ray and its application to internal medicine has placed at the disposal of physicians a method of physical diagnosis which has proved to be of great value, especially in pulmonarv diseases. It has now l)cen used long enough to justify con- clusions as to its utility and its limitations in this branch of medical work, and though, as was to be expected, excessive claims have been made for it ])y some enthusiasts, tlie majority of physicians, including many prominent radiologists, recognize tliat, however great its value, it is to be looked on ratber as an addition to than as a substitute for the standard methods of examination. After having used the Eoentgen ray fluorosco])ically in all his exam- inations for the past seven years, tlie writer believes tbat in the majority of cases an expert physical diagnostician will be able to make a diagnosis of incipient tuberculosis sooner than will the radiologist, but in a few cases the latter will discover small foci of trouble in" the lung which neither auscultation nor percussion would reveal. There are certain pulmonary conditions, especially enlargements of the tracheobronchial glands and peribronchial infdtrations, which can be diagnosed far earlier and better by this method than l)y any other. Despite its limitations, therefore, exploration by Eoentgen rays is a most valuable addition to our means of examination, if used in conjunc- tion with the standard methods. Of the two ways of using the Eoentgen ray, fluoroscopy, or the production of a shadow picture on a fluorescent screen, and radiography, or the record of the picture on a photographic plate, the latter gives more complete details, and by it expert radiologists can now demonstrate the existence of pulmonary tuberculosis in certain cases at an extremely early stage. L. G. Cole, of 'New York, has been able to demonstrate small foci in an apex, and more especially along OBJECTIVE SIGNS 269 the branches of the bronchial tree, and to prove their existence after- wards at antopsy, when they were of such a size as to be entirely undis- coverable by the most acute diagnosticians. While, however, the radiograph can at times recognize lesions undis- coverable by the fluoroscope, the difficulty is that the expert physical diagnostician is rarely an expert radiologist, or vice versa. Moreover, the apparatus for radiography is so complex, the technic so elaborate. Fig. 5fj. — Postekior View of the Lungs in an Acute Active Case, Showing Multiple Cavities (K) in the Infiltrated Upper Left Lobe. In the right lung is infiltration (G") starting from around the roots of the bronchi, a fa\orite spot, and in this region a calcified bronchial gland can be seen (/). The right ventricle of the heart is enlarged. the time required so great, and the proper development and interpreta- tion of the plates a matter of such special skill, that its use will neces- sarily remain confined to specialists, to wliom tlie patient will be sent by his physician for study and report. On the other hand, fluoroscopy, while in certain cases not giving as 270 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS early information as radiography,, gives immediate information of great value, is much less time-consuming, the apparatus and technic is much Fig. 57.— Anterior View of an Old Chronic Process with Intense Consolida- tion IN the Upper Left Lung (H) and a More Extensive but Less Dense Infiltration in the Right Side ((?), and with Peribronchial Enlarge- ments Along the Course of the Bronchial Tree on the Right in its Downward Course. Note also the area of infiltration (G) advancing in front of the consolidation of the upper left lobe. In the right lung are to be seen two cavities (A'), possibly bronchiectatic (surrounding lung relatively clear instead of infiltrated, as usual, around a cavity). The bronchial glands on the right are enlarged at the root and along the bronchi, and where they cross the ribs (L) the summation of the two shadows make denser spots. The heart is drawn slightly to the right, which would suggest the existence of fibroid con- traction in the right side. less complex and expensive, and the interpretation of the findings very much simpler, so that the physical diagnostician can easily adopt it in the routine examination of his cases without loss of time. Moreover, it OBJECTIVE SIGNS 271 not only gives liim assistance in making an early diagnosis, but it will inform him of the topography of the disease and can visualize to him, as can no other procedure, the condition of the lung. The advance and retrogression of the disease thus becomes actually observable. While the radiograph gives such fullness of detail that it is difficult, even for an expert, to distinguish at times between normal and pathologic shadows, the picture given by the fluoroscope shows none of those misleading nor- mal shadows, and thus is much easier to interpret. Correct information as to alterations in motion can only be obtained by it, and, except for the detection of deeply seated small foci of a half inch or less in diam- eter, fluoroscopy is most satisfactory. Holzknecht says that in chest examinations radioscopy must be the method chiefly used, and F. Kraus, one of the best-known diagnosticians and clinicians, holds similar views. The writer believes that the use of radiography will be confined to the X-ray specialist, and that the physician, through want of time, will most advantageously use the fluoroscope. It is hoped that fluoroscopy will be more generally adopted by the profession for pulmonary cases. Before proceeding to a description of the changes found in the lungs by means of flouroscopy, it need hardly be noted that it is essential that the physician be entirely familiar with the normal fluoroscopic picture if he is not to be misled by certain appearances which might at first seem to him pathologic. The normal lungs, from in front, are seen on the fluoroscopic screen as two irregular, triangular areas of mildly glow- ing translucence, separated by a more or less triangular, vertical, dark shadow, with its broad base below, which is produced by the sternum, mediastinum, spinal column, heart, and aorta (Fig. 60). The sternum makes a vertical, bandlike, dark shadow, extending from the diaphragm upward to between the shadows of tlie clavicles, and this central shadow is enlarged to the left from the second ril) to the diaphragm by the shadow of the aorta, pulmonary artery, auricle, and ventricle (Fig. 64). This enlargement to the left consists of three scallops, the smaller, above, being that of the aortic arch (Fig. 60), the medium that of the pulmonary artery and auricle, the largest, below, that of the ventricle (Fig. 60). On the right side, extending from the fifth rib to the diaphragm, is a narrow, paler, triangular shadow, cast by the right ventricle (Fig. 60). The translucence of the lung area increases from above downward, being quite faint above the clavicles and quite bright at the bases (Fig. 60), and brightening considerably on deep inspiration, wliich also in- creases the clearness of the cardiac and diaphragmatic outlines. Across this bright area run the shadows of the clavicle and the ribs, and in favorable cases we also see through the intervening lung the posterior portion of the ribs, the superposition of the two producing a latticelike shadow effect (Fig. 57). Above the clavicle the apex rises in a dome 272 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS (Fig. 59), the apices being normally of equal heiglit and slightly shaded by being covered, on their posterior surfaces, by ribs and thick muscles. The inner border of the lung area is quite sharply marked off from the sternum and heart (Fig. 6U). The outer border is rather indistinct and ill-defined, while the lowei' border is the most distinct of all, standing out sharply in contrast Avith the blackness of the diaphragm and abdo- men. This lower border curves sharply downward at its outer end to form one side of the costodiaphragmatic angle (Fig. G"*;?), and is short- ened at its inner extremity by the projection of the heart, the lower border of whose apex makes an angle with it. In a certain number of patients the air in the stomach makes a bright area below the diaphragm, this muscle being seen in profile as a thin dark arch, movable on respi- ration and separating this area from that of the lung. In thin subjects with heavy bones one can at times see the shadow of the angle and lower portion of the scapula (Fig. 62), showing through the chest from behind and closely simulating an area of shadow in the lower and lateral por- tions of the lungs. In the same way, in women the breast may produce deceptive shadows (Figs. 60 and 61), especially in the posterior view, but movement of the scapula or Ijreast will easily dispel doubt. The heart shadow is (juite clear-cut and dark, though not so dark as the sternum, but is lighter in its auricular and aortic portions, and its motion can be w'ell seen, especially on deep inspiration. The motion of the bases should be even on both sides, but the difference between extreme inspiration and ex])iPation is slightly greater on the left side than on the right, owing to the presence of the liver on the right side. It must be recalled that for the same reason the arch of the diaphragm is a little higher (^ to f of an inch) on the right side than on the left (Fig. 56), and that this must not be mistaken for that pathologic eleva- tion produced by shrinkage of the overlying lung (Figs. 59 and 60). In successful fluoroscopic examinations there is seen on each side of the sternum, from the level of the second rib down to the fifth, a faint ribbonlike shadow (Figs. 59-62), radiating dow^nward and slightly out- ward from the border of the sternum, and formed by the hilus of the lung, bronchi, and blood-vessels, and called the accompanying shadow of the h.eart. On a radiograph the same shadow is much more pro- nounced. The lung markings, indistinct branching or marbled shadows all over the lung, seen in good radiographs of the normal lung (Fig. 61, A), are not seen on the Huoroscope at all, thus removing a fruitful cause of doubt. Seen from behind, the lung area is still of about the same shape, but the outer half of the area is rendered indistinct by the shadow of the scapula, especially by its spine, inner border, and angle, in that order of importance. The shadow of the inner border may re- semble an accompanying shadow, but motion of the shoulder blade will OBJECTIVE SIGNS 273 quickly remove any doubt. From behind, the heart shadow is large and less distinct, being farther from the screen, and the right ventricle shows up more plainly to the right of the spinal column than it does in front. The accompanying shadows are not seen from behind in the normal lung. In thin subjects the clavicle is clearly seen through the intervening lung, dividing the apex from the rest of the lung. Naturally, the fluo- roscopic picture is clearest in thin people and children, while in very Fig. 58. — Axtekior View of an Extensively Involved Left Lung. A cavity is seen in the upper left lobe (K) with infiltration (G) between it and the dense consolidation lower down (//). This consolidation is located outside and slightly above the heart, a favorite ^ite for it (see text as also under Percussion). On the ri^ht is seen glandular enlargement and thickening around the root of the lung (F). The right border of the heart at B, despite the left-sided trouble, is not yet dislocated to the left. fat or very large muscular people fluoroscopy and radiography are both relatively valueless, owing to the lack of definition of the image, which no increase of intensity of the light can overcome. In this connection it is to be noted that the lung should not be examined with tubes of very high vacuum and great penetration, as Ihey obliterate faint shadows and render the ])icture indistinct and unsatisfactory, and that one should work with a tube of llie lowest vacuum that will give a clear picture, just as with the microscope, in the study of details, little light is used, details being obscured by too brilliant illumination. 274 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS The i:>ictnre given by the lung in puhnonary tuberculosis may be varied; on the one hand, with definite and serious auscultatory signs one will, in acute miliary cases, usually be surprised to fuid a strictly normal fluoroscopic picture, the lung being evenly illuminated in every part, although Williams's sign of lessened diaphragmatic action may generally be discoverable. On the other hand, in old chronic fibroid or pleuritic cases, or in cases with much consolidation or caseation, there are large, irregular areas of shadow, varying in density from a pale gray in recent active lesions (Figs. 59-62), to dense shadows in old in- active chronic (Figs. 57 and 58) trouble, pleural thickening (Fig. 63), or effusion (Fig. 64). Between these two one can find anything from faint, slight mottlings, to dense spots of local shadow (Fig. 60, F). The fluoroscope only discovers condensation, and by recalling the pathologic conditions in acute miliary tuberculosis, and in old chronic cases, the reasons for these findings are clear. The fluoroscope gives information, first, as to changes in motion; second, as to changes in density; and third, as to changes in size of the lung; or, more specifically, as to: (1) changes of motion and position of tlie base; (2) increase or, more rarely, decrease in the density of lung tissue; (3) enlarged bronchial glands; (i) the comparative size of the two lungs; (5) the size and position of the heart; (6) thickening of the pleura; (7) collections of fluid and air; (8) ex- cavations of lung or dilatations of bronchi. In considering these changes it is well to discuss them as found: first, in incipient cases; second, in moderately advanced cases; and third, in advanced cases. Changes in Incipient Cases. — The changes in incipient cases are not numerous or pronounced, but they possess considerable diagnostic value, although this value is probably not as great as many radiologists think. AVilliams, of Boston, states that cases where tuberculosis is shown by the rays fluoroscopically before the physical signs are diagnostic are common, those in which the rays and the signs both indicate the disease are more common, and those in which the signs indicate tuberculosis before the rays do are rare. The statement that usually the Eoentgen ray surpasses auscultation in making an early diagnosis is widely at variance with the writer's experience. In a majority of cases a proper physical examination will surpass the Eoentgen-ray fluoroscopic exami- nation in a diagnosis of incipient disease. The number of cases examined by the writer up to date is very large. In these he has used the Roentgen ray for fluoroscopic examinations under the best conditions, and in the large majority of cases physical signs antedated fluoroscopic changes. Walsh says, in disagreeing with Williams's opinion, that he has "not yet seen a case which could be proved to be a case of tuberculosis in which the process could not be demonstrated with a careful (physical) examination." OBJECTIVE SIGNS 275 Beclere quotes the work of Kelsch and Boinon, who in 124 chest examinations of eases of tuberculosis found 73 absolutely negative, which would seem to verify these views. Holzknecht says, as a result of autop- sies, that the cases of apical tuberculosis diagnosticated by the Roentgen ray are anatomically not cases of incipient tuberculosis, but old shrunken foci, only showing activity in spots. Such cases are clinically, but not anatomically, tuberculosis. On the other hand, in undoubted cases of apical catarrh one may fail to find any changes, except abnormal dia- phragmatic action, and at other times extensive focal shadows. This, he believes, is due to the fact that the latter, which appear as in- cipient cases, are really exacerbations in old healed foci. The remainder Fig. 59. — Anterior View of the Lungs in a Case of Early Acute Tuberculo- sis OF THE Left Lung. Note the diffused light mottling in the upper left side (G), showing the acuteness of the trouble. The peribronchial glands on both sides are thickened (F). At / are seen calcified glands or tubercles, and the diaphragm on the right is unduly retracted, possibly as a result of the peri- bronchial trouble. Compare the clear right apex with the left, which is clouded. of the cases which are clinically doubtful but radioscopically positive, are cases with large, centrally located foci and with slight or little catarrh. " The real!}/ anatomically incipient cases — i. e., conglomerate tubercles and catarrh — am/' he says, " radioscopically undeterminable." The incipient changes are, first, limitation of motion of the base; 276 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS second, apex or, more rarely, other shadows; and third, shadows of enlarged bronchial glands. Limitation of motion of the diapliragm on the affected side was first noticed by Williams, of Boston, in 181)7, and has since been verified by all observers. The limitation of motion is at times seen on one aspect (anterior or posterior) and absent on the other, and in any case motion is most markedly limited in that face of the lung which it most involved (Walsham). A limitation of motion can often be found when no other abnormality can be seen on the screen, but the writer has never found limitation to exist in a case where careful auscultation could not deter- mine incipient trouble. Williams, however, considers that it may long antedate any auscultatory changes. The limitation has been ascribed to various causes, but it seems sufficiently and best exj)lained by the loss of elasticity in tlie diseased portion of the lung wliich lessens its expan- sibility, and which also accounts for the retraction of the apex border shown by apical percussion. As the process advances, loss of motion may Ijccome very marked, and is present in all well-marked cases, and, if much dry pleurisy is present, niay be absolute. Diagnostically, a slight limitation of motion of the base of one lung Avould raise other dubious symptoms to a very high value, and make a diagnosis which would otherwise be impossible. By itself limitation of motion is suspicious, but does not justif}' diagnosis. Shddiiuj of tJic apex region (Figs. 5G, G and GO, G), or, more rarely, small spots of shadow in other regions, is the second early sign of pul- monary tuberculosis on the fluoroscope. A shadow in the apex is usually a imiform fogging over the whole ai'ca, and generally of only moderate intensity, and it is often combined with a decrease of apex area (Fig. 62). At times part of an apex will be clear, and again, but not often, there is found one small, sharply defined focus, sometimes just behind the clavicle, more usually above it, and very rarely elsewhere in the lung. Holzknecht warns against mistaking the dark spots at times formed in a dorsal image by the crossing of the first rib and sternal end of the clavicle for an apex focus. In more advanced cases, with cavities in the apex, these cavities, unlike excavations elsewhere, are not bordered by dense shadow on the ui)per side, tlie apex in such cases simply appear- ing unduly bright and clear, with shading below. In certain early cases the writer has found the apex on the involved side smaller than that on the sound side, though it was not shaded, Init usually the shrinkage of the apex and flattening of its domelike outline, with lessening of the height above the clavicle, only occurs wdicn trouble elsewhere in the lung has caused a general shrinkage. AValsham considers a failure of the apex to light up on deep expiration an excellent early sign. In examining the apex for shadows it must be remembered that this OBJECTIVE SIGNS 277 area is normally less bright than the rest of the lung from 1)eing shaded by the ribs and thick muscles behind, but tliis need not give trouble, as the normal apex has a fairly clear outline, while the involved apex has a liazy and indefinite one. The French school of radiologists believes that the right apex is normally less bright than the left, but the writer is in accoi-d with the Germans, wlio have not recognized such a difference. The diagnostic value of an apex shadow is great, but it is not a very early apj)earance. Beclere's statement that the diminution of the Fig. 60. — Anterior View, SHOW^NG Enlargement of the Peribronchial Glands Around the Roots Shown ry Bunched Shadows (F) on Each Side of the Sternum, that on the Left Being Just Outside the Auricular Shadow. At the extremity of the right bronchial tree just above the diaphragm are seen some small calcified glands or tubercles (7). The infiltration of the right apex (G) extends downward and inward through the sterno-clavicular angle to the l)ronchial glands, a common finding, and giving rise to the ohlif|iiity of the shadows of a])ical trouble referred to in the text. Compare the clouded right with the clear left apex. Note mammary gland at M. transparence of Ihe n])ex to the "Roentgen rays antedates hronchopliony, dullness, and crackles is correct, and the writer has not fiuiiid that it can antedate rough inspiration, feeble l)reathing, or slight vesiculo-bronchial breathing, as it must if it is to precede ])hysical signs, and when it is recalled what are the palbologic conditions winch produce these slight changes, it seems most imj)robable that they should cast shadows. 278 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS The next incipient change, and one which often antedates any phys- ical signs, is the shadow cast by enlarged bronchial glands (Figs. 59, P; 60, F; 61, F). These can cause two forms of shading. The most inter- esting and striking, but the least common, is a hemispherical or, at times, a more irregular fusiform mass of shadow on one or both sides of the sternum, at the end of the second interspace, or a little lower, and varying in density from light gray to a very dark gray or almost black, and if the shadow is not very dense, as is the case if the glands are not calcified, it can so merge into the aortic shadow (Fig. 64) as to cause some doubt as to its real nature if it is confined to the left side, as it is usually. The writer has found these shadows quite frequently in cases with incipient apical catarrh, the enlarged glands almost certainly ante- dating the latter by months or years. Under treatment such gland shadows can be seen to lessen notably in size, and in some cases shrink sufficiently to disappear from view behind the sternum. Posteriorly, such shadows can also be seen, tliough not so frequently nor so well, and stand out sharply to tlie left or right side of the spinal column, about the level of the spine of tlie scapula, or again may show themselves as a fusiform widening or thickening of the spinal shadow at this point. A large glo])ular enlargement of the tracheobronchial glands will at times be found in syphilis, and as syph- ilis may cause severe cough and physical signs in the lung, it may be mistaken for tuberculosis. The more common type of shadow cast by the bronchial glands is seen around the root of the lung and along the main bronchus around the accompanying shadow (Figs. 57, 58, 59, 61, 63). On the left side this accompanying shadow almost, or actually, touches the heart shadow. On the right side it stands out plainly outside the sternum. When the bronchial glands are enlarged, and more especially when they are calci- fied, this faint, ghostlike ribbon shadow, which narrows and fades away normally about the level of the fifth rib, becomes thicker, darker, can be traced further, and is closely surrounded by, or mingled with, lumpy shadows of greater density (Fig. 57). Schellenberg considers that ir- regular and pronounced hilus markings are always pathologic, and Koehler believes that only calcified glands or large masses can be rec- ognized by the fluoroscope. While the writer has not been al)le to follow any of his cases to autopsy, the clinical histories of certain of them lead him to think this statement is too broad, and that glands of very moder- ate size, say the size of a cherry, can he seen. The shadows are usually seen close to the sternum, but at times farther down along the accom- panying shadow, making a small mass of shading just to the left of the heart border (Fig. 61), which may be demonstrated by percussion, and which is probably due to enlarged peribronchial glands. OBJECTIVE SIGNS 279 From beliind they are quite frequently seen on the right side as a dark streak bet\veen the scapula and the spinal column (Fig. 62), run- ning from the hilus downward and outward, parallel to the inner border of the scapula. As before noted, the shadow of this inner border must not 1)0 mistaken for them. On the right side, owing to the proximity of the heart and scapula shadows, they are not easily seen. The detailed study of such glands can be made with certainty with the fluoroscope. Fig. 61. — Anterior View of the Lungs in an Old Case of Nineteen Years' Standing, Showing Groups of Calcified Tubercles (/) and also Thicken- ing (F) Around the Right and Left Bronchi. The dark patches (M) on each side caused by the mammary glands must not be mistaken for infiltra- tion. At A the normal markings are well seen; these, as noted in the text, are not seen with the fluoroscope. Both apices are shaded. although small calcified nodules, a quarter of an inch or less in diameter, which radiologists show on their plates (Fig. 62, I) will be overlooked. In incipient cases with congenitally poor chests the fluoroscope draws attention very graphically to the oblique, narrow interspaces and the 280 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS acute angle wliich the ribs make with tlie sternnni. Undue smallness of the lieart, so common in tliis disease, is made especially evident by this measure, and the percentage of cases witli small hearts is shown by its use to Ije very large. In moderately advanced trouble there are increasing degrees of shadow extending downward from the apex to the second or third ribs, and just as the line of percussion dullness is very apt to run obliquely from without and above, downward and inward, so on the iluoroscope one is often struck with the marked obliquity of the lower border of the shadow (Figs. 56, GO, 63), which in chronic and favorable cases is sharply demarcated from the underlying clear lung. Very frequently, while the apex is still clear, the claviculosternal angle will be filled with a small triangular area of shadow, but, as has been noted, this may be simulated in some degree by a large first ril) at its junction with the sternum. Claude, quoted by Cassaet, considers a lack of distinctness of the clavicular shadow in comparison to that in the sound side a good sign at this stage. While in favorable and not very active cases there are quite sharply marked borders and more or less even shadows (Fig. 63), in cases M'ith more activity there will l)e a general diffuse mottling (Figs. 56, 59), or the advancing 1)order of the trouble will be hazy and ill-de- fined (Fig. 64). Very frequently the Avhole area between the clavicle and the fourth or fifth rib is thus mottled over with shadows (Fig. 56) separated Ijy relatively or entirely clear areas, this having a distinctly bad prognostic meaning. When it is remembered that the more sharply defined dark shadows represent old areas of infiiltration and more chronic process, and the lighter indefinite, gray, mottled shadows active and more recent trouble, a fact Avhich soon becomes evident to one working much with the fluoro- scope, it will be possible to inter])rot findings much more satisfactorily. As a rule, the base of the lung, if free from fluid or pleural thick- ening, will remain clear even in very advanced cases (Fig. 56), and a uniform shading from apex to base generally means a thickened pleura. The writer has frequently found in the left lung an isolated focus of trouble, which can easily be overlooked by perciission and auscultation, lying under the left axillary fold, halfway between the heart and the outer border of the lung area. A few times he has found in the lung, seen from behind, dark oblique lines running from within downward and outward, and only visible from certain levels ; these, Holzkneclit says, are due to interlobar pleurisy. That congestions of the lung can give shadows is asserted by Pf abler. That the conditions existing in simple congestion of the lung could cause a shadow seems remarkable, and such a claim would have to be abundantly supported by autopsies be- fore it can win general acceptance. As the writer never rays patients OBJECTIVE SIGNS 281 who have an active disease and fever^ he has not been able to determine this point by experiment. Em2:)hysema, if very general, can be seen as an undue translucence of the lunij, but the writer has not been able to recognize the small areas of Fig. 62. — A Posterior View of an Infiltrated Left Apex (G'j with Slight Retraction of the Heart (B) to the Left. Note the general shrinkage of the left side as compared with the undue size of the right, which is coni])ensa- torily enlarged. A calcified tubercle is seen at /. localized emphysema which arc its commonest form in tidjcrculosis, or use it to discover areas of compensatory emphysema around healing foci. It is in this stage that there is ascension of the liver (Fig. o!») through shrinkage of the lung, the diaphragmatic shadow often reaching high enough to touch the angle of the scapula behind or the fifth rib in front. 282 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS Pleural thickening usually manifests itself as a diffuse, moderately dense shadow over large areas (Fig. 56), without any mottling, and, as Pfahler says, " shading gradually at its edge into the surrounding clear space." As clinical experience would lead one to expect, such shadows are commonest at the lateral base, cutting down or filling up the costo- diaphragmatic angle until the outline of the lower long border runs in a curve from the heart apex upward into the axilla. The writer has found such pleuritic shadings commonest at the base behind, but Holz- knecht thinks they are most pronounced in front. Such patients will show little or no shading at the base on one aspect, and a large shadow when turned to the other. In this stage is also found quite frequently Fig. 63. — Anterior View. In the upper left lung a thickened jjleura easts an even smooth shadow not very dense (R), so that the lung markings can be seen through it. Both apices are infiltrated and around the bronchi is some thicken- ing extending down to their ends at the diaphragm. a marked decrease in the size, and more especially in the width, of the lung area (Fig. 62), while it is still almost clear and about normal in shape, except for a little rounding off of the costodiaphragmatic angle. Small pleuritic effusions the writer has not found often, since, when they are small enough to lie below the, level of the arch of the dia- phragm they can be hidden by its shadow and totally overlooked, unless the level of the tube is changed or the patient is rotated on his vertical OBJECTIVE SIGNS 283 axis po as to get the costodiaphragmatic angle in profile. When such effusions are larger (see Fig. 64) they usually show themselves as dark shadows with distinct upper borders, having a curved outline, similar to that obtained on percussion. Their change of level on motion is not as rapid as the instantaneous alteration in a pyopneumothorax. Their effect on the position of the heart, if of any size, can plainly be seen. The fluoroscope will not infrequently disclose an unsuspected peri- cardial effusion or a dilatation of the right ventricle (Fig. 56), The former produces a pale gray shadow extending more or less outside of the heart shadow, but roughly paralleling its outline. The contrast be- tween the density of the two shadows is so clear as to be diagnostic. Such shadows are much more pronounced on the right side than on the left, and are better seen from behind than in front (Fig 56). Dilata- tion is seen as an extension of the heart shadow outside its normal area and is commoner than percussion would lead one to believe. While the writer has seldom found shadows where careful physical examination could not demonstrate signs, he has been frequently sur- prised in cases with considerable auscultatory signs and with marked symptoms to find a normal fluoroscopic picture. This has been espe- cially the case in those patients, chiefly young girls, who have the phys- ical signs of an acute miliary tuberculosis, but whose disease runs a relatively chronic course, from one to three years, with alternations between periods of fair health and active symptoms, and who uniformly have pronounced tachycardia. Pathologically there must be numerous miliary tubercles which develop much more slowly than usual, and since the fluoroscopic examination demonstrates only condensation, it is natu- ral that such scattered small noncalcified tubercles entirely escape. All writers on the subject note that in patients with scoliosis there are apt to be areas of even shading in various spots which are not due to a tuberculous deposit, and that in such cases even areas of shadow must not be accepted as evidence of trouble. In advanced cases, in addition to the conditions already noted, there is very extensive shading and mottling over one or both lungs, and signs of excavation (Figs. 56, 57, 58). The demonstration of cavities by the X-ray, when feasible, is most satisfactory and graphic, but it is sometimes surprising that cavities of considerable size, owing to the con- dition of the surrounding lung, may be overlooked. .Tust as a cavity must be sufficiently superficial and large to be discovered by auscultation and percussion, so here, though to a much less degree, they must satisfy certain conditions ; they must not be too deeply seated, must not be full of secretion, and while they must not be cut off from the surface by too thick an area of diseased lung, they must be surrounded by con- densed lung, a condition practically always existing except in bronchi- 284 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS ectatic cavities. Large cavities can entirely escape one in a fluoroscopic| examination when smaller ones will be seen distinctly. When the fluoro- scope shows a cavity, reliance may be placed on its evidence, but failure' to find on the screen a cavity of whose existence there are distinct physical signs need not at all shake our faith in the diagnosis. When seen they show up as a more or less circular or irregularly oval bright spot surrounded Ijy a sharply defined dark wall, which merges gradually on its outer border into the surrounding lung tissue, which is always more or Fig. 64. — ^Anterior View of the Lungs in a Case of Pleurisy with Effu.sion AT the Right Base with the Typical Dense Smooth Black Shadow Cast BY Fluid (V). The infiltration around the roots of the lungs would suggest tuberculosis, but the ffiiid was traumatic (fractured rib). less infiltrated (Figs. 57, K; 58, K). Holzknecht considers they must be the size of a walnut to Ije discoverable, and I have never discovered any smaller than this, though some claim to have found much smaller ones. Bronchiectatic cavities, when visible, are seen as lines or chains of radiating c.ylindrical, or more or less spherical, shadows running down- ward and outward, but they can only be diagnosed if at different exam- inations the shadows are sometimes absent and sometimes reap])ear, their absence being coincident with the expectoration of large amounts OBJECTIVE SIGNS 285 of sputum. Their a])Sonce when empty is, of course, explainahle l\v the fact that, being surrounded by nornuil lung tissue, there is not sutTicient contrast to demonstrate them. In view of the seriousness of tlie syni])toms of pneumotliorax one will not usually have the op])ortu7iity of examining patients with a sim- ple pneumotliorax. It is reported by those who have seen it to be a brilliant reflex over the whole lung, except at its root. More usually the case will liave reached the stage of hydro- or ])neumothorax before it is seen. Xo condition demonstrable by the fluorosco})e is so striking as this, and only the fluoroscope can show those motions in the fluid which are an essential part of tlie picture. The upper portion of the affected side of the thorax shows around the hilus of the lung a small, dark bunch of diseased, retracted lung. Around and beneath this is an area of l>rilliant light, bounded 1)elow, at a varying level according to the amount of fluid, by an absolutely horizontal line of blackness, the line changing level aljsolutely and im- mediately with change of position, and showing commotion if the patient is shaken, and slight waves produced by the heart action. The heart, if the pneumotliorax is on the left, is displaced into the right side. Dextrocardia, and other cardiac displacements, are very commonly seen with the fluorosco])e. Quite early one will find slight degrees of displacement toward the riglit in riglit-sided trouble, or toward the left in left-sided trouljle (Fig. G2), and as fibrosis increases this becomes more and more pronounced. The heart is often at first equally bisected by the sternal shadow (Fig. 57), but in extreme cases disappears entirely from the left side, or if the trouble is on the left, it is drawn far over toward the axilla. Finally, until the physician becomes thoroughly famil- iar with its technic he will find difficulty in seeing the shadows on the screen distinctly enough to gain from it the information it can give. He will, if he persists in its use under proper conditions, be surprised at how much ho can see, what assistance he can get from it, and how soon he will l(>arn to interpret the shadow picture correctly. Blood. — The pallor which is so often seen in phthisis, and which gave to the disease the name of the " Great White Plague," would lead one to expect that the blood changes would be very pronounced and an examination of the blood of great value in a study of pulmonary tuber- culosis. While, however, in advanced cases, the alterations in the blood may be marked, in early ones they are slight or, not infrequently, entirel}' absent, and, as Keinert says, " in no other disease is the dispro- portion between the appearance of the patient and the condition of the blood so great as in pulmonary tuberculosis," or, to quote Laache, "Phthisis in itself gives rise to no mai'kcd anemia in most cases." Hematology is so new a branch of medicine, and the blood findings 286 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS in tuberculosis, until recent 3'ears, have been so little studied, that all but the more recent writers on the subject have had little to say about it, so good an authority as Fox saying, as late as the later eighties, " there is nothing definite known about the state of the blood." Even to-day, after Ehrlich's work has placed the study of the blood on a sci- entific basis, the physician is still unable to draw from it much infor- mation in pulmonary tuberculosis, though the recent work of Arneth ('05), if verified, promises to be of great importance in enabling us to form a prognosis from a study of the nuclear structure of the white cells. Most of our knowledge of the subject up to the present date has come from the work of Grawit?, Limbeck, and Appelbaum, no very promising original work having followed theirs until that of Kjer-Peter- Ben and Arneth. In the first stage of the disease we will usually find a moderate degree of chlorosis. The chlorosis of this stage differs from a real chlo- rosis in several respects, and has been called a tuberculous pseudo- chlorosis or chloro-anemia ; but as it is often mistaken for real chlorosis, it leads frequently to unfortunate delays in diagnosis and treatment, and the importance of thinking of the possibility of incipient tubercu- losis in every case of chlorosis cannot be insisted on too emphatically. French writers (Herard, See, Papillon) would distinguish it, first, by the hue of the facies, which is not that peculiar pale greenish pallor so characteristic of the " gi-een sickness," but a dirty yellowish-gray or bluish-gray; second, by the weakness or absence of the souffle in the vessels of the neck (bruit de diable) which is so pronounced in chlorosis; third, by the presence of marked fever, tachycardia, and unduly forcible heart beat; and fourth, by emaciation, the real chlorotic usually being plump. Laache and Sorensen note that the mucous membranes in tuber- culous chlorosis are not pale as in real chlorosis. In the second stage, if the patient is undergoing a hygienic cure, he usually has a normal color, but in advanced cases pallor is the rule, often extreme, the skin being ghastly pale, except where two bright spots of hectic flush ominously light up the sunken cheeks. The morphologic changes in the blood in pulmonary tuberculosis are not very pronounced. The red cells show no very marked decrease in number, except in the last stage. T^sually the erythrocytes are mod- erately reduced in the first stage, normal in the second stage, and mod- erately or at times greatly reduced in the third stage. Sokolowski gives the count for the first stage as from three to six millions, for the second stage five to six millions, and for the third stage two to four millions. Ullom and Craig ('05), in 39 cases, found an average of 4,510,000 in the first stage, 4,630,000 in the second stage, and 4,297.000 in the third stage. Brown ('07) reports 5,502,410 as the average of 80 first-stage cases. OBJECTIVE SIGNS 287 and 5,680,556 as the average of 75 advanced cases. In this connection, however, it must be remembered that Brown's patients were undergoing a hygienic cure, which tends greatly to raise the blood count. In the first stage, as already noted, the findings were those of a moderate chlorosis, and Cabot notes that, unlike this trouble, in which a majority of the cells are small and pale, in tuberculosis only some of them show such alteration, combined with a slight decrease in total numbers. Poi- kilocytosis is rare, and nucleated red cells are very rare (Emerson, '06). In the second stage the slight anemia of the incipient stage is lost, this being generally conceded to be due to a lessening of the total amount of blood by concentration, which produces a relative excess of sojids, pigment, and red cells (Sokolowski, '06). This is due, according to Grawitz, to the effect of the toxins of the bacillus which produce a transudation of serum from the blood into the tissues, or, according to Dehio and Appelbaum {'02), to the drain on the serum by the sweats and profuse expectoration. Emerson notes that the hypercythemia of this stage is said to be compensatory for the dyspnea. In advanced cases there is, with rare exceptions, a fairly pronounced anemia, with a moderate decrease of red cells, produced by the septi- cemia of the mixed infection. L. Brown found the red cells rarely under 3,000,000, but a few pronounced anemias with very low readings. The number of the red cells can be lessened markedly during and just after hemorrhages, and increased greatly during a hygienic cure. Pleth- ora may be so pronounced as to have a causative relation to bleeding. The form of the red cells, except for that pallor and decrease in size already referred to, is considered by most observers to remain unchanged, but Maragliano, quoted by De Eenzi, describes numerous changes in the morphology of the cells, wliich he thinks may be found in the incipient stages as well as later. Cabot and Emerson consider that marked changes in shape only occur in severe mixed infections. According to Maragli- ano, the red cells have not only a reduced diameter, but the central zone is more distinct, with beginning degeneration, and the periphery shows sharp projections and an ellipsoid form. In late cases he considers poikilocytosis and microcytosis, with granulation and destniction of the red cells, characteristic. Malassez notes that, as a rule, the red cells are decreased in number with advance of tlie trouble, and increased with its improvement. Coloring Matter. — Tlie hemoglobin is moderately reduced in the first stage, normal in the second, and considerably reduced in the third. Sokolowski gives it as 43 to 95 per cent in the first, 72 to 104 per cent in the second, and 40 per cent in the third stage. Reimert notes that in tuberculous pseudocldorosis the reduction of hemoglobin is much less than in real chlorosis. As a result of the reduction of the hemo- 288 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS globin, Grancher notes that the respiratory vahie of the cell is lessened and the oxygen intake decreased, the absorption of oxygen falling from 28 to 30 c.c. to the hundred to 23 to 24 c.c. This decrease of hemo- globin is not accompanied by any lessening of the iron content, which' is proportionately increased. Very characteristic of the first stage is the fact, first noted by Neubert, that the hemoglobin is more markedly decreased than is the number of red cells, but in the second stage it is compensated for, the readings being usually normal or above normal. The leucocytes in tuberculosis until recently have only been studied numerically and in difPerential counts. In the first and second stages they are normal, while in the third stage, as in all other chronic cachexias, they are increased in number. ITllom and Craig found them to average 10,285 in the first stage, 12,772 in the second, and 14,041 in the third. As long as the infection is purely a tuberculous one, even if it is acute (Sahli), the white cells are unaffected, the leucocytosis of the third stage being the evidence of the development of a mixed infec- tion (Limbeck, '96), and hence a leucocytosis speaks for softening or cavity formation, or for the development of some complication, such as hemorrhage, pneumonia, or fever. While, however, usually developing with excavation, " absence of leucocytosis cannot l)e considered to exclude the existence of cavities, as has been claimed l)y Stein and Erbmann ('98), though it would probably exclude one of any consideral>]e size." When present, leucocytosis is usually of the polymorphonuclear variety and eosinophil ia, except after the use of tuberculin or at the menses, is absent. Holmes ('96) reported that he was able to estimate the resistance of the patient by a differential count of the leucocytes, but his Avork has not been confirmed 1)y other observers. Ullom and Craig ('05) con- sider that probably an increase of leucocytes is an imfavoral)le sign in advanced tuberculosis, and venture the suggestion that lymphocytes have a dii'ect relation to the resistance of the system to the disease. Within the last year Craig ('07) has made a careful study of the various types of leucocytes found in tuberculous blood, and was unable to draw any definite prognostic conclusions. Therefore, until the work of Kjer- Petersen and Arneth, the only conclusions that could be drawn from the blood examination in tuberculosis were as to the existence or absence of a mixed infection. Kjer-Petersen ('06), quoted by A. C. Klebs, agrees with Stein and Erbmann, who believe that an increase of leuco- cytes in tuberculosis, if there is not a chronic inflammatory process, speaks for cavity formation in tlie lung, that the beginning of cavity formation can be determined by a sudden increase of leucocytes after a prolonged normal period, and that cavity formation can be excluded if normal numerical conditions are found. Arneth ('05) followed a different method than any other observer, not studying the numbers of OBJECTIVE SIGNS 289 the different varieties of leucocytes, but devoting his attention to the neutrophile cells and determining the numbers of those with one, two, three, four, or five nuclear fragments. Quoting Klebs ('06), who reviewed his work: A neutrophile of Class I, with an absolutely round nucleus, he desig- nates as a myelocyte (M.) ; the other forms in this class, with more or less indented nuclei, which he thinks correspond to the polymorphonuclears of other authors, he calls, in accordance with the degree of indentation: W. (wenig) for slight, T. (tief) for deep indentations. In other classes he notes whether there are nuclei in the shapes of loops S. (Schlinge) or round nuclear particles, K. (runder Kernteil). . . . The various combinations of loops and round nuclei in the neutrophiles and the three groups in Class I give a total of twenty subdivisions of his original five classes. This seems at first very complex, but after some experience one learns to classify the cells rapidly, according to their respective subdivisions, provided one has a well-stained specimen. By arranging the numbers found in tables horizontally, one next to the other, beginning with Class I at the left end, he receives what he calls a " neutrophilic blood picture." He finds this picture altered in pathological conditions, though not parallel with the changes in the total number of leucocytes. He can find a profound alteration of the blood picture with a perfectly normal leucocyte count. The cells with the more complex nucleus (higher classes) Arneth thinks are the riper and more efiicient ones, while the others are the youthful and therefore less efl&cient type (contrary to Holmes). The pathological alterations of the blood picture are charac- terized by the disappearance or decrease of the cells from one class, and the appearance or increase of cells in another; one can then speak of a shifting of the blood picture to the left or to the right. By a great number of examinations of the blood picture . . . Arneth has been able to demon- strate a constant and direct relation between the course of the disease and the relations of the picture. The latter are, threfore, an index of the defensive and protective efforts of the body against infection. Arneth's normal neutrophilic blood picture in a case where the actual leucocyte count was 5,500: I II III IV V 5% 35% 41% 17% 2% This " illustrates a normal distribution of various neutrophilic cell types. We see that the types of Classes II and III predominate, with a fair per- centage of cells in Class IV. In the picture next given, I II III IV V 36% 56%, S% — — of a case of acute miliary tuberculosis, the patient dying nine days later, . . . we can observe the typical shifting of the picture to the left; prac- tically all the cells are crowded into the first two classes. Onlj' the more 20 290 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS youthful elements are left to carry on the struggle, and this condition increases with the progress of the case. The total leucocyte count is low, 4,400." The next picture, I II III IV V 14% 56.5% 24.5% 4.5% 0.5% is from a patient with extensive pulmonary lesions and signs pointing to a considerable activity of the process. The number of leucocytes is only slightly increased, while the blood picture is markedly shifted to the left. Prognostically, from every viewpoint, this is a bad case. The total leuco- cyte count is 7,600. The next two were obtained from far-advanced cases with extensive pulmonary lesions; in the first the leucocyte count was 8,400, and in the second 27,080: I II III IV V 55% 38.5% 5.5% 0.5% 0.5% I II III IV V 29.5% 60% 9% 1.5% — From liis own series of examinations, Klebs states, as regards the normal neutrophilic " blood pictures," that tlie}' show similar rel^ions to those obtained by Arneth in healtliy individuals and that a dis- tinct nniforniitv of results is quite striking, as well as the ratios of dis- tribution of the five different t3'pes of cells. In this regard he confirms Arneth's findings. The technie of the method is quite simple; particular attention is neces- sary to insure thin blood smears. Undue pressure in spreading the blood on the glass can lead directly or indirectly to a distortion of the cells, and so change the picture. The stain used by Arneth is the triacid solution of Ehrlich, not a good nuclear stain. . . . For this reason, Wright's stain has been employed in most instances with better results. . . . The accurate and minute classification of the cells constitutes the principal difficulty of the method. The proper distribution of the cells, however, into the principal classes is not so difficult, and for practical clinical purposes this probably suffices. Arneth ('05), describing a "blood picture" from a case of acute miliary tuberculosis with 6,700 cells, as follows: I II III IV V 42% 53% 5% — — says : Almost all the cells are crowded together in classes I and II, scarcely anything but young elements are available for the defense of the body, cells with slightly indented nuclei are heaped togethei', the older classes — III, IV, and V — are practically absent. The whole course of the case agreed OBJECTIVE SIGNS 291 with this picture with almost mathematical accuracy, and with each new blood count a further deterioration of the blood picture could be seen until the end. All these important changes occur, let it be noted, in a patient who, according to former views, showed a leucopenia, and later a perfectly normal number of leucocytes. Speaking of his chronic cases, he considers that, " despite a good temperature and a good general condition, a patient who shows an abnormal blood picture is far from approaching a cure." And further: " We should regard those cases as the most unfavorable witli the most seriously altered blood picture and with a normal or nearly normal total number of cells, for in these the production of cells barely keeps pace Avith their destruction, and is not able to surpass it and produce a leucocytosis. . . . We are, therefore, justified in considering an in- crease in the total number of white cells as proguostically favorable." (This is in conflict with the views of UUoni and Craig.) He quotes one case as an excellent example of the fact that a normal blood count as to numbers and a good general condition cannot be relied on if the blood picture is abnormal. In this case, in which there were 9,100 cells — 51 in Class I, -46 in Class II, 2 in Class III, 1 in Class IV — the patient, on account of his very sliglit trouble, had already been selected from among the cases in Leubo's clinic, from which Arneth's work comes, to be sent to a sanatorium, when suddenly he got worse with fever, severe hemorrhages, extension of the local process, and rapid deterioration of the general condition, and Arneth considers the case excellent evidence of the point he wishes to make. If his claims are verified by further study of other observers, we would evidently have a very valuable aid in the fornmtion of a prognosis, and it is to be hoped that more studies will be made in this direction. I have now used Arneth's method in my lal)oratory for some time, and in a1)0ut 100 cases, and while I cannot here report definitely on my results, I can say that on the whole I have found them to correspond closely with the claims of Arneth. Cases rapidly losing ground have uniformly shown a rapid movement to the left, l)ad cases at the first examination have always shown a marked tendency to a preponderance of classes I, II, and III, while favorable cases Avith good vitality have, on the contrary, almost always shown the reverse. The technic is not difficult, but can be carried out by any careful man used to differential blood counting, and I am inclined to belicA-e that it Avill proA'e a valuable method of estimating the resistance of a ncAv case or of anticipating an advance of the process as j^et not determinable by physical examination. The bacteriologic study of the blood in tuberculosis has hitherto produced small results. The bacillus first found by Weichselbaum in 292 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS post-mortem blood clots in acute miliary tuberculosis was first discov- ered intra vitam by his pupil Meisel, and it has since been demonstrated in acute cases frequently but not in more chronic ones, and in a few cases of mixed infection streptococci have been found in the blood. The chemistry of the blood has been studied by some, and Morac- zewski ('03) has given the most recent complete study of the subject. The alkalinity is markedly decreased, and De Eenzi believes that this favors the growth of the bacillus in the body. In the earlier stages the iron content is increased, though later decreased. In the first and second stages fibrin is increased, but decreased in the third, and the albumin content of the blood gradually lessens throughout the course. In brief, Moraczewski's conclusions are that there is a decrease of coloring matter and of iron, a loss of serum albumin, a steady decrease of potassium salts, a development of cellulose, and a decrease at first, and later an increase, of sodium salts and chlorids. Metabolism. — The metabolic changes in pulmonary tuberculosis are marked, as would be expected in a disease in which wasting is so promi- nent a symptom, and numerous observers have studied them carefully. A comprehension of these alterations in the normal metabolism is by no means of purely theoretic or scientific interest, but is important to a proper understanding of the disease, and especially to a proper management of the feeding of patients, although, unfortunately, a scientific determina- tion of a patient's nitrogenous balance is only possible under exceptional circumstances. In a work of this nature the metabolic changes can only be touched on in their most important aspects, the reader who is inter- ested in the subject being referred to the special works on the subject (May, '03; Winternitz, '04). In the human body, in health, those losses of weight which are produced by the normal tissue waste are compensated for, and the proper relation of ingesta to excreta (nutritive balance) is maintained by a proper dietary and by a normal functioning of all the organs. The oxidation of food pro- duces heat and energy and prevents tissue waste, which else would have to occur in order to produce them. To keep up this constant production of heat and energy, and to allow of the building up of new tissue, the body must have supplied to it, through the digestive tract, proteids (nitrogenous substances), fats, and carbohydrates, not to mention salts and water. These substances, according to Rubner's law of calorific equivalents, or isody- namia, can in some degree substitute each other, but proteids are an essen- tial element and cannot be substituted by either fats or carbohydrates. The necessary amount of proteids for an adult workingman is 118 gm. (483 cal.), 56 gm. (520 cal.) of fats, and of carbohydrates 500 gm. (2,050 cal.), making a daily requirement of about 3,000 calories (Voit).^ If the 1 From recent researches Chittenden ('05) believes himself justified to give the standard of proteid requirement as 56 gm. OBJECTIVE SIGNS 293 food is not sufficient, the deliciency in heat must be supplied by the body, chiefly by the fat, which is the first tissue to show waste in denutrition. In superalimentation, on the contrary, the excess of fats and carbohydrates is deposited as fat, the excess of albumin being decomposed, the nitrogenous part being excreted as urea, while the nonnitrogenous part is thrown off by the respiration as CO2 and H2O, the normal albumin content of the body being but little changed. Thus the nitrogen excreted in the urine is a measure of the albuminous destruction of the body, which normally equals the nitrogenous intake, while the nitrogen of the stools gives a measure of the nonabsorbed nitro- gen. Thus an albuminous gain cannot be accomplished by an excessive proteid diet, but rather by the use of a diet rich in albumin, plus ample fat and carbohydrates, these better serving to economize the albumin of the body, and it is by such a proper mixed diet that the healthy man maintains a fairly constant standard of weight. In active tuberculosis there is always an excess of outgo over in- come, more nitrogen by from 0.5 to 1 gm. being lost daily than is taken in, in average cases, while in severe cases of caseous pneumonia, where the waste is greatest, from the extensive cell destruction in the caseating areas, it can go as high as 12 gm. (Huppert and Riesell, '69). It is this waste which is compensatory for insufficient intake that gave the disease the name of consumption or phthisis. The nutritive balance of such patients is upset. They suffer con- stant loss of nitrogen and of the calories necessary to carry on their economy, or, as Grancher-Barbier well puts it, " the patient is constantly obliged to draw on his resources of albumin if he is to succeed in build- ing new leucocytes to destroy the infective agent and cicatrize his lesion." The causes of this wasting are several : ( 1 ) poor absorptive power ; (2) under-nourishment, due to poor appetite, which in turn is due to the effect of the poisons of the germ on the nervous system, producing lowered nutrition and thus favoring extension of the process; (3) in- creased tissue waste from expectoration and sweats; (-1) effect of the toxins on the cells whose vitality and regenerative power is lessened thereby; (5) fever, due to the toxins. These toxins are not only produced ])y the living germ, but are absorbed in large amounts from the necrotic areas into which they have diffused from the dead bacilli, this being the explanation of the unusual toxic effect in caseous pneumonia. In periods of inactivity of the disease, the nutritive balance is prob- ably normal, and in recovering cases the clinician has evidence of its restoration by the increasing brightness of the eye, the better nourish- ment of the skin, the filling out of hollows, and the increased snap and vitality which arc impossible when the outgo surpasses the income, and 294 SYMPTOMATOLOGY OF PULMONARY TUBERCULOSIS while gain of weight is n.ot always a proof of a restoration of iiutritive balance, since nitrogenous waste can continue even Avhiie fat is being deposited (May, '03), this is not common, and the clinician rightly regards these changes as the best possible evidences of the favorable progress of the patient, and his constant effort is to restore the balance of the economy and to increase the patient's weight and vitality. Only thus can the body cells be vitalized so as to carry on their fight against the invading organism, for on the vitality and fighting jwwer of the cells entirely depend the chance of contpiering the disease. ' The poor absorj^tive power in tuberculosis "was long ago noticed by F. Miiller. In two cases of intestinal tul)ereulosis on milk diet, and in which he made careful estimations, he found respectively 40.2 per cent and 32.9 per cent of fat in the stools, whereas in a normal man he found only 10 per cent. This poor al)sorption Winternitz thinks is not due to fever, von Noorden having found no difference in the al)sorptive power of a tuber- culous patient during a prolonged afebrile period and during a period of fever produced by tubercidin, while Blumenfeld and Spirig (*96) in a series of very exact determinations found the absorption of both fat and lipanin e.xeelk'nt in tulx'rculosis without intestinal lesions. Therefore the lack of absorption may be ascribed to the intestinal le- sions, but it should be remembered that frequently the physician will see early cases where no such lesions exist, and where large aiiu)unts of food are taken, and yet it is impossible to produce any gain of weight. The amount of loss from sputum and sweats is prol)al)ly not great, except in advanced cases, where they are very profuse. Lanz in IS cases and Ilenk in 3 cases found a loss of from 5 per cent to 6 per cent of the total nitrogen, but as Ott ('03) notes these Avere advanced cases, and only in such he thinks coidd the sputum be a material source of nitrogenous loss. The solid portion of the sweats, of which, accord- ing to Argutinsky ("90), 70 per cent is urea, an end product of albu- minous decomposition can deprive the liody of consideraljle nitrogen, but here again this would not ordinarily be an active cause of loss. The under-nourishment produced in tuberculosis by the anorexia is an active source of wasting, this anorexia being considered an effect of the toxins on the nerve terminals. Another cause of tissue Avaste, but according to May ('03) not a marked one, is cell destruction by the toxins, the index of this waste being the amount of organic phosphorus in the urine (Grancher-BarJuer, Mitulescu). A marked cause is the fever produced by the absorption of toxins. Van Noorden found that a nonfebrile tuberculous patient, getting a diet which furnished 43 calories per kilo, made slight gains in his nitrog- enous balance, while, after a period of fever to 103° F. for six days. OBJECTIVE SIGNS 295 he showed a nitrogenous loss varying from 0.58 to 3.54 gm. It should be noted, however, that while fever produces a large waste of albumin, its effect on fat is slight, loss of fat being chiefly due to under-nourish- ment, Avhile in late cases the excess of muscular action produced by the dyspnea and chills is held responsible for the marked fat loss. To recapitulate, then, the chief causes of nitrogenous waste in tuberculosis are under-nourishment, the effects of the bacillary toxins, and fever. The excretion of mineral substances in the urine in tuberculosis is an index of the cell destruction going on in the body, this having been especially emphasized by French authors, notably IJobin and Binet (01), who speak of the " demineralization " of the system in this disease as an early occurrence and consider it of great value in diagnosis. They consider that any excess of excretion of these bodies beyond the point where the total excretion of inorganic bodies is to the total dry residue as 30 to 100 (coefficient of demineralization) is pathologic and can be regarded as a sign of incipient tuberculosis. Ott ('02) and various German authors, however, while admitting a plus of excretion in ad- vanced cases, deny its presence in early cases, and consider that it is due not, as Robin contends, to the toxic effects, but to under-nourish- ment, and points out that the French results rest on urinary analyses alone and do not include those of the feces. The phosphorus compounds are abundant in the body, not only as calcium phosphate in the bones, but as lecithin and nuclein and proteid combinations, and their excretion in the urine the French consider an evidence of increased cell destruction, the cells being the carriers of nuclein and lecithin, which in turn get their phosphorus from the bones and muscles, and the excretion of phosphorus the}^ believe to increase and decrease in direct relation to the advance and retrogression of the process in the lungs. Mitulescu ('03) has shown that where a negative nitrogenous balance exists, the excreted phosphoric acid exceeds the ingested phosphorus, the inorganic as well as the organic phosphorus being in excess. The phosphoric acid is chiefly found in combination with potash, soda, ammonia, lime and magnesia, and one third of it is excreted by the stools as calcium and magnesium phosphate and lecitiiin. Ott found that the excretion of phosphorus goes parallel with that of nitrogen. An excess of lime excretion was at one time reported by Senator, but his results, depending only on an analysis of the urine, have been rejected by more recent writers. Croftan ('03) found an increase of calcium excretion in the urine combined with deutero-allnimose, and believing that there is an affinity of this latter for calcium, and since deutero-albumosc is found in calcifying tuberculous foci, he thinks that the use of calcium salts is indicated in tuberculosis. 296 SYMPTOMATOLOGY OF PULMONARY TTTBERCULOSIS In accordance with what is found in the blood, E. Meyer ('01), in Gephardt's clinic, has found a complete reversal of the relation of the potassium and sodium excretion. Normally this relation is 1 gm. of potassium to 2 or 3.5 gm. of sodium, but in advanced phthisis he found the relation to be 3 gm. of K to 1 gm. of Na, although in early cases he found the relation normal. This he ascribes to the increased destruction of albumin in the tissues, especially the muscles. Aside from the loss of nitrogen and mineral substances, tuberculous patients, with much intestinal trouble or with large purulent cavities, lose considerable amounts of indican through the urine. Albumoses are found in the urine chiefly in cavity cases and as the result of fever (Krehl and Matthes, '95). Acetone and diacetic acid is also found in old cases with much tissue destruction, according to Winternitz, but this is denied by Ott. Amyloid and fatty degeneration are the evidences of the deposit in the body of tissue waste. Hoppe-Seyler ('91) found an increase of urobilin after injections of tuberculin, and concludes from this that the toxins have the power to destroy red cells. The gaseous metabolism in tuberculosis is but slightly, if at all, al- tered, the system accommodating itself to the lessened lung area, and, as is usual in the body, accomplishing the same amount of work with the de- creased amount of tissue. The earlier experiments seemed to demonstrate a decreased COg excretion, but later and much more accurate work by Moeller in Pettenkofer's clinic by A. Loewy ('91) and by Kraus and Chvostek ('91) have shown this last to have been incorrect. A mod- erate increase of oxygen intake and CO, excretion was found by these observers, but not to the extent taught by Kobin and Binet ("01). These latter claimed a marked increase of respiratory exchange in tuber- culosis in 92 per cent of their 392 cases, and they consider this an inherited tendency in those susceptible to the disease, and contrast it with the decreased exchange in gout and rheumatism. Loewy consid- ers that an increase of oxygen intake and CO, excretion is evidence of an increased destruction of albumin but not of fat. Winternitz, going over the same ground as Robin and Binet in afebrile cases, comes to the conclusion that cases of chronic afebrile tuberculosis have an oxygen consumption which, while within the limits of the normal, is somewhat high if the patient is emaciated or if there is much destruction of tissue, but if the nourishment is good, even if the process be advanced, it is strictly normal, and he considers that a plus of oxygen consumption in advanced cases is due to emaciation and to the increase of respiratory action, he having found the oxygen consumption proportionate to the degree of emaciation. CHAPTER II PHYSICAL EXAMINATION By CHARLES L. MINOR Physical Examination. — In the examination of an incipient case of puhnonarv tuberculosis the most careful, thorough, painstaking work is demanded, and the frequent failure to diagnose the disease in its beginning is due chiefly to a lack of sufficient time and care in the examination. Physicians, accustomed chiefly to seeing acute diseases, do not always realize that the slight changes existing in early tuber- culosis can produce at most only slight alterations from the normal, which can easily be overlooked unless an amount of time and pains be given to the examination which is not always necessary in more acute troubles. While a few great diagnostic experts, like the celebrated Oppolzer, of Vienna, can make a diagnosis in some cases with a glance and a touch, quickly and yet surely, such men will always be the excep- tions, and, as a rule, it is safe to say that good work cannot he done in a hurry or without proper equipment and surroundings, and thus he who gives himself time and the right conditions, and follows a carefully determined routine in his work, wall make correct diagnoses in many cases where the less painstaking will fail, and will discover small foci of trouble which else would be entirely overlooked. Equipment of Examining Eoom. — The proper equipment of the examining room is a matter of real importance, and the physician will save time and increase the accuracy of his work by seeing to it that he has all the necessary apparatus close at hand, and so conveniently and systematically arranged that it can be used quickly and easily. This is the secret of the excellent diagnostic work done in large hospitals, infinite pains and proper equipment being used systematically; by re- producing these conditions the private practitioner can reproduce the results. Too commonly the physician has nothing ready; he must hunt up a stethoscope and tape, has no skin pencil at hand, no special table and examining stool, and has to use whatever comes handy. Thus, following no set routine, and often not recording his results on a systematic form, he places perfectly needless handicaps on his nervous efficiency, decreases proportionately his powers of observation, 21 297 298 PHYSICAL EXAMINATION and, moreover, keeps no proper record for future reference. The exam- iner's mind should be entirely free to concentrate itself with intense earnestness on the problem before it, undisturbed by anything, and his body should be so relaxed and at rest as not to hamper him in the least. Few realize that for the most complete use of any faculty one must be entirel}^ undisturbed not merely by outside noises, etc., but by strained positions or tense muscles, and that by avoiding these handicaps the keenness of hearing, sight, and touch can be greatly increased. The Room. — The room should be quiet and as free from outside noises and disturbances or interruptions as possible. It should have, if feasible, northern light through large windows, and since the patient must be stripped to the waist it must be heated easily and rather more than comfortably warm — about 75° F. There should be a special table kept solely for the examination, and on which all needed instru- ments are conveniently arranged with a place for everything and every- thing in its place, and the writer has found the common glass-topped, glass-shelved, enameled iron ward table very good for this purpose. On it should be placed the regular stethoscope and any modified forms that we may wish to use for special cases, such as the phonendoscope or Bowles's stethoscope. There should also be a steel tape measure, a leather-covered lead tape, a pair of chest calipers, a skin pencil, colored pencils for recording findings, and a spatula and a jar of cold-cream vaselin to anoint dry, harsh, or hairy skins. Fixed on the table should be a paper clip to hold the examining chart steady, so that find- ings can be recorded easily. Beside the table, with its back to the window, should be the physi- cian's examining chair, the common laryngologist's chair with springy back being the best for this purpose. Facing this chair shoidd be a stool for the patient, and I consider it a detail of real importance that this should be a rotating one, the ability to spin the patient around quickly to get at any part of the chest saving much time and often avoiding the use of .strained attitudes. In order to be able to map out the stomach or to study Litten's diaphragmatic phenomenon a sofa is necessary. In addition, a height measure, permanently fastened to the wall, a reliable scale, and a wet spirometer are necessary. Barring the laryngoscopic and Eoentgen-ray outfits, this completes a list of all the essentials, and they are easily had and very cheap, so that no one who does any chest examining need be deprived of the great assistance they offer. The necessary equipment for a laryngeal, oral, and nasal examination (an aural examination is rarely needed) should be regarded as essential, and it is time the profession realized that no pulmonary examination can be said to be complete unless we know the condition of these vestibules of the lungs. PHYSICAL EXAMINATION 299 While a Roentgen-ra}' equipment is not esi^ential, it is of ver}' great value. If the Roentgen-ra}^ is used the room must be made a])Solutely dark, and it is better to have for this purpose, and for the laryngeal examination, a special room with walls colored a dark red and with windows and doors so adjusted as to exclude the smallest ray of light. Time of Examixatiox. — This will usually, of necessit}', be largely determined by the arrangement of the physician's day. However, in incipient cases where the detection of a few fine, isolated rales may be of great importance, the time immediately after waking, when there is most secretion in the lungs, is unquestionably the best time for exami- nations, as at such times one can hear rales which are entirely inaudible during the rest of the day. Such a time, however, for the full exami- nation is not usually feasible except in special cases, in which case we should make a special visit to the patient's house early in the morning for this purpose. The doctor should not undertake such examinations during his regu- lar office hours while he is subject to many and constant interruptions, making concentrated consecutive thought impossible, and when the con- sciousness that other patients are impatiently waiting to see him is apt to tempt him to hurry through his work. He should, therefore, especially if he devotes himself particularly to such work, have an espe- cial time of the day to make such examinations by appointment, when nothing will interrupt him and when he can concentrate himself on the work in hand. The time necessary for a thorough examination varies considerably with the difficulties of the case and with the physician. A first exami- nation, including a painstaking history, a laryngeal, fluoroscopic, and physical examination, demands at the very least one hour, often much more. Eeexaminations can be completed usually in from half an hour to forty-five minutes. Frequent reexaminations are unnecessary and undesiral)le in tuberculosis, and the usual custom of monthly examina- tions, with such brief studies of the auscultatory findings in between as the developments of the case may demand, is ample, and chronic favoral)le cases with which we are thoroughly familiar can at times go two or three months without examinations, the changes in such cases being too gradual to render more frequent examinations of value. On the other hand, in active, acute, advancing cases the chest may need to be watched two or three times a week. In setting a time for an examination, the menstrual period should be avoided in women, and routine examinations should not, if possible, be made in cases where the temperature is over 101° F. or during acute congestions, or even slight colds. Except in the case of patients who are too sick to leave the house, all regular examinations should be made 300 PHYSICAL EXAMINATION at the office, where the physician has at hand every convenience, and where much better work can be done than at the patient's house. History. — Aside from the great importance for a correct diagnosis of a carefully taken and recorded history of the patient, a step that should be the beginning of every examination, the time thus occupied allows a patient to get over some of his natural excitement and to quiet down, and a tactful physician will take occasion to lay the foundations of relations of confidence with his patients at this time. Most, if not all, patients come to the office greatly excited, apprehensive, and Avrought up, and this should, as far as possible, be allayed before beginning the physical examination. The presence of relatives and friends during the history taking, Avhile at times adding useful facts to the history, often causes a patient to withhold valualjle information as to his past life which, if alone, he will confide, and thus histories of past dissipations, syphilis, love affairs, family troubles, etc., which bear on the cases are missed. At the same time, relatives, especially wives or mothers, can often sup- ply facts as to the patient's personality, past life, sickness, and family history, better than he, so that it is wise, after having taken the history with the patient alone, to have the relative come in and add any infor- mation possible. A regular routine in the history taking should be followed to get histories systematic enough to be of value for reference, and while printed history forms are a great inconvenience by limiting one to a fixed space in every case, they are valuable since they prevent us from forgetting any of the many details to which we should turn our attention. The recording of histories in bound volumes is a great mistake if we ever expect to use them for reference, the card index, using large sheets of very thin cardboard, being infinitely preferable. In private practice, no less than in sanatoria, facts as to birthplace, previous resi- dences, various occupations, age, sex, condition, permanent address, should always be included if we hope ever to be able to follow up the future history of our cases. The family history must be taken carefully if it is to be of any value. The general statement, so popular with patients when speaking of the health of their families, such as " all my family have been per- fectly healthy," " none of my people have had Ivmg trouble," etc., should never be accepted, but the health, age, cause of death of the paternal and maternal grandfathers, grandmothers, uncles, aunts, and first cousins, and of the father, mother, brothers, and sisters, should be inquired into individually. We should also investigate the possible existence on the paternal or maternal side of any marked tendency to dyspepsia, nervousness, anemia, or weak lungs. In this way we will often PHYSICAL EXAMINATION 301 discover cases of probable tuberculosis in the families of patients who have asserted that their family was entirely healthy, or it may reveal a tendency to gout and rheumatism which has a distinctly favorable prognostic value. The rest of the history is best divided into sections on " Childhood History," one on " Past Life and Sicknesses," one on " Habits," one on " Present Sickness," and a statement as to the " Status Prsesens," or existing conditions, at the time of examination. The childhood history in women ends at the beginning of the female life, and in men the writer has found it practical to have it end at the time of going to college or into business. The condition of the home during childhood, as to its sanitary conditions, ought to be noted, as well as possible exposures to infections from sick relatives or others. Any exanthemata, especially measles, attacks of pertussis, pneumonia, pleurisy, bronchitis or tonsillitis, any enlarged cervical glands, otorrhea, and the childhood's habit of appetite and digestion — all are of value. The conditions of school or college life must always be investigated — the health of roommates, the ventilation of rooms, and the quality of the food all giving valuable information. The past life and sicknesses should include the life from childhood up to the present trouble, and should bring out information as to the hygienic conditions of the houses lived in, and of the various occupa- tions, possibilities of infection, marriage, and the health of wife and children, and all past sicknesses. Habits is an important heading often omitted. From it we should try to get some idea of the exact mode of life and method of spending the time. The hours of work and the methods of work, the tempera- ment and mental attitude, the average weight and best weight, appetite, digestion, sleep, and nerves, and any undue tendencies to catching cold, should all be noted, as well as past histories of malaria, neurasthenia, dyspepsia, pleurisies, etc., which without questioning the patient will often forget, and which can give a possible hint as to the commence- ment of the trouble. The information given under this head gives some idea of the life and personality of patients. The Present Sickness. — The first question here, if we wish to find the real beginning of the trouble, should be not " When did your sickness begin," but " When were you last perfectly well ? " for most patients have had a more or less extensive period of imperfect health before the development of symptoms sufficiently active to draw their attention to them, and by inquiring in this way we get a much earlier date for the beginning of the trouble than the patient would otherwise report. The average patient, when asked how long he has been sick, will usually date it back to the cough, cold, grip, hemoptysis, etc., 302 PHYSICAL EXAMINATION that to him seemed to hegin his sickness, whereas to the doctor it may- date back from months to years before the present trouble, and may be separated from it by quite a period of good health. At such times a patient will generally report he was pale, somewhat off in weight, strength, or appetite, had a slight clearing of his throat, but with a little care he got over these symptoms and forgot them. With these data and facts determined the patient should then be urged to give his own account of his trouble, only omitting, as far as .Ave can induce him to do so, the many utterly irrelevant family details he usually wishes to mention. After this a few questions will make clear the course and development of the disease. Finally, the Status Prccscns, or actual condition at the time of ex- amination, should be recorded for future comparison. We should note the amount of cough and expectoration, and the presence or al)sence of fever, sweats, chills, dyspnea, hoarseness, dysphagia, pallor, blood- spitting, the condition of the appetite, digestion, bowels, sleep, nervous system, the mental attitude, and the weight. A history so taken is in- valuable for future reference or for scientific study. The Exajiixation. — If this is to yield the maximum of infor- mation, it must be carried out systematically, according to a logical plan, and to assure this the physician should have a well-designed chart whose routine he can follow in every case, and on which he records his findings. Only thus can even the most careful man avoid the omission of certain points and get records which are complete and of value for future study. The writer believes that each physician can do best, after consulting good standards, to plan his own chart, the cuts for which he can get from numerous books of reference and which can be made cheajjl}^ by almost any printing house in electroplate, and which can be printed for him under his own eye. Such a chart will probably be more usefid to him than anything he can buy ready made. It must not be so small as to be crowded and awkward for reference, and should be of such a size that when folded once it will match the size of his history chart and be filed away with it. There should be printed matter for recording the findings on inspec- tion, palpation, and mensuration, as well as graphic outlines for record- ing the laryngologic findings. The Eoentgen-ray, percussion, and aus- cultation findings should be recorded on three sets of outline pictures of the thorax from the front and from behind, but there should also be a place for writing a verbal description to supplement the graphic record, where that is necessary, since, whereas the graphic record is usually more valuable than a written one, there are times when only a written one can properly describe certain conditions. It is best to begin the examination by taking the patient's weight PHYSICAL EXAMINATION 303 and height. Since we will usually have no opportunity to weigh patients naked, and since the weight of the usual clothing is fairly fixed, it is distinctly better to weigh the patient in his clothes. The height is taken in his shoes, from Avhich subtract the height of his heels, which should always be measured, so as to get figures for the height that can be used in estimating the normal capacity and chest circumference, and the corpulence if this is desired. Since the vital capacity necessitates very deep breathing, it should best be postponed until the end of the exami- nation. . Xext in order should come the laryngeal, oral, and nasal examina- tions, and if there are any ear symptoms, an aural examination. Un- fortunately, many physicians doubt their skill in laryngoscopy or rhi- noscopy, and either omit this important step entirely, or, if marked laryngeal symptoms exist, send the patient to the laryngologist ; but since a report from another as to existing conditions is of distinctly less value in the impression it produces on the mind than is the impression gotten Ijy the use of our own eyes, this is much to be re- gretted. The information to be gained both for diagnosis and prog- nosis is of such value that every physician should master the simple technic, and this anyone who is willing to take a little trouble can do. When once this technic is mastered, a 3'ear or so of careful study of the larynx in every patient, with the use of a well-illustrated atlas of larjTigoscopy, such as that of Krieg or of Grunwald, will enable him to recognize abnormal conditions and acquire suflficient diagnostic skill to greatly assist him in the study of his cases, while difficult or puzzling ones can still he referred to the specialist for final judgment. Inspection of the mouth often gives a hint of syphilis; the condition of the teeth and gums can throw light on the causation of digestive troubles; unduly abundant adenoid tissue in the pharynx or enlarged tonsils give information as to the patient's constitution; while the dis- covery of an enlarged lingual tonsil, pressing on the epiglottis, will often clear up the causation of an oI)stinate. inexplicable cough. An examination of the nose very often demonstrates an hypertrophy of one of the turbinates, the presence of polypi, a deflection or spur of the septum, resulting in obstruction to the free access of air to the lungs in nasal breathing, and gives a valuable therapeutic hint, the removal of such occlusions in these cases often having remarkably bene- ficial effects. Perforations of the septum will at times be found, and will explain abnormal breath sounds which this condition can produce. Posterior rhinoscopy is difficult to any but the specialist, but can be very useful in revealing adenoids. Lar}Tigoscopy reveals some lar}Tigeal abnormality (see Laryngeal Symptoms) in a large number of cases, and should under no circumstances be omitted. 304 PHYSICAL EXAMINATION The nose and throat examination being completed, and they need take but a very short time when once a physician is familiar with their technic and has acquired a familiarity with the normal and abnormal conditions, the patient should he requested to undress to the waist. In these days of accurate work it should not be necessary to insist on the absolute necessity of examining directly on the skin if we hope to get reliable results, but, though our German confreres have for years taught this, the American profession, especially when examining women, still very commonly neglect it, and I have heard good men maintain that they could listen as well through clothing as not. The latter statement is too diametrically opposed to the results of the best clinical experience to need refutation, and the claim that we will shock a patient's modesty is equally unsupportable. The writer has for many years examined all patients stripped to the waist, the patients coming largely from the more refined walks of life, and he has yet to find any expressed objection to this most necessary step by any women except, strange to say, by a few who alone of all the number had no right to modesty at all, but in such women we do frequently find an appalling excess of modesty, which is most amusing. Doubtless, if the doctor hems and haws and seems embarrassed at ask- ing the patient to undress, and does not go out of the room to give her an opportunity to do so, he would suggest to her the very feelings that he fears she may have, but if he goes about it directly and as a matter of course, he will find no trouble at all. There should always be a light flannel shawl at hand to tlirow around the patient between the various steps of the examination, but none will object to its removal during the examination. Some patients are unduly afraid of catching cold, and having such a wrap handy re- assures them, but, since we examine in an imduly warm room, this is a matter of imagination rather than fact, and the writer has seldom seen patients catch cold. As to whether the Eoentgen-ray examination should precede or fol- low the physical examination, is a question that will be differently set- tled, according as to whether the physician considers the one or the other the more reliable. Personally, considering the Eoentgen-ray as of inferior accuracy to the physical examination, the writer puts fluoroscopy first, so as not to find himself prepared to detect by it evidences of the lesions discovered by auscultation and percussion. After the Eoentgen-ray examination, look for the physical signs which its findings have suggested. This is wiser than to reverse the procedure, for physical signs are of more value in forming an opinion than Eoentgen-ray shadows. However, a description of the steps of the Eoentgen-ray ex- PHYSICAL EXAMINATION 305 amination will be given later as being a newer and less important procedure. The patient ma}^ assume either the standing, sitting, or lying-do^\Ti position. Very sick patients must, of course, be examined lying down in their beds, but any patients who are al)le to come to the office should be examined in the upright posture, unless the recumbent position is indicated for special reasons, such as in a search for rales or in study- ing Litten's phenomenon or for an examination of the abdomen. While some physicians prefer to examine the patient standing, this is not de- sirable, as both the patient and the physician are thereby placed under more or less of a strain, and in nearly every ease the sitting posture will be found the most satisfactory. Inspection. — The room being properly warmed and the patient stripped to the waist, one proceeds to the inspection. For this step espe- cially, which calls for the closest powers of observation on the physician's part, the patient should be seated stripped to the waist directly facing the window, best in diffuse bright da3light with each side equally illu- minated. When first he seats himself, the patient should be allowed to take his natural posture, for in this way one will often get an excellent idea of habitual faults of position which call for correction. After this the patient should be made to sit erect, but not " strutting," in an easy upright pose. First one notices the position and prominence of the clavicles and the condition of the supraclavicular and infraclavicular fossae, the ster- num, then the remainder of the anterior thorax should be observed for abnormalities. Slight flattening of the shoulder outline or shoulder droop must also be looked for, and the general build and form of the thorax, its length, breadth, and the angle of the ribs and breadth of the intercostal spaces noted. Posteriorly, one notes the position, height, and motion of the scapulae, the fullness or flattening of the supraspinous muscles, and any possible scolioses or other spinal deformities. Then follows inspection for alterations of motion. This is done in two ways: First, facing the patient's front or back, and noting the relative upward motion on deep inspiration of the ribs and shoulders; then, standing behind the patient and looking down the anterior chest wall, observe the lifting of the ribs, outward and upward, and in this way one can note very slight differences of motion between the two sides. Too hasty and cursory inspection is condemnable. Inspection is a valuable but a very delicate method, and one should observe very closely and carefully in order to profit fully from this procedure. In addition to inspection of the chest, note the patient's general build and nourish- ment, the condition of the skin and complexion, the condition of the pupils, hair, finger tips, nails, teeth, and gums, as well as the tongue and any existing dyspnea. 306 PHYSICAL EXAMINATION Palpation. — Palpation of the apical regions and of the first and second interspaces is hest performed with the ulnar border of the hand, below that level applying the four fingers, evenly but not too firmly is better. Goldscheider ('07) recently recommended for orientation previous to his percussory determination of the absolute height of the apex the deep palpation between the heads of the sternocleidomastoid of the tubercle of the first ril), which is in definite relation to the apex. The writer has found this feasible in thin subjects, as well as in the determination of the inner border of the first rib, but the procedure is painful to the patient, as Goldscheider admits, and the information gained is not indispensable. While palpating, one should be sure to examine the neck for possible enlarged cervical glands, and the pulse for its tension. As noted under " Blood-Pressure," finger estimations of tension are uniformly lower than would be expected from the readings such pulses give with the sphygmomanometer. Estimation of the pulse-rate during an examination is usually worthless, the patient being too excited and the heart beating abnormally. Palpation of the apex beat in very debilitated subjects is often difficult, the heart being very weak. Ab- dominal palpation, while usually neglected, may be useful in revealing dilated stomachs by splash, and enlarged mesenteric or retroperitoneal glands, but the abdomen of such patients is usually too tender to make glandular palpation easy. Peritoneal friction may also be discovered in some cases of peri- toneal tuberculosis. Sahli considers a firm lumpy band between the xiphoid and the umbilicus very characteristic of tuberculosis of the omentum. Mensuration.- — The weight and height are determined, as noted, be- fore the patient undresses. The estimation of the vital capacity is best postponed . until after auscultation, as the deep inspiration necessary may remove scanty rales. Most patients can be taught at the first trial how to fill the lungs fully, and then to exhale evenly, steadily, and com- pletely into the spirometer, but a few, especially women patients, can never learn to use this instrument. The wet spirometer is the only reliable form. The use of the sphygmomanometer to test blood-pressure is not necessary as a regular part of the examination, the finger estima- tion of pressure being sufficient. The tape, for reasons of cleanliness, had best be of steel. The measurement of the total circumference at extreme inspiration and extreme expiration is of little value, but the determination of the circumference of each half of the chest separately in inspiration and expiration is useful, often revealing limitations of motion confined to one side, or decreases in size. A smaller right half of the chest in PHYSICAL EXAMINATION 307 right-lianded persons has some value in strengthening other signs. The total circumference when at rest should be noted to find out whether it is equal to one half the patient's height as it should be. For all tape measurements the anterior and posterior central lines should be marked on the sternum and spine at the level at which the tape is applied. The level to be preferred lies between the fourth ribs in front and the eighth dorsal spine behind, which two points should be marked by a cross or vertical line. The Icdd tape cyrtomcter, Avhile it has fallen into disuse, is a most useful instrument, not simply in revealing often unsuspected asym- metry, but more especially in showing those shrinkages and reexpan- sions of the thorax, which are so common in the disease, and which prognostieally are of great value. The elaborate cyrtometers of the instrument makers are not necessary. A pair of simple calipers, capable of being opened to at least twelve inches, and a lead tape are all that is necessary. The latter can be made by any pluml^er from three- sixteenth sheet lead, and should be half an inch wide and tweny-six inches long, and for cleanliness had best be covered with calfskin by the shoemaker. The aim is to get a graphic record of the horizontal plane of the chest, vertical to its long axis, and so recorded that we can compare the tracings taken at one examination with those taken at another. I have found it convenient to use the instrument at the level of a plane cutting the fourth rib in front and the eighth dorsal spine behind, this plane being aljout at right angles to the axis of the thorax, being low enough to miss the scapula behind and the axillary folds. The first step is to take the depth of the thorax between these points and lay it out on the chart, which should be large enough to hold the full tracing of the largest chest — i.e., twelve inches wide by sixteen inches long. Sitting facing the patient's left shoulder, pass the tape between the body and the right arm and place its posterior end carefully on the eighth spine, taking care thereafter that it does not slip from this point. It is then molded from behind forward to fit the chest snugly, being careful in crossing the axilla to follow its outline, and not arch across it as can be so easily done. As the tape is brought around toward the sternum it is best to roll the anterior end inward, which produces a better approximation. The snug fit of the tape and its correct position at the spine behind being verified, and any displacements of the skin being corrected, the patient's chest being in repose and not expanded, mark the point where it crosses the midline in front and remove it by raising its two ends and slipping it off the chest obliquely without bending. The depth of the chest having been laid out on a line which runs across the chart, the two ends of the tape are made to correspond with these marks, and the perimeter is then traced in colored pencil. 308 PHYSICAL EXAMINATION The left side, being similarly taken, is laid down opposite the right, the two adjoining end to end, and giving an accurate reproduction of the perimeter of the thorax. When this simple technic is once mastered it is easy to take absolutely accurate tracings, which will correspond with others taken the same day, or if the case is inactive and no change of form takes place, the tracings taken months or years apart will corre- spond accurately. At reexaminations the new tracings are not only traced on the new chart for that examination, but also over the old tracings, and marked in different colors, taking care to first lay out the depth by the calipers, as this may change between examinations. In this way we get very striking pictures of the increase or decrease in size of the patient's chest under treatment. Aside from its prognostic use it demonstrates very plainly flattenings or distortions of the thorax and differences in the two sides. Since the thorax is generally largest on the side of the arm used chiefly, a proper interpretation of tape measurements or lead-tape tracings and of percussion findings demands a note of the patient's right- or left-handedness, which should be marked on every chart. Prognostically a progressive shrinkage of the perimeter during the course of the disease, except in old fibroid cases, where it is compatible with fair health and a relatively stationary troulile, is uniformly a bad sign. Expansion of the perimeter, on the contrary, especially if there is deepening of the anteroposterior diameter, is imiformly a good sign, and the writer has never kno^Ti such expansion and deepening to occur except in improving cases. In incipient cases reexpansion of the chest occurs first on the affected side, the good side, which has not had time to shrink, gaining little until later. In old cases, on the contrary, the least affected side is the first to show gains, which are evidently com- pensatory, and only later, if the patient improves, will expansion on the most affected side be found. In the slight scolioses so often seen in tuberculous patients, there is a bulging backward of the ribs on the side of the convexity, and if the patient is getting along well, and this scoliosis disappears, as it often does, the disappearance of this asym- metry is shown by the tracings. Technic of Percussion. — In percussion one can use either the fingers alone or the percussion hammer and pleximeter. In this country the fingers are used almost universally. While in a few cases the hammer may be useful, in the large majority of cases the results of finger-finger percussion are much superior. The force of the blow is more under control, the note is purer and not complicated by the overtone of the pleximeter, valuable information is given by the sense of resistance in the parts, and there is less likelihood of percussing too hard. PHYSICAL EXAMINATION 309 Fig. 65. Percussion, however, demands a perfect technic, and if the technic is poor the hammer will be preferable. A perfect technic can be acquired in a short time by practice, taking the piano hammer as a model — i. e., the blows must be vertical to the part percussed, the finger must rebound instantly, and the motion must be absolutely confined to the wrist and met- acarpophalangeal joints, the rest of the arm being held perfectly motionless. This can be practiced by laying the forearm flat on the table top and practicing vertical blows on the table with the finger, the motion being necessarily limited to the joints men- tioned. The middle finger is the best to use, for, being nearer the center of the hand, the lilow is better balanced, and a vertical blow and a good recoil are thus more easily obtained, but the index finger can be used instead, or even the ring finger in an emergency. Except over very muscular backs, two fingers should never be used, as this favors unduly hard percussion and does not give a pure note (see Figs. 65, G6, 67). The pleximeter may be any of tlie four fingers, though usually the middle finger, or the index of the left hand, is best, ])ut over the apex, or when outlining areas with Fig. 66. Figs. 65 and 66. — Proper Position of the Fingers and Wrists, the Motions Being Altogether in the Wrist Joint and the Metacarpophalangeal Joint of the Second Finger of the Right Hand, THE Blow Being Vertical, Light (65) AND Rebounding (66), the Pleximeter Finger Being Laid in the Interspace Parallel to the Course of the Ribs. precision, or in children, or in subjects with narrow interspaces, tlie little finger is to be preferred. The •finger must be applied evenly, but not too firmly; the blow of 310 PHYSICAL EXAMINATION the percussing finger must never he oblique, but absolutely vertical if the resultant note is to be pure, while the rebound must be instan- taneous to allow of the vibration of the parts, excejjt only in eliciting cracked-pot resonance, when it should remain in contact for a moment. The blows must be even in force, not too rapidly re])eated, and in doubtful cases sbould occur during tbe same pliase of respiration, since the note during inspiration and expiration is not identical. Usually two successive blows, regularly given, produce the best impression on tbe ear, but in cases where sliglit differ- ences between tbe apices are suspected, single blows over each apex in turn are useful. It is also better, in doubtful cases, to percuss upward toward tbe diseased area ratlier than to begin over the impaired area and percuss downward, finer distinctions ])eing ol)tainable in tills way. Although every writer on the subject has dwelt on it, too much stress cannot be laid on the importance of light percussion in the large majority of cases and localities, the occasions when heavy percussion is needed being increasingly rare with increasing skill of percussion. No faults of percussion are so common as unduly heavy or oblique blows, and he who would percuss well must avoid them. The aim is not to produce the loudest sound possible, but the clearest and purest, and if the blow is quick, resilient, and very light, we will attain the best results, and added force Avill not increase, but lessen the clearness of the resulting sounds, and give rise to confusing vibrations from remote parts. Only when we desire to detect deep-seated foci of condensation, or when percussing over very thick layers of muscles or fat, should deep percussion be practiced, and the practice of hard percussion to re- veal suspected tympany in the search for cavitation is al)solutely useless, tympany so produced being more likely to come from deep-seated large bronchi than from excavations, while such violent Idows can have a harm- ful effect on the diseased lung, and not infrequently produce hemorrhages. Fig. 67. — To Show the Use of the Little Finger in Delicate Percus- sion, IN this Case, of the Outline of Apical Resonance. Percussion is here outward from the clear area toward the dull, but this can be reversed. Note the very moderate amount of wrist motion in light percussion, the chief motion being in the metacarpophalangeal joint. PHYSICAL EXAMINATION 311 Fig. 68. The percu.ssion should be of two kinds: (1) Comparative, in which alternate blows are delivered on corresponding parts of the two sides, and (2) unilateral, in which percussion is limited to one lung. Ordinarily percussion is best jDcrfornied during shallow respiration, but comparative percussion during extreme inspiration and expiration is at times necessary to reveal slight differences. Tbe patient should l)e seated easily erect, with his arms hanging by his side and his head strictly in midline for anterior percus- sion ; Avith the arms on top of the head, and the elbows held well backward for axillary percussion; and bent forward moderately from the waist, not fi-om the shoulders, with the head slightl}^ drooped and the arms lightly crossed for posterior percussion. When the areas covered by the scap- ulae are to be examined, the patient should place his fin- gers behind the posterior ax- illary folds on opposite sides, which will uncover all of the lung it is possible to get at. During percussion, positions wliicli make tbe muscles tense or distort the symmetry of the thorax, such as straddling a chair, are to he avoided, the most undistiirbed easy ])osition always being l)est. Brown has noted that the volume of the percussion note can be increased l)y standing the patient in ibe angle between two walls. The first step of a percussion should l)o the marking out of all the lung borders with a skin ])('iicil. and this should be omitted from no Figs. 68 and 69. — Fibroid Tuberculosis OF Six Years' Duration in a Man of Fifty-six in which the Fat Hides the Shrinkage of the Chest, avhich in Any Case is Moderate. Only the limi- tation of the resonant areas in the right apex are noticeable with slight limitation of motion at the right base. 312 PHYSICAL EXAMINATION Fig. 70. Fig. 71. Figs. 70 and 71. — To Show the Deforming Effect of Pulmonary Tuberculosis UPON THE Thorax. Chest of an athlete, in which right-sided tuberculosis (stage II) had existed for two years. The shrinkage of the right side as compared to the left side is well shown, as also the falling in of the regions below the nipples. There is right shoulder droop, retraction of the right base and of the right apex. The flattening of the for- merly prominent chest walls is well shown in the three quarters view. examination, as it will greatly improve the accuracy of the work and guard against over- looking any portion of the lung in the examination. The base line should l)e marked all around during shallow breathing, while in the mam- mary line in front and in the scapular line hehind tlie base line should be marked on deep inspiration, recording the excursion of the lower borders of the two lungs on the chart. Apical Percussion. — The ])ercussory projection of the apical outline (" isthmus ") proposed by Kroenig ('89) the writer has practiced for a number of years, and has found it a very valuable pro- cedure. The pathologic fact on which its value depends is the well-recognized tendency of the apex of the lung, and the lung as a whole, to shrink when a tuberculous focus de- velops in it, not alone from fibrosis, but even before any fibrosis occurs through the lessened functional activity produced by the disease. Le- Grange has noted the rapid modification of the volume of the lung coincident with in- crease or decrease of func- tion. Were apical shrinkage due to fibrosis alone, their de- termination would naturally be of no value in early diag- nosis, but since the lung de- creases in size when disused PHYSICAL EXAMINATION 313 or when disease is developing in it, such shrinkage becomes a valu- able early sign. As great accuracy is desirable, the little finger is best used as a pleximeter, and the percussion stroke must be deliv- ered very carefully and cor- rectly, only the most perpen- dicular, elastic, light stroke being desirable, and the pa- tient's head must be held ex- actly in tlie middle line to avoid uneven tension of the muscles. Percussion of the inner an- terior line should start well up the side of the neck above the lung, coming slowly downward until pulmonary resonance is found, the spot being marked by a dot with the skin pencil. Working from behind forward, the whole line is mapped out, which is slightly concave in- ward above, becoming rather convex inward in the lower third of its course, and end- ing rather indefinitely Just ex- ternal to the sternoclavicular joint, the bones here making accuracy difficult. The outer border should be approached from the shoul- der and marked in the same way. It is steeper than the inner and runs downward and outward, with its concavity outward to the junction of the inner and outer third of the clavicle. The posterior lines are marked in tlie same way. The normal level of the apex behind, according to Kroenig, is that of the first dorsal spine, and it is 2 to 2.4 inches outside the midline of Fig. 72. Fig. 73. Figs. 72 and 73. — Tuberculosis of Left Apex. Note slight limitations of area of resonance at apex and of motion of left base. Also flattening of outline of anterior chest wall as shown in side view. 314 PHYSICAL EXAMINATION the spine. The inner line converges with its convexity toward the spinal column, until it reaches the level of the lower border of the second dorsal vertebra, when it runs downward parallel and half an inch from the spine. The posterior external line the writer has found to run downward with its concavity outward and to terminate with great regularity at the middle of the spine of the scapula. The lines having been percussed out, they should be inspected carefully, and even in very early cases there is often found some degree of dislocation inward of one or more of them. The dislocation is chiefly in the inner line, but dislocation of the outer line is also common, as the writer has determined again and again by careful percussion. In early cases the demarcation between resonance and dullness is less sharply pronounced than in the normal lung, being as it were " blurred."' Goldscheider ("O?) recently objected to Kroenig's work on the ground that the resonant area thus outlined does not correspond to the anatomic apex, being only a projection field of lung resonance. This cannot be denied, but since these fields decrease in direct propor- tion to the contraction of the underlying lung, their determination does not thereby lose in clinical value, and, unlike Goldscheider's method, the outlining is sufficiently simple to be applied by anyone well skilled in percijssion. Goldscheider, by the use of a bent-glass rod pleximeter, percusses out the absolute height of the apex anteriorly and posteriorly. After having used his instrument and method, the writer has found that the absolute area can be so percussed, but the method is much more complex and the results not more satisfactory than those of Kroenig. The lung borders being marked out, the percussion of the lung should be commenced. This usually begins over the apices in the inner, mid- dle, and outer zones in succession, comparing these from side to side, and thus small areas of dullness are often discovered that otherwise may be overlooked, one zone at times being dull when others are clear. When, owing to emaciation, the supraclavicular' fossa is a deep hole, percussion of the apices should take place from above and behind. We should also not omit to percuss the clavicle directly, without the use of a pleximeter, as at times this bone will give a dull note when above and below is clearness, and if we can exclude old fractures and uni- lateral abnormalities of the bone, such information is valuable. The remainder of the chest should now be studied, taking pains to percuss absolutely symmetrical points and not to miss any portion of any interspace. Turban notes the necessity of not neglecting the apex of the axilla, a necessary warning, since, owing to motives of niceness, one is apt to avoid this region. The heart should always be mapped out on the anterior chest wall, care being taken not to overlook small areas of dullness on each side of the sternum, due to enlarged bronchial glands. PHYSICAL EXAMINATION 315 The back demands firmer percussion than the front, and in fat or very muscular persons percussion of this region may be most unsatis- factory. Small areas of dullness at the extreme base behind, from an i'lG. 7t). Fig. 77. Figs. 74 to 77. — Typical Case of Fibroid Phthisis of Left Lung in Case of Four Years' Duration. Note shrinkage of left side, dislocation of heart to left (right border to left of sternum, apex five and one quarter inches outside midline).' Extreme limitation of resonant area at left apex, anterior and posterior areas not joining, limit of motion of left base. old pleurisy, arc easily missed unless the bases are carefully marked. When scoliosis exists, producing abnormal arching of the ribs, percussion over such arched regions is more or less dull and percussion in scoliotic cases is not to be relied on implicitly. Technic of Auscultation. — Usually and logically auscultation is the last step, as it is unquestionably the most important, of a physical exam- 316 PHYSICAL EXAMINATION ination, but some have advocated placing it first, so that the deep breathing necessitated by some of the preceding steps may not remove scanty adventitious sounds which may be of importance in diagnosis. In doubtful incipient cases this may be necessary, but in such it is better, when the examination shows the case to be a suspicious one, and we suspect rales we cannot detect, to repeat the auscultation on another day, soon after the patient wakes, when such sounds are found most easily. Ordinarily it is best to place auscultation last, as this tends to give a more complete idea of the case, the various facts discovered by the other steps leading the mind logically onward and preparing it for a proper interpretation of the auscultatory findings, a knowledge of which enables us to correlate them into a complete whole. Moreover, if it is performed first, it tempts us to slur over the other steps which follow it, and we fail to get that broad view of the case which can only come from a consideration of all the discovered facts. The teclmic of auscultation is simpler than is that of percussion, but it needs a careful training of the ear, and if the physician has a musical ear it will be of gre«t assistance. Auscultation, may be either immediate or mediate. In the former the ear is laid directly on the chest, in the latter the sound is conveyed to the ear by an instrument, practically always a single or double tube. While the sound heard by immediate auscultation is very pure and gives an idea of the condition of a larger area of lung, it is faint, not sharply localized, and the finer adventitious sounds can be missed by it. More- over, the ear cannot be placed in the supraclavicular fossa, and ofteii not in the infraclavicular; the method brings one into disagreeably close contact with the patient's body, and it often necessitates very strained attitudes for the physician. For these reasons mediate auscultation is the method most commonly used, but the other should not be neglected entirely, since certain types of breathing, notably bronchial, are heard more distinctly and typically by it, and it gives one an excellent general impression of the lung as a whole. Mediate auscultation, devised by the great Laennec, is performed by the use of the stethoscope. This instrument is either for use with one ear (monaural) or with both ears (binaural), the former having been invented by Laennec in 1816, the latter by Dr. Camman, of New York, in 1840. The binaural stethoscope is in universal use in this country, the monaural on the Continent ; and the clinicians of the Continent and those of America seem unable to agree as to the merits of these instruments. Aside from custom, whose large part in the settlement of this question for any individual practitioner should not be forgotten, the reasons which have caused the profession of this country to reject PHYSICAL EXAMINATION 317 the monaural stethoscope are: the very awkward and strained attitude necessary in its use, the inability to control its position and application by the eye, the difficulty of avoiding undue pressure upon it by the doctor's head, and the fact that the sounds it transmits, while pure, are unduly faint, and that certain sounds can escape entirely. Sahli criti- cises the binaural stethoscope for its complexity, for the false sounds which he considers are created in it, and for unduly magnifying and distorting the sounds which it transmits. While some binaural stethoscopes are complex, the best type is prac- tically as simple as the monaural, and if it is without joints, as a good stethoscope should be, it produces in itself no confusing sounds, and though it moderately magnifies the sound as heard by immediate aus- cultation, as well as the monaural, in a lesser degree, this magnification, if moderate (as it is in good instruments), is an advantage rather than a disadvantage. However, the chief advantage which the binaural stethoscope possesses is the fact that it allows the physician the maxi- mum amount of ease and relaxation during his examination, and this, as noted elsewhere, is essential if he is to properly concentrate himself on the sounds to which he is listening. For these reasons, what follows refers entirely to the use of the binaural stethoscope and of the directly api^lied ear. . A^arious forms of binaural stethoscope have been invented, but the simplest is the best, and for this reason the writer prefers what the instrument dealers catalogue as Snofton's English model. This consists of a simple metal and hard-rubber chest piece, two metal conducting tubes connected by a curved spring, and hard-rubber ear pieces, the chest piece and ear pieces being united by rubber tubes. This instru- ment is extremely simple, and for all practical purposes as simple as the monaural. In buying a stethoscope the physician should see to it that the curves of the tubes are such as to tit the axis of the canals of his ears, and that the shape of the rubber ear pieces is such as to accommodate itself well to his canals. The spring, while firm enough to keep the ear pieces in close contact with the ears, must not produce undue pressure. The chest piece, which is best made of hard rubber or ivory, screwing into metal, should not be over seven eighths of an inch in diameter, and its cavity can either be conical, the apex of the cone running into the two tube openings, or almost hemisplierical, with one central opening at the top branching into the two tubes. The edge should be rounded, but not too thick. The rubber tubing which connects the chest piece with the ear piece should be perfectly flexible, yet tliick enough not to kink when quite sharply bent. The only absolutely satisfactory tube for this purpose is a good, rather thick-walled, smooth stomacli-tube. The 318 PHYSICAL EXAMINATION lengtli of tlie tube slioidd not be less tban eight inches nor more than twelve, ten inches being the best, allowing amply for motion and cliange of position without kinking. Stethoscopes meant to magnify the sound by the use of diaphragms, of which the plionendoscope is the best-known exam})le, tend to lessen the acuity of the physician's hearing, though useful at times for auscul- tating indistinct sounds or for those who are hard of hearing. Of course every stethoscope magnifies somewhat, but the very moderate magnifica- tion found in such a stethoscope as advocated strikes the happy mean between the faintness of sound of the monaural and the undue loudness of the plionendoscope. Cabot recommends the Bowles' stetlioscope, which differs from the instrument described in the chest piece, which is two inches in diameter, very slightly hollowed out, and covered with a hard-rubber diaphragm. It seems to share, in a lesser degree, the disadvantages of tlie plionendoscope, and to unduly magnify the sound, but Cabot says the diaphragm does not act in this way, since the instru- ment acts as well when it is cracked. In any case, in the choice of a stethoscope, tlie important thing is that tlie physician should accustom himself thoroughly to the use of one instrument, and use that exclusively. In this way any instrument will be found to yield satisfactory results, though the awkward positions necessitated by the monaural stethoscope are, to my mind, an irremovable handicap to its utility. The only other instrumental equipment necessary in auscultation is a pot of cold cream vaselin and a spatula, which is often very necessary in anointing patients whose skins are harsh, scaly, or hairy. Position. — The patient should be seated opposite and within easy reach of the physician, his hands hanging by his sides or lightly crossed in his lap, and his body in an easy, symmetrical position. The physician should be seated comfortably not too far from the patient, witli absolute ease and relaxation on the part of the physician and tlie patient if the former is to absolutely concentrate his undivided attention on the sounds in the chest, undisturbed by uncomfortable or strained attitudes, and if the latter is not to produce muscular sounds in tense muscles. Before beginning the auscultation, it is a matter of no little impor- tance to listen carefully to the patient's method of breathing. The majority of patients produce some sound in their noses on moderately deep or deep breathing, or even sometimes on quiet breathing, these sounds being transmitted to the chest and affecting the pitch and qual- ity of the expiratory and, less often, of the inspiratory sound. Opening the mouth is not always sufficient to cure this, many patients continuing, nevertheless, to breathe through the nose, others producing a loud bron- chial sound in the throat, and a few a sibilant sound against the teeth. But if one will take pains to breathe properly for them, they will learn PHYSICAL EXAMINATION 319 quickly to respire normally and silently, even during deep breathing, by opening their mouths, and to maintain during deep breathing the normal relation of inspiration to expiration. Some patients, however, can never learn this, especially those with perforated septums, and such are very difficult to auscultate. Having taught the patient how to breathe, and being sure that he is not cold, since this can produce shivering, and thus muscular sounds, the auscultation may be begun. It should alwa3's be carried out in two separate portions. First, directing attention entirely to the breath sounds, and neglecting any adventitious sounds, study their pitch, in- tensity, duration, rhythm, and quality. This should be comparative, exactly similar spots on each side from top to bottom of each lung being compared, ins})iration with inspiration, expiration Avith expira- tion (Grancher), noting also tlie relation of inspiration to expiration. By concentrating attention entirely on the breath sounds one scarcely hears any rales. Such comparative auscultation should first be made during quiet, easy breathing over the whole lung, and then during mod- erately deep breathing. Deep breathing should not be used in the aus- cultation of breath sounds, since during it they are never entirelv nor- mal, but moderately deep breathing, well performed, will at times reveal bronchovesicular breatliing which would be missed on quiet breathing. Care nnist be taken to cover every portion of the lung area, the chest piece of tlie stethoscope being applied along the whole length of each interspace, not omitting the apex of tlie axilla, the pleural sinus, the body of the scapula, and the area of cardiac dullness. Beginning over the apices whose inner, middle, and outer zones must be auscultated, ])roceed downward in slightly diverging lines so as to cover tlie whole anterior lateral and posterior aspects ; in this way noth- ing will be missed. Finally, we should study the breath sounds in different portions of the same lung, noting the relations of inspiration to expiration, and remembering the normal variations in the sounds in various regions. Before completing comparative auscultation, vocal reso- nance must also be tested, remembering that it is best judged by the use of the whispered voice. The results of tlie auscultation being noted on the chart wliile still fresh in mind, one should turn to the second jjortion of tlie auscultation, which the writer calls unilateral aiiscuUuiion, in which attention is directed only to adventitious sounds. This is the most delicate part of auscultation, and demands the most concentrated attention. For this reason the patient should sit close beside the physician, but facing the other way, and close enough so that the stethoscope may easily be placed on any ])art of the chest. The type of breathing used should be, first, natural breathing, then moderately deep breatliing, then very deep 320 PHYSICAL EXAMINATION breathing, and finally deep breathing preceded or followed by a short cough, rales which are absent at first often appearing on deeper breath- ing. Xaturall}', those rales heard easily on quiet breathing speak for a more advanced process than those which can only be elicited by deep or forced breathing. The writer usually has the patient cough just before taking a deep breath; Babcock, of Chicago, prefers to have the patient cough Just at the end of a deep breath; Brown, of Saranac, has recently recommended cough following a complete expiration, and fol- lowed by a complete inspiration. If the cough precedes the breathing the patient must be told to avoid that act of swallowing after the cough which is natural with most people, and which can produce deceptive esophageal sounds. Of the rales heard, the phase of respiration in which they occur should be noted, as well as their size, their quality, and their appearance on natural or forced breathing. The physician should use some convenient system of signs for recording breath changes and adven- titious sounds, thus simplifying his charts. Such a system will be found in the Appendix. Technic of Roentgen Examination. — If used only occasionally, the in- formation the fl.uoroscope can give hardly compensates for its great cost, and unless it is used frequently and systematically the physician will not develop sufficient skill in its use in chest work to avoid the many possible sources of error in interpreting the shadow picture, and he is apt, therefore, to be misled ratlier than helped by it. If, however, the physician will use the fluoroscope regularly in all his cases he will soon develop such a familiarity with it as to get from it great assistance. The essentials are a dark room; a source of electric current, either to actuate the coil or to drive the plates of the static machine, though for the latter a water motor can be used ; a device for interrupting the current, perfectly insulated conducting cords, a Eoentgen-ray bulb, an adjustable stand to hold the bulb, a large fluorescent screen in a rectan- gular frame, and a large protective lead screen. The current can be obtained from an induction coil, or produced in a static machine, driven by electric or water motor, hand power being useless for practical work. The coil is more popular, being less bulky, not affected by weather, and yielding a powerful light. The static machine is preferable for fluoroscopy because of its steadier light, intensity after a certain point being a disad- vantage rather than an advantage, and secondary in importance to steadi- ness because of the very greatly increased life of the tube, and the simpler and therefore much cheaper tube which can be used. It is also less likely to produce harmful effects on the patient (dermatitis) or physician (azoospermia). If a coil is used it should be capable of producing from an eight- to a sixteen-inch spark ; if a static machine, it must be well and strongly built. PHYSICAL EXAMINATION 321 with not le^;s than eight thirt3'-inch revolving plates, and should produce at least a twelve-inch spark under good conditions, and must be run at at least 500 revolutions per minute. It must be kept in a dry room, and in damp weather kept dry by keeping calcium chlorid in the case. When once understood it should run every da}- in the year without difhculty. An interrupter for use with a coil, or with a static machine a mul- tiple spark-gap, is essential. Much of the failure to get proper results with the static machine has come from failure to heed Williams's advice to use a multiple spark-gap, the single spark-gap on the pole of the machine being entirely useless. By it the penetration of the tube can be raised or lowered at will, an essential thing in the study of the lungs, under different conditions or penetration, either to reveal areas of shadow invisible with bigh-vacuum tuljes, or to penetrate thick chests, opaque until a series of sjjarks is introduced into the current. The apparatus is simply a series of brass balls inserted in the course of the current, and so arranged that the current can be made to .jump the gaps between a given number of balls at will. Each new gap inserted in the circuit raises the penetration of the tube, so that a tube of such low vacuum that it will not penetrate the chest at all can be raised until it accjuires any necessary degree of penetration. This ap- paratus must be close by the observer's hand, so that he can make the changes instantaneously, and without removing his eyes from the screen. The cords must be thickly and well insulated, as the high-tension current used will leak from ordinary ones. The hulh for thoracic work should be of the lowest vacuum tliat will give a clear picture. A bulb that will liglit up with a one-half-inch or a one-inch gap between the poles is satisfactor}'. Bulbs to be used with a coil need a heavy platinum cathode, with some arrangement for keeping the cathode cool, and an apparatus to lower the vacuum when it gets too liigh, since with a coil the vaciuim rises very rapidly, until a nonadjustable tube is soon use- less. Such tubes are very expensive and add greatly to the cost of ajjparatus. With the static machine the cathode can be of light platinum, needs no cooling device, and, as the vacuum rises very slowly, an adjusting apparatus is not needed, such a tube lasting for a year or two in daily use, while for the same reason a six-inch tube is sufficiently large. Six- inch, light anode, nonadjustable tubes of the best make are very rea- sonable in price and are cheaper to use, until too high for satisfactory use, and then get a new one rather than buy expensive adjustable tubes. Laid aside for six months or a year, high tubes reduce their vacuum and can often be used again later. Care must be taken to choose bull)s carefully, seeing that they have a sharp focus — i. e., cast a clear-cut and 22 322 PHYSICAL EXAMINATION not a hazy or foggy shadow ; so, if possible, a bulb should always Ije seen in action before being bought. The stand must be firm, with a broad foot, and capable of easy and free adjustment to any angle and to the height of the chest of the tallest patient. A lead screen, in view of what we know of the effect of the Roentgen ray on the human body, is an important essential. The lead should be one sixteenth of an inch thick, three feet high by two feet wide, and mounted in a firm frame on an adjustable stand, and per- forated by a circular four-inch hole, capable of being diaphragmed down to various smaller diameters. Such a screen, placed between the bulb and the patient, and about two inches from the bulb, cuts off all rays save those transluminating the thorax; it protects the patient as well as the physician from harmful effects. The fluorescent screen should not be of the type usually furnished by supply houses, with a stereoscopelike eye piece or camera, but should be a large sheet of cardboard, sensitized by platino-cyanid of barium, sixteen by twelve inches in size, framed in wood, and with a handle at the middle of its longest side. With such a screen the whole thorax can be seen at once, and, since the work is done in a dark room, the camera is unnecessary and in the way. The patient is best examined standing, though if too weak he may sit on a stool ; patients so weak as to be obliged to recline are usually not in a position to leave their homes. While one can examine through the clothes, metal ornaments, objects in the pockets, buttons, etc., make so much trouble that it is better to examine the patient stripped. Tlie two chief directions for illumination are anteroposterior and po?-tero- anterior, but oblique examinations from one side in front tc the other side behind, or vice versa, must not be forgotten, especially when exam- ining the contents of the mediastinum. Except in oblique examina- tions, the axis of the rays must be at right angles to the transverse plane of the patient's chest to avoid distortion, very slight changes from an absolute right angle producing deceptive appearances. The patient had best be placed about two feet from the cathode, or farther, as by placing him too close to the tube there results undue magnification of the shadows. The most useful level for the tube is that of the fourth rib at the sternum, but Holzknecht advises using also a higher and lower level. The physician should be in the dark, with his eyes closed, for about five minutes before he makes the examination, as when he comes directly from the light he is at first practically blind, and can see nothing at all, whereas if he gives his retina time to become sensitive in the dark, he will be able to see and study the shadow pic- ture. If he comes from bright sunlight, more time may be necessary. The beginner must be careful not to conclude quickly that a shadow PHYSICAL EXAMINATION 323 is pathologic, but must consider and exclude all possible sources of error, which, as noted, are numerous. A regnlar order of observation should be followed, noting : First, the comparative size and shape of the two lung areas; second, the position and size of the heart; third, the mediastinal shadow and shadow of the roots of the lung; fourth, the motion of the bases; fifth, the clearness and size of the apices; sixth, an}' shadows in the body of the lungs. The picture well seen and fixed in the memory, the physician should record it at once on his chart, reproducing, as closely as possible, the extent, shape, density, and nature of the sliadows, and any bright spots he has observed; and while tliis has not, of course, the accuracy of a photographic plate, it is very satisfactory for clinical use, and enables one to keep a close watch on decrease and increase of areas of shading. The physical examination liaving been completed, it remains for the physician to draw from it such conclusion as it justifies, and here the writer would warn not simply against making positive diagnoses in doubtful cases with few signs, but more especially against the far more dangerous and harmful fault of excluding tuberculosis because the first examination, even if made tliorouglily and carefully, has proved nega- tive. Xo clinician, however skillful, can be positive in such an exclusion after one examination, and since so much depends on it, and since the patient, comforted by such an assurance, will go back to his ordinary life, it is wiser to tell liim tliat no positive signs were found and lie is probably free from disease, Imt that it is preferable to watch him for two weeks or a montli, studying his temperature, etc., and reexamining him before giving a final opinion. After such a course one can feel fairly sure of his position, though faith in tlie diagnostic methods of modern medicine must never cause one to forget that in this life the absolute is always unattainable. Again, one is often tempted or urged by the patient to give a prog- nosis after one examination, but the longer one treats tuberculosis the more wary will he become of making a positive prognosis. Again and again one sees cases that have impressed us favorably develop a rapid and destructive process, while cases which seem so desperate that we risk the statement that they will live at most two weeks or a month, will survive for one or two years, to be claimed by the Christian Scien- tists as cures or to remind us that prognosis, at best, is an uncertain art. The study and combination of all the results of our examination should be noted carefully, and the small departures from the normal, revealed by the earlier steps, should not be neglected, but should be used to corroborate the findings given by the more important ones. It is desirable also to record on the charts at the time of the examination an opinion of the case while the impression made on the mind by the 324 PHYSICAL EXAMINATION different findings is fresh and sliarp, for, however well these are recorded, reading them over will never reproduce at a subsequent date the clear impression obtained wlien the examination was just finished. Finally, a note of warning should be sounded against yielding to the temptation when tired of omitting any part of the examination. Unquestionably, in some cases, certain steps can be omitted without affecting the result, but one can never tell just which these cases are, and there is not one step which in certain cases is not of the greatest value. Moreover, by commencing to omit certain steps, one enters on an easy but downward path tliat will surely lead into careless and slip- shod work. Facilis decensus Averni. CHAPTER III DIAGNOSIS By CHARLES L. MINOR In these days, when pathology and clinical medicine are working together so effectiveh', the recognition of pulmonary tulierculosis need no longer be postponed until the disease is well advanced, and for the modern physician the diagnosis of this trouble means principally, and practically, its early diagnosis, and in what follows I shall pay atten- tion chiefly to the discovery of the trouble in its incipiency. When the disease has reached the stage which justifies the use of the term " consumption," its discovery makes no demands on our diag- nostic skill, and offers little assistance to our therapeutic efforts, and the physician who hopes to be of use to his patient must remember that his results, save in acute or galloping cases, will be in direct proportion to the earliness of his diagnosis, and must be prepared to recognize the trouble in its very beginning, when the signs and symptoms, unless closely and logically studied, can be so ambiguous as to be confusing, and when he will, more often than not, be deprived of that absolute proof which can be given only by the discovery of the bacillus iu the sputum. Such an early diagnosis is often a difficult task, calling for the most careful clinical work, but such, fortunately, has been the advance of diagnostic methods, and such the improvement in medical education, that every physician Avho is willing to take the time and trouble, and to follow a proper system in his work, should be able to make the diag- nosis, except possibly in a few unusual cases, and it should not so often as it is be left to the specialist to discover the patient's trouble. The diagnosis of pulmonary tuberculosis is a result of the careful study of the facts yielded by three separate procedures, and not of any one of these alone — i. e., a history, a physical examination, and a study of the s}Tnptoms and clinical course of the case for a longer or shorter period — and can be fortified by the use of certain special procedures, such as the tuberculin test; but while we can thus reach practical cer- tainty, it need hardly be stated that absolute certainty can only be attained by the discovery of the tubercle bacillus in the sputum. While, 335 326 DIAGNOSIS however, this discovery can alone make an absolute diagnosis, it is by itself unable to make a complete one, and if such a complete diagnosis is desired the physician must make use of each of tlie procedures to which reference has been made. Moreover, one cannot too strongly dwell on the folly of postj^oning a diagnosis of pulmonary tuberculosis until the bacillus is discovered. While it appears early in some cases, it is very freiiuently absent until the disease is well advanced, and when |)roper methods of physical examination can make us morally certain of the nature of the trouble, no one, therefore, should deprive his patient of the advantages of early treatment because he cannot demonstrate the germ. The physical examination yields such valuable information that its findings are too often taken as final and sufficient in themselves, and a positive diagnosis made from them alone. This is an unwise practice, and no physician, however skillful, should in a doubtful case finally exclude tuberculosis after one examination, or until he is able to study together the facts gathered from a full and searching history, a thorough physical examination, and a study of the symptoms and clinical course of the case, followed, if necessary, by a reexamination. Only thus can we venture to exclude tuberculosis, or sometimes diagnose it, in certain doubtful cases where bacilli are absent, and these are the very cases where it is most important that we should be sure of our position. Of course, in the large majority of cases, a positive diagnosis can be made without so much effort. The period of observation is chiefly occupied with a careful study of the temperature, which should be taken every two hours during the day, and also on one or two nights, to reveal possible night fever. More- over, since at such times certainty is important, it may be necessary to take the rectal temperature for a day or so to determine its relation to the mouth temperature, and the reliability of the latter. If the tem- perature proves normal, one or two excessive walks should be ordered, which will often reveal otherwise concealed fever (Penzoldt). If neces- sary, other doubtful symptoms can be studied, and if the sputum anal- ysis has proved negative we can use special measures to demonstrate the bacillus. It need hardly be noted that, whatever his suspicions, the physician should try not to let his mind be prejudiced in favor of or against any special diagnosis, but should keep it open to conviction in any direction, not striving, like a special pleader, to make out a case at any cost, but, like the true scientist, seeking to discover the truth from the facts, however at variance it may prove to be with his pre- conceptions. Since an absolute diagnosis depends on a discovery of the bacillus in the sputum or stools, this will be considered first. SPUTUM EXAMINATION 327 Sputum Examination. — The best sputum for examination is usually that raised on awakening, coming as this does usually from the lung proper. When, however, the patient has some other chief time for clear- ing out his lungs, it should be collected then. In early doubtful cases, when little or no sputum is raised, the patient must carry around with him the sputum receptacle at all times so as to catch any chance expec- toration that may be brought up. In the morning the mouth is apt to be contaminated with saliva, etc., so that it should be well rinsed before spitting, to avoid any unnec- essary contamination of the specimen, which should come from deep down in the chest, and not be hawked from the nose. The patient's statement that he raises nothing should not be accepted too quickly, as often by training he can be taught to furnish a specimen which he was unconsciously swallowing. Furthermore, the fact that the sputum is only glairy or salivalike should not be a cause for rejection, if no other can be had, as at times numerous bacilli can be found in such mucoid sputum. In the case of children, who cannot raise their sputum, but swallow it all, it maj- be necessary to administer an emetic on waking and search the vomitus for masses of sputum, and this may also be necessary in difficidt cases with those adults, chiefly women, who swallow their sputum. It has lately been suggested that the fasting morning stomach be washed out for this purpose. If there is no sputum, some advise giving potassium iodid for a while to produce bronchial secretion, but the very harmful effect of this drug on the pulmonary process, which I have frequently had oppor- tunity to observe, leads me to think this an unwise procedure. The drinking of warm alkaline waters or the use of small doses of ipecac is harmless, but not very effectual. Usually three or four expectorations are sufficient, but in negative cases it may be necessary to save all the day's sputum and concentrate it if bacilli are to be found. This need not, however, be resorted to until frequently repeated examinations have failed to demonstrate the bacillus, and it need hardly be noted that not one, two, or even ten examinations suffice to exclude the possibility of tuberculosis, but that we are justified in believing the process very prob- ably nontuberculous if very many repeated examinations are negative. There are various methods of concentration, dependent on rendering homogeneous the total mass of the sputum by alkalies or digestive fer- ments and centrifugalizing the product. The writer has used with satis- faction the method recommended by Czaplewski, who considers the use of the stronger alkalies harmful to the staining qualities of the germ. He uses twelve per cent of borax, dissolved in hot distilled water to which an equal amount of boracic acid is added. This is filtered while warm, 328 DIAGNOSIS and the excess of chemicals allowed to crystallize out. Of this two or three parts are taken to one part of sputum, these agitated together in a tall, stoppered cylindrical glass till homogeneous, when it is either sedi- mented for twenty-four hours or centrifuged. The sputum should be collected in water-tight, wooden boxes, painted black inside. These are not only easily burned after use, unlike glass or metal receptacles, but the black surface and the wide opening permits picking out easily the particles to be examined, without removing the sputum from the box, which is both dirty and dangerous. The sputum should be examined within a few hours of its expectora- tion, as otherwise many bacteria which often liquefy the whole mass, and change the appearance of the preparation, can develop. Once spread and fixed, the cover-glasses can be kept for a more convenient time, but the greatest care must be taken not to confuse different preparations, which, where many samples are being examined, is a very easy matter. The porcelain dishes, used by architects for mixing their water colors, are very convenient for this purpose. The names of the patients are written in the different compartments with a skin pencil, and the cover- glasses are placed accordingly, the whole being covered by a bell glass to wait until a convenient time for examination. If boxes with black bot- toms are not used, the sputum must be spread on some black surface to assist us in selecting proper portions for examination. All authors speak of picking out the small rice masses or cheesy mat- ter, but while these yield very large numbers of germs, they are never found in the sputum of early cases, which is usually mucoid, or mucopuru- lent, hence we have to satisfy ourselves in such with picking out the thickest, most purulent parts of the specimen, taking from each a small portion, mixing these all together intimately and taking the final lump from the mixture. In this way we lessen the chance of taking the sample from a part of the specimen free from germs, while they might be present in some other portion. Some sputums are remarkably tenacious and rubberlike, so that it is difficult to take up a jjortion on the platinum loop, but if this is heated the sputum will adhere to it easily. The portion taken must not be too large, else it will make a thick, dirty specimen, and will ooze out between the cover-glasses and soil the fingers. A piece the size of a No. 2 shot is sufficiently large. The sputum can be spread either on a cover-glass or on a glass slide. While the former method de- mands neater work, and the breaking of a cover-glass may soil the fingers, it yields better specimens. With a proper technic the fingers need never be soiled, or the glass broken, and when the examination is over, if the prep- aration is not to be preserved, the covers can be burned quickly in the Bunsen flame. The best cover-glasses to use are those of medium thickness, seven- eighths of an inch square, round glasses being inconvenient and dirty to spread. The covers must be iT^rfectly clean and fat free, which is best ob- tained by boiling them in ten per cent chromic-acid solution, washing them well in running water, and keeping them in ninety-five per cent alcohol. SPUTUM EXAMINATION 329 The aim in spreading is to get a thin, even layer of sputum, so that the staining and decolorization can take place easily, and the study of the speci- men be simplified. In order to accomplish this, place the proper amount of sputum in the center of a clean cover-glass, lay on the second cover- glass so that the corners do not coincide, and by gentle pressure between finger tips, combined with lateral movements, rub out the sputum to an even, thin layer, draw the covers apart, lightly warm them both over the Bunsen flame, thus drying the thinnest portion of the spread only, and continue this drying until the sputum is evenly spread on the two covers. The sputum may be rubbed out with a platinum spatula on one cover-glass, but the film is streaky, of varying thickness, and we get one cover instead of two for examination. If not dried fractionally, the spread covers must be dried in the air, or by holding them well above the Bunsen flame until perfectly dry, when they can be passed rapidly through the flame three times, more passages than this tending to burn the specimen and lessen its staining qualities. Many stains may be used, but Ziehl-Neelson's is the best. This stain consists of a mixture of one part of a saturated alcoholic fuchsin and nine parts of a five per cent aqueous carbolic-acid solution, which is not perma- nent, and is best mixed fresh each time. The cover-glass is covered with stain, and it is then held over a Bunsen flame, until the fluid steams and sends off one or two bubbles, when it is laid aside for a minute or two, then drained and washed thoroughly in distilled water. The decolorizing of the specimen, which aims to remove the stain from all the elements of the sputum except the tubercle bacillus, which is acid- resisting, is the essential feature of the whole staining procedure. Usually a dilute mineral acid is used. On the examination of urine or stools where smegma bacilli may be present, alcohol must be used in the decolorizing process, either with or after the acid, but in sputum work an aqueous solution is satisfactory. Twenty per cent nitric or sulphuric acid is usually used, the latter, according to Czaplewski ('00), being the better, but these strengths must be handled carefully to' avoid ovcrdecolorization, though when their use is understood, they give beautiful results. Other decolorizers are Orth's hj'drochloric-acid alcohol (1 per cent in 70 per cent alcohol), Ebner's fluid (2.5 parts hydrochloric acid, 2.5 parts sodium chlorate, and 100 parts dis- tilled water mixed, to which add 500 parts 95 per cent alcohol), and sweet spirits of niter. Pure alcohol, while an excellent decolorizer, is too slow. Whatever solution is used, decolorization must not be carried too far. The cover-glass should be so placed in the fluid that every part is wet at once, and should be removed in a second to the water, which brings back the red color which was changed by immersion in the acid. This should be repeated until the proper color is gotten. The color to be aimed at is a faint pinkish-gray tint in the thin parts of the specimen. Washing well with 70 per cent alcohol is necessary if we wish to exclude smegma bacilli. For counter-staining, either concentrated aqueous methylcne-blue solu- 23 330 DIAGNOSIS tion or Loffler's alkaline methylene blue is the best ; methylene green makes a very beautiful contrast, but fades out very quickly in daylight. Methods which combine decolorization and counter-staining, such as that of Gabbett, prevent the control of the decolorizing process, hence are uncertain and should never be used. The counter-stain should act only one or two minutes, and the cover-glass should then be well washed and dried under filter paper and in the air till perfectly dry, as dampness will cause it to cloud. A properly prepared cover-glass should show a smooth, even spread, evenly stained a bright blue, with no thick streaks and no red spots. The specimen is mounted in immersion oil (B. Fraenkel) and studied with a one-twelfth inch (2 mm.) oil immersion lens, a No. 4 Zeiss ocular, and a good condenser. Abbe's being very generally used with abundant light. When numerous, the bacilli are easily found, but if they are scanty the search is often a long one. In a doubtful case a diagnosis should never be made on the discovery of one bacillus, unless it is absolutely typical in form, size, and peculiarities. If the result is negative, the sputum must be examined frequently and carefully, and if many such examinations are negative, we should homogenize the sputum. Hesse puts streaks of sputum on a solidified Hayden's culture medium, which he places in an incubator, at blood temperature, and in five or six to twenty-four hours bacilli are found which before were undiscoverable. By means of animal inoculations bacilli may be demonstrated when none can be found by the microscope. Intraperitoneal injections of sus- pensions of sputum in 2 or 3 c.c. of sterile saline solution are made in guinea pigs, which are killed in from three to seven weeks and carefully examined for anatomic or bacteriologic evidence of tuberculosis. Pure sputum may be inserted through small skin incisions in the groins, which incisions are then sealed with collodion. The inguinal glands swell in from eight to fourteen days in positive cases, and in from five to seven weeks the animal is killed and examined. Unfortunately, other bacteria in the sputum kill a large number of the animals very soon, especially in the intraperitoneal method, hut if skillful observation is obtaina])]e the results are positive and valuable. In the case of children or others who swallow their sputum, a diag- nosis may sometimes be made by an examination of the mucus flocculi from the stools, but intestinal tuberculosis must be excluded before a diagnosis of pulmonary tuberculosis is made. Smegma bacilli can be differentiated by the fact that they decolorize easily in alcohol, unlike the tubercle bacillus. When treated with a saturated alcoholic solution of methylene blue they slowly turn blue, unlike the tubercle bacillus, having been deprived of their fuchsin by the alcohol, and thus being able to take up the counter-stain. History. — The patient's history is of the greatest aid in making a diagnosis in a suspected case of pulmonary tuberculosis, but a carelessly PHYSICAL SIGNS 331 taken histor}' is worse than useless, as it is misleading. F. WolfE ('94) places the history ahead of the physical examination. It will almost always prove that the trouble had its beginning long before the patient suspected himself to be sick, and gives information as to his family idiosyncrasies and constitution, his resistance to disease, and his oppor- tunities for infection. The Family History. — The discovery of one or two cases of tuber- culosis in a patient's relatives has but little value, but a tuberculous father or mother, especially if they were sick during the patient's child- hood, or tuberculous brothers or sisters, not only renders probable a decreased resistance to the disease, but, much more, demonstrates oppor- tunities for infection in early life, when such infection is easiest. If many relatives have died of the disease, it is naturally both diagnos- tically and prognostically of importance, as is also information as to the course which the disease took in these persons. The childhood history should show home and school conditions, opportunities for infection, as well as those sicknesses or states of health which favor or suggest the development of tuberculosis, such as measles, pertussis, scrofula, otitis, pleurisy, pneumonia, bronchitis, delicacy of constitution, sickliness, rickets, etc., and should also give an idea of the general health of the child. The personal history can demonstrate not only unsuspected chances for infection in office, store, or workshop, where the abominable Ameri- can habit of promiscuous spitting makes itself especially evident, but often reveals suspicious past sicknesses which masqueraded at the time as malaria, neurasthenia, or dyspepsia, or will reveal the occurrence of ischiorectal abscesses or pleurisies, which usually mean tuberculosis. Family, financial or other worries should also be inquired into if the patient is willing to be frank. The habits, by revealing the mode of life and of Avork, dissipations or idiosyncrasies, are of great value, and we should record the patient's norm as to appetite, weight, sleep, etc., as standards for comparison. The present history, at least, is not apt to be neglected, but we must ascertain the real beginning of the present trouble and not merely the time when the symptoms became so marked as to draw the attention of the inattentive patient. A history of an old pneumonia or pleurisy, for instance, often serves to explain the physical signs found in the chest. The status prcBsens, or present condition, giving tlie existing symp- toms, is, of course, of the greatest value in diagnosis, and for further comparison and should always be recorded. Physical Signs. — The facts revealed by a pliysical diagnosis have been fully dwelt on under Physical Signs. Here we will only con- sider briefly their relative value in diagnosis. No physical sign in 332 DIAGNOSIS and by itself proves tuberculosis, and every sign can be produced by other conditions; hence a final diagnosis is impossible except after a synthesis, not simply of the facts yielded by the physical examination, but of those gathered from the history and a clinical study of the case; the practice of snap diagnoses based only on a brief physical exami- nation, leads into error. Auscultation and percussion always show less than the full extent of the trouble, there always being an area outside the limit of a])normal sound where the disease is making inroads. Inspection, if carefully performed, will in a large number of cases give a very good idea of the chief seat of the troul)le and suggest its nature, but, as Babcock ('07) well says: "It is the detection of very slight differences . . . which is important." Thus pronounced defor- mities, faulty build, long flat chests, narrow angle, delicate skin, silky hair, etc., have value chiefly in prognosis, and are of but slight use in diagnosis. Often a first glance, revealing a slight flush of one cheek, is suggestive, although unilateral pupillary changes cannot be relied on, as also cannot Thompson's rod line on the gums. In acute cases, cyanosis of the fingers without clubl)ing is ominous, as is an ashy gray pallor or widely dilated pupils. Very slight flattening above the clavicle, combined with slight limi- tation of motion and slight shoulder droop, will be found very early in the disease. Flattening of the shoulder outline comes soon after these alterations as muscular wasting begins, and is accompanied by flatten- ing below the clavicle and of the upper portion of the pectoralis. The more pronounced flattenings occur only after the diagnosis is almost self-evident, but from their nature one can at times suspect the pres- ence of large cavities, or more especially the development of marked fibrosis. In the former case we will at times find localized hollowings in the upper one third of the chest in front, as in large shrinking cavi- ties. In the latter there can be marked contraction and shortening of one side of the chest, producing concavity of its lateral outline and drawing the shoulder down toward the hip markedly. Palpation is not of great value in diagnosis, and especially in early diagnosis, but a distinct increase of vocal fremitus, particularly on the left, can be used in corroborating other signs. Decrease of fremitus is too difficult to determine accurately to be of value. Small areas of increased fremitus at the bases behind or in front are useful in calling attention to slight areas of consolidation or pleuritic adhesion bands, which later steps will verify. The discovery of enlarged cervical glands is important, and if excitement from the examination can be excluded, tachycardia has the very greatest diagnostic value in very early cases. Distortion of the apex beat is also suggestive of fibrosis. Mensuration is much more reliable prognostically than diagnostic- PHYSICAL SIGNS 333 ally, though the discovery of an undue shrinkage of the perimeter on one side of the chest by the lead tape can, in conjunction with other signSj enable us to decide in a difficult case which is the most seriously affected lung. The spirometer findings can at times have diagnostic value, an abnormally low vital capacity increasing the value of other findings, but usually it is the increase or decrease from time to time which is valuable, and then rather as an aid to prognosis. Percussion. — Percussion changes do not appear as early as do changes in auscultation, but by very careful and light percussion great diagnostic assistance can be gathered in very early cases. Eeal dullness is never an early change, but a short or slightly high-pitched note, or slight tympany appears very early. In incipient cases one should be careful to study the apex in the three vertical zones already referred to, as one of these may be impaired while the others are still resonant. For this reason, if for no other, the marking out of the apical borders is of the greatest value. The posterior aspect of the apex, no less than the anterior, should receive light percussion, heavy percussion often failing to reveal the changes here that the other will demonstrate. Percussion directly on the clavicle must also not be neglected. It is important to hunt carefully for small isolated areas of impaired reso- nance, especially, as noted elsewhere, in the fourth interspace outside the left nipple line, or between the scapula and the spinal column low down, but we must be careful not to be misled by undue arching of the ribs, producing localized dullness. Auscultation is recognized as the most accurate and delicate of diag- nostic methods, and on it is placed reliance for the final rounding out and completion of the diagnosis. The breath changes are not as positive diagnostically as are rales, but they appear earlier and combined with other signs, justify a posi- tive diagnosis without waiting for the development of these latter, and if the physician will take care to study the various alterations of the respiratory murmur, he will not have to wait for adventitious sounds before he ventures to diagnose the trouble. The sequence of these various alterations, in the writer's experience, is (1) rude or granular breathing, chiefly inspiratory; (2) feeble breathing; (3) cogwheel breathing; (4) harsh vesicular breathing and prolonged ex- piration; (5) vesiculobronchial or bronchovesicular breathing. Bronchial breathing is not an early sign. Transmission of the heart sounds to the right apex speaks for incipient consolidation. Grancher ('90) gives the order of the signs as (1) feeble; (2) rude; (3) cogwheel; (4) bronchovesicu- lar; and Turban as (1) rude; (2) cogwheel; (3) harsh vesicular; (4) feeble, and (5) bronchovesicular. The value of vesiculobronchial breathing or harsh respiration at the right apex is, of course, less than when found at the 334 DIAGNOSIS left, and many authorities teach that in young girls or women such a change has no diagnostic value, but while it must be accepted with great caution and must always be corroborated by other signs, its presence should cause one to use every possible care in seeking for more positive signs of trouble. The subclavian systolic murmur has no real diagnostic value. Changes in vocal resonance at times give information of begin- ning consolidation sooner than will percussion, and we should, there- fore, be careful to test it, chiefly, however, by the use of the whispered voice, small isolated patches of bronchophony or whispered pectoriloquy revealing such patches as in a less degree can increase a vocal fremitus. Rales. — The importance of rales in the diagnosis of pulmonary tubercu- losis does not need to be insisted on. They cannot be called a very early sign, the process being diagnosticable for some time, and often for a long time, before they appear. Nevertheless, they must always be sought for with the greatest care, using forced breathing and cough, as well as those changes of position (horizontal) and of time (early morning) which favor their development. The use of potassium iodid is unwise, but the use of hot alkaline drinks, or of ipecac in small expectorant doses, is harmless and may be useful. Creosote preparations or ichthyol or alcohol will de- crease the adventitious sounds so that in doubtful cases these drugs must be stopped for some days before the examination. When rales first appear they are usually isolated fine crepitations (dry crackles) not different from those of pneumonia, except in their scantiness, or, as Babcock thinks, in being less sharp and crackling. A few (often only one or two) such rales located in an apex, and discovered at various times (persistent), possibly disappearing after cough, but reappearing after some hours or a day, are, perhaps, the strongest diagnostic sign, though after an attack of grip an obstinate spot of apical catarrh can produce just such signs for a while. Even when not at an apex, persistent rales, accompanied by voice changes, have always a high significance, and foreshadow the future development of an area of involvement (Sokolowski). Indeed, the essential difference of the signs given by a tuberculous process from those given by those of any other catarrhal process is their persistence, and persisting pulmonary signs are always presumptively tuberculous. Beginners must be on their guard against mistaking false rales of various sorts for the real ones. (See Physical Signs.) Fine sibilant rales at an apex, while by no means so diagnostic, are also, if persistent, very suggestive, as are a few isolated friction sounds, speaking for an apical pleurisy. With the appearance of fine moist rales (moist crackle, subcrepitant rale) the ineipiency of the process is passed, and as it ad- vances these rales increase in number and size, until they gradually develop, to terminate in a gurgle, that fatal sign which usually presages the approaching end. Some authors consider the mucous click, an isolated sticky, moist rale of medium size over an apex, diagnostic, but while it generally speaks for tuberculosis, it does not occur soon enough to be classed as an early diagnostic sign. The transient atelectatic rales often found at the bases posteriorly have no diagnostic value. SYMPTOMS AND CLINICAL COURSE 335 The laryngeal examination is in many cases of the greatest value diag- nostically. When slight signs in the lungs have excited strong suspicions of tuberculosis, the discovery of a tablelike elevation of the mucous mem- brane of the posterior commissure, a reddened, swollen arytenoid, a uni- lateral cord paralysis (if aneurysm can be excluded), or even a pale and wrinkled posterior commissure, will transform an uncertainty into a cer- tainty. Fluoroscopy. — The fluoroscope is not a means of early diagnosis in most cases. At times it will show a contracted shaded apex when dullness or marked breath changes could not be discovered, but such findings are the exception. Limitation of motion at the base (Williams) is much more common and is valuable, but too much diagnostic importance should not be placed upon it. In the early diagnosis of bronchial-gland enlargement, however, the fluoroscope far surpasses all other methods, and even if this in- strument is not regularly used, all patients in whom this condition is suspected should be subjected to the X-ray for verification of the diagnosis. Symptoms and Clinical Course. — The symptoms, like the physical signs, have been considered in detail and will here be only considered relative to diagnosis. In taking the history they should be inquired after most carefully, avoiding leading questions which might suggest the desired answer. It is often surprising to see how difficult it is for patients to give a rational and clear account of their symptoms and how anxious they are to substitute for a statement of facts that have come under their own observation, the diagnostic terms suggested to them by some friend or physician. The statement that a patient had " grip " should never be accepted, but he must be made to describe and enumerate the symptoms which led to this opinion, and very often it will be found that the grip was an exacerbation of a preexisting tuberculosis, that a typhoid was an acute attack of the same, or a malaria only the chills and sweats of a pulmonary process. Fever will not usually have been recognized by the patient in incip- ient cases, and he will have to be put on two-hourly measurements for from two to four weeks. In doing so a reliable thermometer is essen- tial. Great assistance will be derived from making a graphic curve of the temperature and marking red lines across the chart at 97, 98, and 99, which makes much more striking rises above or falls below these points. A two-hourly record during the day should always be insisted on, and in suspicious cases night measurements at eight, twelve, and four may be necessary. Thus short-lived rises during the day and unsuspected night fever will be discovered. It is probable that some persons normally have a temperature above or below the usual limits, but as we rarely have an opportunity to learn the patient's normal curve, this cannot always be 336 DIAGNOSIS determined. Persistent afternoon rises above 99.2° F, are very suspicious if the patient is at rest, and if above 99.6° F. and other causes can be excluded, it can be ascribed to tuberculosis, for, as Ruchle aptly says, "■ a persistent fever for \\hich a reasonable cause cannot be found is most probably due to tviberculosis in the system." It must be remembered, however, that all men have some rise in temperature for about an hour after eating, and, therefore, temperatures taken after the midday meal must be over 100° F. to be of value (100.4° F., Penzoldt). The frequent premenstrual rise in women must not be forgotten when studying slight temperatures. The curve in tuberculosis is fairly regular in early cases, and marked irregularities while the patient is at rest throw some suspicion on its tuberculous origin. The temperature may be normal for several days together, followed by periods when a constant slight afternoon temper- ature will be found, but two or four weeks of observation will clear this up. The rise in early cases rarely comes before one or two o'clock in the afternoon, and usually lasts but a short time, say to four or five o'clock, or even less, and the morning is marked by a fairly pro- nounced subnormal temperature, which has considerable diagnostic value. At this time morning temperatures of 90° F. and evening rises to 99° F., or rarely 100° F., are the rule, and greater rises would sug- gest a more advanced or more active troul)le. At times when fever, dis- coverable by the thermometer, is absent, there is flushing of the cheeks after meals or on excitement, and this should always suggest the taking of a rectal temperature. When tlie temperature is pronounced, diag- nosis by physical methods is usually easy. Patients with a dilated stomach and retention can run a suspicious temperature, which will entirely disappear on the correction of the gastric trouble, and this possibility should be kept in mind and the level of the lower border of the stomach determined. Chills in early cases, unless the process is acute, are not found, and they are thus of value as suggesting the nature of the case. Cyanosis of the fingers and face is likewise suggestive of acute trouble, but the cyanosis seen in childbed fingers has no diagnostic value. Languor is a common and early symptom and a very valuable one. It is too often explained by anything else rather than tuberculosis, such as neurasthenia, overwork, malaria, etc., but persistent languor should always excite attention. Anorexia, when combined with other symptoms, adds weight to the suspicions. Early tuberculosis often manifests itself as dj/spepsia and a per- sistent sense of fullness and weight in the epigastrium, belching, dis- comfort, or other signs of fermentative dyspepsia, combined with wast- SYMFl^OMS AND CLINICAL COURSE 337 ing and fatigue, are of great importance in diagnosis. Ischiorectal abscess should always suggest tuberculosis. The writer has never found diarrhea in very early cases, though it has been reported. Sweats as an initial symptom are rare. They were present in one case seen by the writer as the only symptom, but were finally followed by rational signs. Dyspnea, while present to a slight degree in some early cases, is not of value diagnostically except in acute disseminated cases, when marked dyspnea, out of proportion to the ph3fsical signs, would suggest extensive dissemination of tubercles. In a later stage of the trouble it is almost diagnostic of fibrosis. Emaciation. — A persistent loss of weight is at times the first symp- tom, and always arouses the anxiety of the family and the physician. In such cases a suspicion of tuberculosis is justified if no other cause is found. Babcock ('07) states that men should weigh twenty-five pounds per foot and women twenty-three, and that any reduction below this is important in making a diagnosis. The method of Pignet of estimating the corpulence — i. e., the height in centimeters minus the sum of the chest circumference in centimeters, and the Aveight in kilos, which should yield a result under 25 — is considered by Meissen a useful means of estimating the patient's resistance. Figures under 10 show a very strong constitution, those between 11 and 15 a strong one, those between IG and 20 a good one, 21 to 25 a moderate one, 26 to 30 a weak one, 31 to 35 a very weak one, and over 35 a very bad one. Papil- lon gives the corpulence as the relation of the weight in hectogrammes to the height in centimeters, which he states must in girls be over three. Hoarseness. — In a doubtful case a persistent hoarseness or clearing of the throat suggests weak lungs and demands a laryngeal and pul- monary examination. Circulation, Blood. — Tachycardia, if persistent and unaffected by change of position from the erect to the recumbent (Wells) or paroxys- mal on slight and trivial excitement is a common finding in tubercu- losis, and a very valuable one in diagnosis, especially in the absence of fever, a pulse running persistently over 90 to 100 being suspicious. The tension of the pulse as a diagnostic factor has been insisted upon by Papillon especially, but while hypotension, comljined with tachy- cardia, is suggestive, too many other conditions can affect the blood- pressure to make it of great value by itself. The morphology of the leucocytes cannot at present give any aid in diagnosis, though Arneth's work (see Blood) promises to lead to valuable developments in this line. Pain. — Pain is not of great diagnostic value in early tuberculosis, but " rheumatism "' of the shoulder at times means apical pleurisy, and a burning spot in a supraspinous fossa or pain in the point of the shoul- 338 DIAGNOSIS der on cough is suggestive. At the same time it is unwise for the physi- cian to belittle the importance of pain in regions where he cannot find any physical signs, for very often there will develop later at these sites evidences of trouble. Fullness and pain behind the sternum is at times found in tracheobronchial adenopathy. Head's painful spots have not proved of value, but pain on percussion over the apex will sometimes be found very early, and a sensitive apex is always highly suspicious. Cough. — Cough is the symptom most commonly associated by the layman with this disease, and is rarely absent in any case. It appears very early and remains often long after all other symptoms have gone. It is first usually dry, and more of a " hack " or clearing of the throat than a real cough, such a " hack " as already noted being most suspi- cious, but often scarcely noted by the patient. Absence of cough is of much value in excluding tuberculosis, and a persistent cough which gets worse in summer and often does not disappear in winter, is with few exceptions due to tuberculosis, and while there can be a cough arising from irritation of the pneumogastric in the stomach justifying the term " stomach cough " so dear to the layman, this explanation should be accepted only after a careful stomach examination. Nervous cough may persist for long periods, but does not tend to change in character, as the tuberculous cough always does with a lapse of time. Expectoration will often be absent in early cases. When present it strengthens the diagnostic value of cough as a symptom, even when no bacilli are found in it. Hemorrhage. — Hemorrhage from any cause except tuberculosis is so rare that it is astonishing to see how diligently physicians seek to explain it as coming from any other possible cause, a practice that has been disastrous to many patients. At the same time, hemorrhage should not be regarded as of tuberculous origin without a conscientious effort to exclude other causes, notably heart disease (mitral stenosis princi- pally, but also any other condition which can produce pulmonary en- gorgement). The expectorated blood in early and dubious cases should be examined carefully for bacilli, though even in tul^erculosis they are not always found. Brown quotes with approval the method of Nattan- Larrier and Bergeron, in which twelve to twenty volumes of water are added to the blood before centrifuging as assisting the discovery of the germ. Small streaks and spots of blood in the sputum do not justify the term of hemorrhage, and can come after severe cough in ordinary bronchitis, but should cause the physician to keep his eye on the patient. The nose and throat, on whose diagnosis so much depends, should be examined carefully in these early and doubtful cases to reveal bleeding points, and disease of the trachea must be excluded, as also other local and constitutional conditions, such as aneurysm, heart disease, hemo- THE TUBERCULIN TEST 339 philia, etc. In incipient cases the exclusion of the gastric origin is not difficult. It only becomes difficult in large hemorrhages, where much blood has been vomited and swallowed. Cornet says ('07) : "However numerous the causes may be, we will seldom go Avrong when the patient feels a tickling in his throat and brings up, with a violent coughing fit, foamy, aerated blood (one or two teaspoonfuls or much more) in con- sidering the case tuberculous, and treating it as such until the contrary is proven." Other Diagnostic Measures. — When we have exhausted all the usual steps of an examination, including repeated sputum examinations, and find no evidence of tuberculosis, we should be content with the negative result, it being neither necessary nor wise to go further, but in some cases the history or the signs will be very suspicious, while not con- clusive, and it may be very important in these cases to find some other means of arriving at a diagnosis. Of these other means, the first and most important one is : The Tuberculin Test. — This test, as a means of completing the diagnosis of a doubtful case, has been before the profession for a num- ber of years, but only recently has the fear of this preparation which resulted from its abuse at the time of its discovery, calmed sufficiently, as the result of a painstaking study of its value by such men as Petruschky, Turban, Cornet, Bandelier, and others in Germany, and in this country by Trudeau, Baldwin, A. C. Klebs, Otis, and others, to allow of any considerable use of this method by the profession. The neglect was unquestionably due to a fear lest it might tend to aggra- vate or disseminate the process, as was taught by Virchow, but while the preparation is a powerful one, and needs the most careful hand- ling, the work of innumerable careful observers has demonstrated satis- factorily that tuberculin^ carefully used in proper doses in properly selected cases, is free from harmful effects, and while some of the best workers in this line are still ultra-conservative as to it (Sokolowski, Meissen), and while it should never be resorted to until all other means of making a diagnosis have failed, it is safe to teach that no strongly suspicious case should go undiagnosed because of a fear of the danger of tuberculin. Osier said : " An important point is its harmlessness. I remember no cases in which injurious results have followed the in- jection," and this is to-day the view of such a majority of the leading clinicians that no physician need fear to recommend its use to his patients if properly applied. The question is, however, does a positive reaction always demonstrate the existence of tuberculosis, or a negative one always exclude it? An absolute, positive, and negative diagnostic measure it certainly is not. As M. Wolff says, " an absolutely easily applied method for the certain 340 DIAGNOSIS determination of beginning tuberculosis . . . would be almost as valu- able to us as a specific," but a method to be useful need not claim to be absolute, and the test yields such a large per cent (eighty-five to ninety per cent) of reliable results as to make it of the greatest value in diag- nosis. The work of no one man, however extensive, could alone serve to decide the question of tlie diagnostic value of this test, but only by a consideration of the results of the work of many men can it be answered. Since 1890 the tuberculin test has been used in a great number of cases in human beings, not to mention its use in cattle, where it has a greater diagnostic value than in man (over ninety-seven per cent, A. Fraenkel, Nocard), and a study of the results of all this work proves that a positive reaction to the tuberculin test, if the dose is not too large, justifies the diagnosis of the existence of tuberculosis in the patient, while a failure to react casts great suspicion on the tuberculous nature of the process if we can exclude old healed lesions or advanced trouble, both of wliich can fail to react. Those interested in the statistics should refer to the literature of the subject. It is to-day considered that from eighty-five to ninety per cent of cases of tuberculosis will react positively, suspicious cases in- cluded, and that very nearly a hundred per cent of first- and second- stage cases which are demonstrably tuberculous will react to the test (Beck). Brown states: "No case of early or incipient pulmonary tuberculosis has been shown to fail to react to a dose of 0.01 c.c. (10 mgm.) or less of old tuberculin." Dunn ('03), of Asheville, wlio has a very large experience with tuberculin, says : " The test is a safe, reliable, practical, and justifiable diagnostic resource in those cases in wliich its use is indicated." Turban, who has had a very large experience with it for a number of years, states that a pronounced reaction is never noted in the healthy, or in other diseases, but this is too wide a statement, and despite the statement of Brown that " no case of syphilis, actinomycosis, leprosy, or chlorosis, which reacted to tuberculin, has been proved at post mortem to be free from tubercu- losis," the work of Otis ('01) and others justifies the belief that fresh syphilis can give this reaction, and even such enthusiastic advocates of tuberculin as Bandelier and Eoepke admit that probably syphilitics will react. Of course, it must be remembered that modern work has shown (Naegeli, etc.) that a large number of people have a latent tuberculosis, and that thus positive reactions in those having other diseases may well be due to such concealed foci in the system, but whether such foci exist can only be determined by post mortems, and unless such are available the results of careful clinical work must decide whether the patient has tuberculosis or not, and a positive reaction to tuberculin. THE TUBERCULIN TEST 341 unaccompanied by an}- clinical evidences of disease, should not lead us to declare the patient to be clinically tuberculous, but should demand careful and prolonged study of the case. While, however, tuberculin is not an absolute proof of tuberculosis, the fact tliat it is positive in eighty or ninety per cent of the cases makes it an invaluable addition to our diagnostic armamentarium, and in cases with ver}' dubious signs it is more positive than anything except the discovery of bacilli in the sputum, and the physician is safe in assum- ing that any patient whose symptoms and signs justify the use of the test, reacting distinctly to a moderate dose of tuberculin, is tuberculous. Likewise, if such a patient fails to react after a repetition of the final dose, he is justified in considering that, barring a possible encapsulated, healed focus, the patient is probably free of tuberculosis. Te clinic. — While any of the various preparations of tuberculin can produce the reaction, Koch's old tuberculin is now universally used for diagnostic purposes, and, as in diagnostic work, uniformity of proce- dure is most desirable, the use of any other product cannot be considered wise. The old tuberculin is now made in excellent quality in this coun- try, and for a long time was made and most generously supplied to the profession by the Saranac Laboratories under Drs. Trudeau and Bald- win. It is a sirupy, light-brown fluid which, while undiluted, is per- manent. BroAvn wisely draws attention to the fact that the strength of tuberculin is far from constant, even when made hy the same process, so that it should always be carefully standardized. Dunn ('03) reports a case exemplifying the variability of different samples of the drug, in which 5 mgm. of one preparation produced neither recognizable, local, nor general reaction, but in which, after the proper interval, the use of 2.5 mgm. of another preparation, which had shown itself unusually active, gave a marked general reaction. For use it is diluted under strict aseptic precautions with 0.5 to 0.25 per cent carbolic acid in distilled water, or normal salt solution, using pipettes graduated in cubic centimeters and tenths of a cubic centimeter. The dilutions needed are two : one of 1 per cent and one of ^ per cent, and these will last for a week at least if kept in the dark. The 1-per-cent solution contains in ^V c.c. (one division of the usual hypodermic syringe containing 1 c.c.) 1 mgm. of tuberculin and the ^V-pcr-cent solution contains in yV c.c. yV nigm. Thus, by diluting measured quantities of the fluid with the carbolic-acid solution, and using one or more tenths of this dilution, we can get any dose from Y^ mgm. up to 10 mgm., hence no others are needed for diagnostic purposes. For example, in preparing a dose of yf^j- mgm. we suck yV of a cubic centimeter of the yV-p^r-cent solution into the syringe (one division), this equaling y*g- mgm. of tuberculin, and dilute it with j-^^ 342 DIAGNOSIS c.c. of a carbolic-acid solution, each division of the mixture therefore equaling ^^ mgm. of tuberculin, and, of course, five divisions contain the YT 0" nigm. of it. The syringe must be sterile, and is best kept in 1-per-cent carbolic water, or, if made of glass, in alcohol. The needle should be boiled before use. The usually chosen site for tlie injection is under the angle of the scapula, but any convenient region can be used. The site is cleaned with alcohol. The writer prefers driving the needle vertically into the muscles up to -its socket, which avoids all veins and is less painful than the subcutaneous method. While cleanly injection prevents any abscess formation, a local reaction around the site of injection — i. e., some red- ness and tenderness and stiffness — occasionally occurs, but never goes any further than this. Some have advocated the patient's going to bed for twenty-four hours after the injection, but this is not necessary unless strong reaction occurs, although the next day should be spent quietly in a reclining chair. Since nervous patients can very easily produce the symptoms which they are led to anticipate, it is important in diagnostic cases not to let them know what you expect. Three days or a week preceding the injection should be given up to a two-hour study of the temperature and a record made of the exact pulmonary findings, for it is only by a comparison with the norm that the method has value. After the injection the temperature must be taken two hourly in the daytime for thirty-six hours, and the chest watched for local signs. Dosage. — There is considerable difference of opinion as to the best doses, but fair uniformity as to its maximum and minimum limits. Koch originally recommended an initial dose of 1 mgm., followed in two days by 5, and this by 10, with a repetition of the last dose, if negative. Turban uses 0.5 mgm., 2 mgm., 5 mgm.; Cornet, 1 mgm., 3 mgm., 5 to G mgm. ; L. Brown recommends ^ mgm., 1, 3, 5, and 8 mgm. M. Wolff begins with yL- mgm., then -^ mgm., then 1, 2, 5, and 10 mgm. Eoepke uses -^^, 1, and 5. Petruschky, in young people or children, ad- vises -jV> tV> 2' ^"^^ 5 mgm. Loewenstein and Kauffmann ('06) advocate a different plan, using a dose of -f-^ mgm., repeated at three-day intervals, four doses, and then, if necessary, though this they think will rarely be the case, 2, 5, and 10 mgm. The hypersusceptibility created in the body by one dose is the fact on which they rely in the use of these repeated small doses, believing that in this way the small doses are raised to the value of larger ones.^ Others have suggested that such repeated small doses might create an immunity and so defeat the test, 'This hypersusceptibility is the same as that prochiced in the body by the tubercle bacillus and its products, on which the tuberculin test depends. THE TUBERCULIN TEST 343 hence this method has not met the approval of most experts in this work. There is certainly no harm, and there are many advantages, in a moderate initial dose, and the writer favors y% nigm. for a begin- ning dose, followed by 1, 2, and 5 mgm., which will usually be satis- factory; while if this is negative and the patient is strong we can use an 8 or 10 mgm. dose, repeated once. More than 10 mgm. should never be used. If one dose produces a mild, indefinite reaction, the same dose should be repeated in two days, when it will frequently result positively and distinctly. Koch considers a strong reaction, follow- ing a repetition of the dose, as especially characteristic, and believes that this may be regarded as a quite infallible sign of the presence of tuberculosis. In view of the fact that the reaction can be delayed for thirty hours, or even more, it is essential that two days elapse between the doses, and some authors advocate an interval of three days. It should never be forgotten that reaction to tuberculin is not limited to the tuberculous if the dose be large enough, the tuberculous person differing from the normal not in reacting but in reacting to small doses, and it is there- fore of the utmost importance that the largest diagnostic dose shall never be large enough to produce a reaction in a normal person. Koch has set this maximum at 10 mgm., and while reactions will usually be obtained with smaller doses, most authorities are united in considering that a reaction to 10 mgm. will not occur in the normal man. The usual tiine for injection, and that recommended by Koch and others, is as late in the evening as possible, so that any possible tem- perature rises in the night should not be missed, but Bandelier and Roepke ('08), who have had a very large experience, advise injections between eight and ten in the morning, since most reactions come in six to eight hours. The dosage in children must be smaller than in adults by ^ to j\. usually yV nigm. ; j\, 1, and 3 mgm. are advisable. Koch is very particular in insisting on ascertaining the normal tem- perature of the patient before the beginning of the test, and believes that the temperature must not go over 99.1° F. in the afternoon. Brown, and also W. L. Dunn, believe that 100° F. is not too high a limit in the hands of one experienced with the method. Tlie Reaction. — This is local and general. The former is the specific feature of the reaction, and is due to congestion around the tuberculous focus, probably resulting (Citron) from the combination of the tuber- culin in the blood and the antibodies in the focus. If the lesion is visi1)le (skin, larynx) this reaction is manifested by redness and swelling, and, if concealed, l)y an increase of physical signs, the result of the engorgement and swelling around the lesion. Turban considers the signs of a local reaction in the lung as the most valuable 344 DIAGNOSIS part of the test, and watches the patient daily for the development or increase of dullness, breath changes, and especially rales, but while such local signs, when found, are very valuable, they are often absent and are not essential to a diagnosis. The cough and sputum are natu- rally also increased, and bacilli which have been absent may appear, hence Turban advises the careful collection of all the sputum during the test. The general reaction is not specific, since sufficiently large doses of tuberculin produce a reaction in normal people. It is manifested by fever and constitutional symptoms, and is not different from the effects of any other bacterial toxins on the human system. The patient feels badly, complains of headache and chilly sensations, or has a definite chill, his joints ache, he feels weary, loses appetite, and has a rapid pulse, and at times will develop nausea and vomiting. If tuberculous glands are concealed in the body they will frequently be revealed in this way. The writer has known areas of localized tenderness in the abdomen to suggest probable intra-abdominal glands. The temperature rise may be slight, moderate, or great, but usually runs from 100° plus to 103° F. (see accompanying charts). A reaction with temperature not over 100.5° F., and with few con- stitutional symptoms, is called mild, one in which the temperature runs from 100.5° to 102° F., with more pronounced symptoms, is considered medium, and one with fever above this point accompanied by marked prostration is considered severe. A rise to less than 100° F. (Roepke, 100.4° F.), unless supported by a local reaction, when a rise of 1° F. is enough, should not be considered diagnostic, but should call for a repe- tition of the dose. While the reaction may begin in four hours or be postponed for thirty- six, most reactions occur in from six to eight hours, or slightly more, and persist for from six to twelve hours, then disappearing rapidly, and leaving behind only a sense of fatigue for a little while, until by the third day the patient is himself again, and often feels better than be- fore. Very early (under four hours) or very late reactions (after forty hours) should be excluded from consideration, as not resulting from the injection. In the very nervous, whose excital)ility can give them slight rises, it is at times necessary to make the first dose of sterile water, or five-per-cent carbolic solution, to exclude this "nervous tem- perature." A positive and distinct reaction, if accompanied with other suspicious signs or symptoms, justifies, as already said, a diagnosis. To quote Petruschky ('00), one of the most faithful students of this subject, " if several times typical reactions follow injections (chiefly on the next day) when between and before the temperature is normal, we can with certainty conclude that the patient is tuberculous." 103' KC Mr lor 09 = 98' 97 = 14 in 1« ~ T^ 19 ^ ei •22 23 24 25 26 2T 2S 29 lu.3 l'J2 101' ll» 3 -1 i 6 s 9 10 11 12 13 14 15 16 17 18 19 ^ . 1 , i = 1 ' I ' ' ; : 1 C - ' ' ) ^ : ^ 1 _J_ ^ _ ^ _ _ - 1 _ ^ 1 _ _ _ _ J^ ^- — =1 -^ i ^ ^ X - u - ^ _ -r - P 17^ — - ^ ;q- ^ :ir ^-1 -^ -=- ~r 4 " ^~ ^ -^ ~- M / 7\ - *- -1 r - _ •^ A 4. T« -^ -/ V^ -1^ T* -^ x^ nA / A _ ^ ^ - - V t "t" «<- i/r ^ *i / i^ fcf^ «/j ./ ^- ^^- */- ^- ^- -T^ - H - J - Jj 1 X J- X -^ + X -H X -L 4- J- i X X 1^ X -4_ -^ ^- X -L J^ X i= - Fig. 78. — Tuberculin Injection Fig. 79. — Mild Re.\ction After WITH Xeg.\tive Result. Slight reaction after second injection. No rise after third and fourth. Diagnostically negative. Fourth Injection. Local reac- tion in right lower lobe. Bacilli in sputum during reaction. Diag- nosis: Tuberculosis right apex and right lower lobe. Fig. 80. — Mild Re.\ction After Sec- ond Injection (1 mg.). Stronger reaction after repetition of same dose. Fig. 81. — Active Reaction After Third Injection (o mg.). Rapid rise on day of injection. Fall by lysis in course of three days. Di- agnosis: Tuberculosis upper right lobe. Local reaction. Fig. 82. — After First Injec- tion Pseudo-reaction from Parulis. After second in- jection (same dose) no reac- tion. After third injection (1 mg.) moderate reaction. Tuberculosis of both apices. Fig. 83. — Tuberculin Diagnosis in Neu- rasthenia. Fluctuating temperature (over 98.6° F.) before injections. Con- trol injection with water; no distinct reaction, normal conditions. After first tuberculin injection mild reaction; on repetition stormy. Local reaction at left apex. Note. — The temperature charts here given are from Bandclier and Roepke ('08), transposed into Fahrenheit degrees. 345 346 DIAGNOSIS Contraindications. — However useful this test may be, its indiscrimi- nate use is to be discouraged, and, as already noted, it should only be resorted to when every means of making a diagnosis has been used, and even then it should not be applied unless the case seems strongly sus- picious. Further, the temperature must not be higher than 99.2° F. Recent acute diseases in the chest or elsewhere are a contraindication, or any hemorrhages within the month. Heart disease, if the heart be compensated, need not prevent its use, but if uncompensated or of a severe form, it is a contraindication. Nephritis and epilepsy are also regarded as contraindications. The tuberculin test in itself, and unsupported by anything else, does not justify the diagnosis of a case as clinically tuberculous, as it may be caused by an inactive encapsulated focus, and, as Hamman ('08) has well said, "the tuberculin reaction acquires significance only as a part of the general clinical picture," or, to quote Sokolowski ('06), " Excluding the appearance of bacilli we know no single pathognomonic sign for this disease; our diagnosis must rest upon a consideration of all symptoms, their critical weighing and the exclusion of all those processes which could produce the existing condition in the patient," and this test should be regarded as an addition to, rather than as a substitute for, regular measures, and to l)o used only when distinctly indicated. Modifications of the Tuberculin Test. — Among the various causes which have served to delay the general adoption of the tuberculin test is the unfamiliarity of the profession with its technic, which is really very simple. As a consequence, the announcement in 1907 by von Pirquet, Wolff-Eisner, and Calmette of new and simple modifications of this test have awakened very general interest. Von Pirquet's reaction, better called the cutaneous reaction, is pro- duced when the skin is aljraded through one or two drops of a twenty- five-per-ccnt solution of old tuberculin (one part tuberculin, one part five-per-cent carbolic glycerin, two parts normal salt solution), which is left in place for a few moments, and then ruljljcd off (it has been shown that rubbing of stronger solutions without abrasion is sufhcient, Ligniere's, '07; ]\Ioro, "08). In from twenty-four to forty-eight hours a zone of light pinkish redness, about half an inch in width and ac- companied by swelling, api)ears, and finally a papule forms. These signs disappear in about eight days and leave behind some temporary discoloration of the skin. The ophthalmic reaction, better called the conjunctival reaction, which was first observed after the application of stronger solutions (ten per cent) by Wolff-Eisner, was clinically applied and modified by Calmette. It is produced when, in tuberculous subjects, a one-per-cent solution of dry tuberculin (alcohol precipitate) in sterile water is dropped into the MODIFICATIONS OF THE TUBERCULIN TEST 347 conjunctival sac. In the normal man, according to Caluictte, this has no result, or at most a very slight temporary reddening, but in the tuber- culous, shortly after the application the patient feels a sense of itching, burning, and smarting in the eye. To quote Calmette's original de- scription ('07) : Five hours after the instillation, at times in three hours, all the tuber- culous develop a marked congestion of the palpebral conjunctiva; it be- comes bright red and shows a more or less intense edema. The caruncle sw^ells, reddens, and is covered with a slight fibrinous exudate. The vas- cular injection increases by degrees and is accompanied by lacrymation. At the end of six hours the fibrinous secretion becomes more abundant and collects in filaments in the inferior conjunctival cul-de-sac. The maximum intensity of the reaction is between six and ten hours. The patient complains of no pain but only a little discomfort, with a sensa- tion of a slight swelling, and some trouble with vision, in proportion to the degree of exudate. There is no chemosis. The course of the rectal temperature is not sensibly altered. ... In children at the end of eighteen hours, in adults at the end of twenty-four to thirty-six hours, the phe- nomena of congestion decrease and finally disappear. In healthy non- tuberculous people the instillation of tuberculin is without any result. At most one notes, in from one to three hours afterwards, a slight red- ness, which disappears quickly and is not accompanied by any fever or lacrymation. Further use of this method by many physicians has demonstrated that this description is excellent if we refer to mild or moderate reac- tions, but that severe reactions occur at times which can greatly exceed this picture in intensity. The pain and photophobia can be extreme, and the swelling so intense as to close the eye. Calniette, in his modification of the test, reduced the maximum dose to one per cent, which it is now recognized should not be passed, as, like the tuberculin test, a sufficients strong dose can produce reaction in anyone, and the effect of strong doses can be very severe. Collin, of Berlin ('08), an oculist, has dwelt on the possible dangers to the eye from this tost, and calls attention to the necessary uncertainty of the dosage, and other physicians and oculists have reported very severe conjunctivitis, ulcerations, and keratitis, and Serafini ('07) even an abscess. To avoid possible severe reactions, Comby ('07) recommended the use of 0.5 per cent solution for this reason, and Baldwin ('07) would reduce this to 0.35 per cent for the initial dose. The instillation is best made in the morning, so that the eye can be examined from time to time during the day for signs of reaction. It is convenient to use a delicate dropper, yielding a small and uni- 348 DIAGNOSIS form drop. The drop is deposited in the conjunctival sac of one eye and carefully distributed around so as not to be promptly winked out. Briggs has suggested that the rapidity with which the lacrymal duct removes secretion from the eye in some people is so great as possibly to affect the results of the test, and he advises position directed to pre- vent this, a suggestion which seems to me worthy of consideration. If in one day there is no reaction, instill into the other eye the next stronger solution. A 0.5 per cent solution for the first dose, and 1 per cent for the second dose is best; the writer has not found the 0.35 per cent solution to produce reactions. The use of the other eye for the second dose is important, as, even in normal people, a certain degree of hypersusceptibility is created in the eye by the first dose, and in the tuberculous in the other eye as well, hence a false reaction might occur in the nontuberculous with the second dose if the same eye is used twice. T'nlike the tuberculin reaction, tliere is no effect on the temperature in the large majority of cases, though Wolff ('08) and Cohn ('07) have reported cases where this occurred, and in Cohn's case there was both local and gland reaction and general phenom- ena. Baldwin ('07) advises classifying the results as: first, nega- tive; second, doubtful, in which tliere is slight reddening of the caruncle; third, positive -|-, distinct pali)ebral edema and secretion; fourth, posi- tive -| — |-, ocular and palpebral edema, with well-marked secretion; and fifth, positive -| — | — \-, deep injection of entire conjunctiva, with edema of lids, photophobia, and secretion. The contraindications are the presence of any ocular disease, espe- cially conjunctivitis, and more especially what has been called the stru- mous diathesis. In a patient with this diathesis the writer has seen a very severe reaction, with great discomfort for ten days, pain, great photophobia, lacrymation, severe edema, with swelling of the lid so as to nearly close the eye, and profuse secretion. The advantages of the method are its simplicity and ease of appli- cation, its rapidity, but to my mind especially its applicability in febrile cases where tuberculin is contraindicated, and in children who are frightened by the hypodermic injection. It is too soon as yet to decide on the reliability, utility, and safety of these tests, and in view of the large number of latent, unsuspected cases of tuberculosis, a positive reaction in apparently healthy people cannot be regarded as proving them unreliable. Only time and clinical work can decide the percentage of reliability, which has been reported anywhere from fifty to ninety- eight per cent, the statistics of different authors differing widely. Some, especially French writers, are enthusiastic; some well-known authori- ties, like Moeller and M. Wolff, have given them up entirely as no more simple and far less reliable than the older method. It seems, however. MODIFICATIONS OF THE TUBERCULIN TEST 349 probable that the cutaneous method, and even the more general!}' applica- ble conjunctival method, cannot be regarded as complete substitutes for subcutaneous injection, but only as an occasional resort in the cases noted. It would seem that the cutaneous application is chiefly useful nega- tively and in nurslings under one year, and may possibly prove useful in suggesting the presence of latent foci, while the conjunctival is more useful clinically and in the diagnosis of active trouble (Wolff-Eisner, '08; Engel and Bauer, '07; Warfield, '08). The negative result of a cutaneous test is strong evidence of the absence of tuberculosis, but a positive reaction, save in infants, as noted, cannot safely be made the basis of a diagnosis of active tuberculosis; but it should cause us to reexamine the case most closely and apply the subcutaneous test. At present the tendency to accept a positive cutaneous reaction as proof of active tuberculosis in adults seems likely to lead to errors in diagnosis. Detre ('08) has suggested the use of the cutaneous test to distinguish between human and bovine infection, using human and bovine filtrates cutaneously in parallel rows. Sixty-nine per cent of his cases reacted to the human inoculation ; only four per cent to the bovine ; twent3'-two per cent to both. This, however, will need further proof. The specific nature of anaphylactic reactions is made the basis of a diagnostic test in tuberculosis by Yamanouchi ('08) by transferring the fresh blood or serum of the patient to healthy young rabbits (weight, 400-800 gm.). About 5 c.c. of blood are withdrawn from a vein into 2 c.c. of one-per-cent sterile sodium-citrate solution to prevent coagula- tion. This is injected without delay into the peritoneum of a rabbit, or the same amount of fresh blister serum may be employed. After twenty-four hours 5 c.c. of a saline extract of tubercle bacilli are injected intravenously. Instead of this, from i to 1 c.c. of old tuberculin, diluted to 5 c.c, may be used. If no symptoms of anaphylaxis follow immediately, the same dose is repeated twenty-four hours later, when the sudden death with respiratory failure and convulsions ensues if blood from a tuberculous subject has been used; otherwise, no apparent irconvenience results even after further repetition of the toxin injection. Yamanouchi details 42 cases of tuberculosis and 12 of other diseases, with miiform success in their differentiation. Baldwin, of Saranac, has been able to confirm the results in 4 cases thus far. The Agglutinative Serum Reaction. — A few years ago Arloing and Courmont ('05) recommended this reaction as a diagnostic measure in tuberculosis. Homogeneous culture of bacilli are obtained by a special cul- ture method (growth on glycerin peptone bouillon of old cultures which are shaken up to insure even distribution and yield a homogeneous mixture of bacilli). Mixtures of the serum of the suspected case with this culture or with a dead culture which can also be used (Koch and Remberg) in 350 DIAGNOSIS portions of 1 to 5, 1 to 10, and 1 to 20, are examined at twenty-four-hour intervals, both with the eye, to note the clearing of the serum, and the deposit of small flocculi, if positive, or with the microscope to note the clumping of the bacilli, which should occur with tuberculous sera only. French authors have been very optimistic about this test, but the workers of other countries have been unable to verify their results. Among others, Kinghorn and Twitchell, in 1900, reported a careful study of the subject, through two years, in which they came to the conclusion that it is not a specific sign of clinical tuberculosis, since healthy and tuber- culous sera have practically the same agglutinative properties. They, therefore, conclude that it is of no value, especially for early cases, and this is in accord with the more recent opinions of the students of the subject. Cijtodia gnosis (Widal). — This depends on the study of the cellular elements of the serum in tuberculous subjects. This serum is either collected from blisters or from natural collections in the pleura or else- where, and is mixed with nine-tenths per cent salt solution, with a two- tenths per cent ammonium oxalate addition to prevent the cells from being caught in the fibrinous deposit. The fluid is then ceutrifuged and the cells are studied microscopically after spreading and drying in the air, and staining with eosin-methylenc blue. Widal believes that the preponderance of lymphocytes speaks for tuberculosis, while a major- ity of polynuclears of the neutrophile and eosinophile varieties excludes it. Outside of France this method has not won general acceptance. Opsonic Index. — The attempt to apply Wright's work on opsonins and the opsonic index to the diagnosis of tuberculosis has so far not been as successful as has been its use in therapeutics, and the results obtainable scarcely justify the amount of time and labor necessary for its very elaborate technic. This technic (see Appendix) is only appli- cable by an expert in the best-equipped laboratories, and with ample assistance, and the claims of its advocates as to its diagnostic value have not been corroborated by the careful work of such observers as Simon, Cole, Potter, Thomas, and others. It is needless, therefore, to enter very fully into the subject in this place, but the principles on which it rests demand some notice, and the claims of its advocates should be stated. Opsonins are those substances in the blood which so act on the bac- teria as to facilitate their phagocytosis. They are normally present in the blood (normal opsonins) and are present in disease (immune opsonins) and are supposed to represent one of the efforts of nature against the infection. The opsonic index is the ratio of phagocytosis in the serum of the blood of the patient to that in the serum of normal blood taken from one or more healthy people. Thus if a hundred leu- MODIFICATIONS OF THE TUBERCULIN TEST 351 oocytes in serum from a tuberculous case take up 50 bacteria and a similar number in serum from a control take up lUO, the index is ^%, or 0.5. The normal index is from 0.8 to 1.3, and according to Birkett and Bulloch ("05) is fairly fixed, though Thomas ("07) disputes this. Diagnostic conclusions are drawn from the amount of phagocytosis as to the presence or absence of tuberculosis. Unfortunately, it is chiefly in advanced cases in which a diagnosis is easy, that positive conclusions are justified, as even its advocates admit (Ross. Birkett). In tuberculosis we can have five types of indices — normal, high, low, fluctuating, and a heated serum index, and in their study we must consider also the effects of rest, exercise, massage, the existence of other diseases and the injection of tul)erculin, and also must compare the index of the blood serum with that of the serum procured from other fluids arising near the focus of trouble. (a) Normal Index. — Wright and Eeid, according to Potter, claim that with a persistently normal index tuberculosis can be excluded with all probability. (&) High Index. — Eoss, of Toronto, considers a high index (1.4 or over) on several occasions diagnostic, and Birkett thinks it is a valu- able sign tliat nature is combating the bacillus, and tlius tliat it is evi- ^dence of active tuberculosis in the system. Butler Harris says : " A valuable feature of the opsonic inethod lies in the fact that a new weapon is provided for accurate diagnosis. "Wriglit, Bulloch, Lawson, Urwick, and others have conclusively sliown that no normal person ever gives a high index." Bulloch, who is much more conservative in his claims, says: "An abnormally high index is probably a sign of infection, but it cannot be used prognostically, as it may occur in cases which do well and in those which are quite hopeless." Wright and Reid, quoted by Potter, consider a high index proof of a systemic tuberculous infection. (c) Low Index. — Harris considers that this occurs in all early cases of tuberculous infection of the hings, and tliat such an index is found in cases in which the lesion is shut off almost entirely from the blood stream and little or no bacteria get into tlie circulation. Bulloch says that from determinations he has made " it appears that an index below 0.8 is abnormal, but whether it actually represents that an infection has already taken place or merely may take place it is impossible to say, as the diagnosis at very early stages of tuberculosis, especially of the lungs, is an impossibility without resort to the tuberculin test. The question whether a low index is the cause or the effect of the infection is unan- swerable at the present time." Eoss doubts its reliability, but consid- ers an index of 0.6 or lower strongly suggestive of tuberculosis, but not absolute. Birkett thinks a low index has com])aratively little value, 352 DIAGNOSIS as several types of infection give it, such as pneumonia, chorea, and malignancy. Fluctuating Index. — Birkett considers this suggestive of tuberculosis if the patient be at rest in bed, but only severe, easily diagnosed cases will run such an index while in bed; hence he considers that only when normal in bed and becoming fluctuating by exercise or massage can it be valuable, and he thinks tbis can occur in quite early cases. Ross considers a persistently fluctuating index very probable evidence of tuberculosis. Harris notes that in doubtful cases where there is no tem- perature, if frequent readings show a constantly fluctuating index, a little above or below normal alternately, the patient is probably suffering from an early tuberculous infection. The Heated Serum Reaction. — Heating nornuil serum to 60° C deprives it of almost all its ojjsonic power, but with tuberculous serum, on tbe contrary, there is a marked gain in opsonic power in comparison to tbe normal. In this connection Birkett says : " If a patient, there- fore, wbo is obviously reacting from some toxin, as shown by constitu- tional symptoms, fails to give an opsonic index with heated serum of 2.5 or more, I believe it to be very strong evidence against tuberculosis being tbe cause of the mischief. . . . But this does not apply so forcibly to cases running an apyrexial course." The cases where a heated-serum reaction is present have, according to Ross, a manifestly toxic nature (pyrexia), in which a diagnosis is usually easy; hence, save to exclude typhoid, it has not much practical value, though in such cases he thinks it as diagnostic as a Widal test. Serum from a focus of infection, pus, pleuritic, or peritoneal exudate, joint effusion, etc., shows a much lower index than that of the serum from the same patient's blood, and Birkett considers such a difference strongly diagnostic, while similarity of the indices of tliese two sera, he thinks, suffices to exclude tuberculosis in the process yielding the effu- sion. However, he says of this method : " Theoreticall}', the method is ideal, but practically it is disappointing," and adds: "Therefore I place very little reliance on this method as a help to diagnosis," although he holds that a nonfluctuating index, or a similar index for blood serum and pus serum, is very strong evidence against tuberculosis. Da Costa ('07) says that the opsonic index can be helpful in determining cases of tuberculosis by the fact that a drop in the opsonic index caused by an injection of tuberculin is greater and more persistent (a week or so) in tuberculosis than in normal people (two days). As to the diagnostic value of readings of the opsonic index, Ross considers that opsonic investigations of the blood for diagnostic purposes, while valuable for exceptional cases, is not of use in ordinary incipient cases, and considers that the two most important factors are abnormal phagocytosis with DIFFERENTIAL DIAGNOSIS 353 heated serum and fluctuation of the index, whether spontaneous or as a result of exercise, massage, or tuherculin injections. Bulloch ('05) says : " Much more evidence must he accumulated hef ore a definite opin- ion can he expressed upon this important point." After such a resume of the views of those most familiar with opsonic technic, it seems to me justifialde to conclude that as yet we have not reached a ])oint in the development of this method where the informa- tion it can give us diagnostically is certain enough to demand a resort to so complicated a technic in our diagnostic work. DIFFERENTIAL DIAGNOSIS There are various conditions, hoth pulmonary and systemic, which can closely simulate pulmonary tuherculosis or he simulated hy it, and can render the diagnosis, even of an advanced case, diificult. Of these the one that will most frequently be met with is bronchopneu- monia, and as pulmonary tuberculosis so commonly manifests itself as a broncliopneumonia, the determination of the real etiology of the trouble may be difficult. This is especially the case when we are dealing with the influenza pneumonias which are so common. Finkler and "Wassermann have also drawn attention to the occurrence of strepto- coccal bronchopneumonias that can be confusing. In every influenza epidemic one sees some cases which develop into tuberculosis and some which simulate it closely, but finally clear up, leaving an apparently intact lung, justifying the belief that the sus- picious signs were due to the influenza, although, of course, it cannot be denied that it may have been an alwrtive tuberculosis. While such cases are usually in children, and while West and Brown have both stated that a bronchopneumonia in an adult is presumptively tuberculous, the author has seen cases in adults whose signs were those of tuberculosis and which later cleared up entirely. Lord, of Boston, has reported a number of carefully observed cases of chronic influenza simulating tuberculosis, and it behooves us to keep this possibility always in mind. In children, after attacks of grip, it is often most diificult to decide whether an apical catarrh is tuberculous or influenzal, the physical signs being identical. The presence of the influenza Ijacillus is not enough to exclude tuberculosis, and in young children it is usually difficult to get any sputum for examination. Lindsay considers that the signs of bronchopneumonia are usually bilateral, but the author has seen cases in which they were unilateral and whose subsequent course sufficed to exclude tuberculosis. The history in influenza is usually shorter and the symptoms at first more acute, but, as noted, the physical signs are 24 354 DIAGNOSIS identical and the temperature curve cannot be relied on, and in grip we can have sweats, hectic and wasting (Fraenkel, Lindsay). Personally 1 believe tliat the course of the trouble, which is relatively short in grip and tends to clear up, while it is protracted and obstinate in tuberculosis and tends to spread, must be our chief reliance, but, as noted above. Lord has seen cases with a prolonged course. Lobar Pneumonia. — This may at times be tuberculous, but in this case the imperfect resolution, the persistence of tem])erature, the pro- gressi\;e weakening, and the appearance of bacilli, which in acute tuber- culous pneumonia is not long delayed, quickly clear the diagnosis. However, I have found that in negroes, who so often develop a tuberculous pneumonia with rapid breaking down of the lung and fatal course (acute ulcerous phthisis), not a few cases of ordinary pneumonia will raise our anxiety by their atypical course, absence of distinct crisis and very slow resolution, and will 3^et finally clear up satisfactorily and permanentl}', and I have come to expect a slow atypical course in this race. Chronic pneumonia (cirrliosis imlmonum) can very closely simulate fibroid phthisis, and here the histor}^ and the persistent absence of bacilli will often be our only guide, though in fibroid phthisis bacilli can be absent for long periods. In such cases only an autopsy will at times serve to clear up the doubt. Acute hronchitis should rareh^ give rise to difficulty, but in old peo- ple, where it tends to a sluggish course, the distinction may not be easy. The facts on which we have to depend are the al:)sence of dullness, the absence of marked alterations of the respiratory murmur, the fact that bronchitis is commonest in the lower parts of the lung, and if general clears up above sooner than l^elow; the ])uljbling or sibilant rather than crepitant nature of the rales, the fact that in bronchitis the rales are usually similar on both sides, which is rare in tuberculosis, and that they are disseminated rather than localized, and, finally, tlie fact that in tuberculosis a sputum so abundant will usually show bacilli. The tem- perature also in bronchitis is usually only temporar3^ However, it must be recalled that tuberculosis at times can begin as a generalized bronchitis. Chronic bronchitis is difl'erentiated in the same way, the history and the sputum examination being especially useful. Asthma gives rise to diagnostic difficulties chiefly in masking a tuber- culous focus, and in doubtful cases it is necessary to wait for a time when the asthmatic signs are absent before we can satisfactorily search for the coexisting tuberculous trouble. The two conditions have been supposed to be antagonistic, but not a few real asthmatics will be found among our tuberculous cases, not to mention the pseudo-asthma we find in old fibroid cases. DIFFERENTIAL DIAGNOSIS 355 Tlie X-ray is very useful in demonstrating a concealed focus in an asthmatic, and the sj)utum examination is very important in all doubt- ful cases, hut the presence of tlie spirals of C*urschniann or of Charcot- Leyden crystals in a sputum does not, of course, exclude the existence of tuberculosis. Pleurisy. — The fact that the large majority of pleurisies have a tuberculous basis is now so well recognized that we are less likely than formerly to overlook a tuberculosis masquerading as a pleuris}^ with effusion. In every pleurisy we should study the apices as carefully as the heart in rheumatism, but should not forget that pleurisy can produce transient rales at the apex that cannot be differentiated from fine crejntant rales. While the fluid in a pleurisy rarely shows bacilli microscopically, even when we precipitate with alcohol, it should always be examined, and animal experiments resorted to to determine the possible presence of the germ. The appearance of the fluid is of some value, as tuberculous fluid is frequently bloody and rarely purulent, but if the possibility of cancer exists, in which bloody fluid is also common, this will not help us. The fluoroscope I have found of help as revealing sometimes apical shadows and more commonly enlarged broncliial glands. Bronchiectasis must at times be differentiated from old cases of tuberculosis with cavitation. Here we rely cliiefly on tlie history of a persistent bronchitis without marked constitutional symptoms and with the discharge of large amounts of fetid, stinking sputum at intervals, with intervening periods when but little is brought up. In some cases of tuberculosis the F])utum can at times be offensive, but never has the persistentl}' foul odor of bronchiectasis. A pronounced case, with its remarkably abundant paroxysmal empty- ings of the tul)es and a sjmtum which separates into three layers, is too typical to cause any doubt, while so abundant a sputum in tuberculosis would alwa3's show bacilli which here are absent, as are also elastic fibers. The presence of blood cannot help us, as, while rare, it can occur in bronchiectasis. Fever is often absent, and when present is irregular and intermittent, ])eing usually absent just after the evacuation of the tubes. Bronchiectasis usually affects the lower bronchi and the upper lung is apt to be free, while in tuberculosis, if a cavity exists in the lower lobes, there will practically always be considerable old trouble in the upper part. Tuberculosis, when cavities are present, is also always bilateral, while bronchiectasis is usually unilateral. Bronchiectatic cavities show up as spindle-shaped, irregular shadows, usually radiating down and out, and it is typical of them that after 356 DIAGNOSIS evacuation of their contents they nearly or totally disappear from the screen. If, however, as Holzknecht notes, there is much peribronchial thickening, considerable shading may be left, and we may be in doubt whether we are dealing with a cavity in the lung which has emptied or a bronchiectasis. Around tuberculous bronchiectasis there will, of course, be infiltration. Pneumothorax can be mistaken for a large, smooth-walled cavity, as the latter can yield amphoric breathing, tympanitic resonance, and large resonant rales, but careful physical examination should settle the doubt, while the X-ray gives great assistance in diagnosis. The sudden dyspnea has been taken for asthma, but the cardiac dislocation, the bulging chest, and the percussion and auscultation findings should clear up the question. Actinomycosis. — This disease can present insuperal)le difficulties in earl}^ primary cases, but, fortunately, primary actinomycosis of the lung is rare (twelve to fifteen per cent of all cases, Fraenkel), and if sec- ondary, the primary lesion in the tongue, jaw, intestines, or liver makes the diagnosis simple, though it must be recollected that the two condi- tions at times coexist. In early cases a moderate cough, with scant expectoration and signs of pulmonary catarrh, give no points on which to base a diagnosis, though the central or basal location common in this disease may l)e sug- gestive. Even after the first stage the usually very chronic course — the wasting fever and formation of cavities, and the subsequent fibrosis with shrinkage, and the tendency to adhesive or effusive pleurisy — can be strongly suggestive of tuberculosis. Of course tlie discovery of the typical organism in the sputum is final, but this may not appear till late, and the absence of bacilli and elastic fibers cannot exclude tuberculosis, save in cases with advanced lesions, where they will scarcely be absent. On the whole, the history of an occupation wliich brings one much in contact with grain or hay (coachmen, millers, etc.), the usually lat- eral basal location of the trouble, the tendency to bulging of the side, the formation of thoracic-wall abscesses and fistula^, and the pain in the side must be our chief reliance. The good effect of potassium iodid in many cases cannot be relied on in diagnosis, as it is often without therapeutic effect. Echinococnts cyst of the lung is not only an exceedingly rare con- dition, but, practically always, only diagnosticable l)y the microscope. ^AHien the cyst evacuates itself, shreds of membrane, booklets, or daughter cysts may be found, and as this evacuation is often accom- panied with hemorrhage, these should be looked for in examinations of hemoptysis. • DIFFERENTIAL DIAGNOSIS 357 The physical signs are of little assistance. The disease is commonest in the bases and rare in the apices; moreover, there may be localized bulging of the chest wall, and if the cyst be full there will be dullness and weak breath sounds, but no rales. Fever is absent. Even if a cyst be suspected, puncture for diagnostic purposes is not wise, as such puncture has frequently proven fatal with severe pseudo-asthmatic attacks and edema of the lung (Ma3'dl). It is probable that the X-ray will prove our most reliable means of diagnosis, judging from the cases of Eosenfeld and of Levy Dorn-Zadek. The skiagraph of the latter showed in the right lung a more or less circular clear space surrounded with a dark border, which below was prolonged by a dark l)and into the dome of the diaphragm, while on the left was a smaller area not so connected. If the cyst were full the shadow would, of course, be solid. Fungous Infection of the Lung. — Certain fungi, nota1)ly the Asper- gillus fumigaius, the stroptothrix, and the cladothrix, as well as certain protozoa, can grow and produce pathological changes in the lung with S3anptoms suggesting the presence of tuberculosis. The diagnosis can only be made by discovering these various organisms in the sputum. In doubtful cases, Avhere tubercle bacilli cannot be demonstrated, we should therefore be careful not only to stain for tubercle bacilli but to look for other organisms with special stains (carbol thionin-aqueous salfranin). Pulnionarg Si/pliilis. — While syphilis can be localized in the lung, the physician should be very careful before he makes such a diagnosis, and the coexistence of syphilis and tuberculosis is too common to justify us in concluding that a pulmonary lesion in a syphilitic patient is syphilitic until we have used every means of excluding the one and diagnosticating the other. While, however, pulmonary syphilis is rare, it occurs in a certain number of syphilitics, Haslund, quoted by West, rejiorting 2 diagnoses intra ritain in 6,000 syphilitics; and in 18 syph- ilitics dying of the disease, 3 showed pulmonary syphilis. Excluding the white pneumonia of the new-born, which here does not interest us, there are, according to the excellent classification of Sokolowski, three forms of pulmonai-y syphilis — a focal, a destructive gummatous, and a fibroid — though French authors make numerous classes. The last of these forms is the more usual, but the first is the most important, as it can simulate early tuberculosis, and its recognition lias valuable therapeutic results, while the latter is scarcely to be distin- guished from advanced fil)roid phthisis, and is therapeutically uninflu- enced by the iodids. The focal form can deceive us entirely. There is an area of consolidation and catarrli most commonly around the root of the lung, Init at times at the apex. The cough can be moderate. 358 DIAGNOSIS but at times it is very obstinate and liarassing, and while fever can be present, it is usually absent. I had such a case under my care where the signs were typically those of apical tuberculosis, and it had been so diagnosed by an excellent observer, but its failure to respond to treat- ment and the development of certain throat lesions aroused my sus- picions, and reexamining the history carefully in the absence of the patient's wife I got a frank confession of a syphilis of two years' dura- tion, and the rapidity with which all signs and symptoms cleared up on iodid of potash, and the subsequent perfect health for two years, justified the diagnosis. In another case there was consolidation between the spine and the angle of the scapula beautifully shown by the fluoroscope, Avith constant harassing cough, but with very little expectoration and no fever. This patient had received a test dose of tuberculin from other hands, and was said to have reacted positively. Here also iodid removed all symptoms rapidly, and for the six months during which I was able to follow the case there was no return, probably justifying the diagnosis of sy2:)hilis. The obstinate cough has been supposed to be a diagnostic sign of pulmonary syphilis, but as it is not different from the cough produced by enlarged bronchial glands, and as these exist often in syphilis, its diagnostic value is doubtful. The therapeutic diagnosis by the use of iodid of potash is very relialile. Xot only the symptoms, but, to be cer- tain, all signs must disappear, as otherwise one may have removed the syphilitic element but left l)ohind a coexisting tuberculous lesion. The destructive form the M^riter has not seen, and it is said to be , very rare, but can go on to cavity formation. The sclerotic form is marked especially by dyspnea, or even pseudo-asthma, but this cannot be considered characteristic, as the same can occur in fibroid phthisis, from which it is impossible to differentiate it. Aside from the dyspnea there are physical signs of fibrosis with bronchostenosis, and, as would be expected from the nature of the lesions, iodids have no effect. To recapitulate the points on which one can base a diagnosis of pul- monary syphilis, they are the existence of syphilitic infection, laryngeal or pharyngeal lesions, less constitutional symptoms than we would expect in tuberculosis, moderate or no fever, and, chiefly, the therapeutic test of mixed treatment, with subsequent observation of the case. On account of the harmful effect of iodid of potash on tuberculosis one should not resort to it unless suspicions are very strong. Malignant disease of the hings, whether carcinoma or the much rarer sarcoma, is fortunately uncommon, few clinicians having seen many cases. When located in the apices or running a slow course it may be very DIFFERENTIAL DIAGNOSIS 359 difficult of diagnosis, but as the large majority are secondary to malig- nant growths elsewhere the diagnosis is usually facilitated. In view of its occurrence secondarily a very careful history and a thorough examination of the body for cancerous growth is necessary. Aside from this the points deinanding attention are as follows. They are apt to be central or basal in location, present a more marked and more rapidly developing exhaustion than tuberculosis, while the wast- ing, on the contrary, is less pronounced than the signs would seem to justify. The waxy pallor of the cancerous cachexia is suggestive if present, but may be absent till later; the infiltration develops very rap- idly, sucli a rapidity in tuberculosis being accompanied by severe con- stitutional symptoms, and the dyspnea comes on early and is more marked than in filjroid plithisis. Pain in the chest is more common and far more severe, while fever is usually absent. The cough is very variable, some authors reporting it hard and obstinate, some moderate, due probably, as in syphilis, to the greater or less involvement of the bronchial glands. The expectoration is scanty and the currant-jelly expectoration, held by some to be typical, can be entirely absent, though there is a marked tendency to bloody expectoration. Symptoms of pressure on the veins or lymphatics are common, so that we can have dilated bunches of small veins in the thorax, and in late cases enlarged glands, especially above tlie clavicle and in the axilla, can be found. Pleuritic effusions are common, but share with tubercu- lous effusions a tendency to bloodiness. Tlie physical signs are not very characteristic, though Fraenkel thinks that the lack of corre- spondence between the flatness on percussion (with greatly increased resistance) and the insignificant breath changes— i. e., weakened breath- ing and few or no rales — is a sign of great value. If cancer cells are found in the sputum they are, of course, decisive, but this does not often occur. However, as has been said in connection with echinococcus disease and fungous disease, in doubtful cases the sputum examination must be thorough, histologic as well as bacteriologic. Heart lesions wliieh cause congestion of the lung and hemoptysis, chiefly mitral stenosis, are at times diagnosed as tuberculosis, but a careful and systematic study of our cases should make this mistake impossible. Malaria is a very common, ])robal)ly the most common, source of error in diagnoses which exclude tuberculosis erroneously. Every year one sees many cases which have been treated for longer or shorter periods for malaria when the disease was a more or less incipient tuberculosis, and while in a malarial country where so many cases of irregular fever are seen, and where so many are really atypical 360 DIAGNOSIS malaria, this is perhaps natural, it is, now that the microscope is avail- able to all and can so easily settle the question, no longer excusable. Blood examinations must, it need hardly be said, be thorough and frequent, and the recognition of the plasmodium certain and positive before we can afford to treat a slow, irregular, remitting fever as malaria and exclude tuberculosis entirely. The therapeutic test of quinin, while valuable, must be made with caution, as it will often suppress a tuberculous fever for a time. Moreover, it should be standard practice in every case of such sus- picious fever to examine the sputum and the lungs most carefully and repeatedly, and if necessary one should resort to tuberculin. Typhoid fever is frequently given in a history as the beginning of a tuberculosis, but it is probable that some of these cases were merely the acute beginning of a case that later took on a more chronic course. The diagnosis of acute miliary tuberculosis from typhoid fever is one of the most difficult in medicine, and often can only be made at the autopsy, hence in every case of suspected typhoid of slightly atypical course we should take care to exclude this possibility. The Widal reac- tion is here of great value if past typhoid can be excluded. Ausculta- tion is not of great assistance owing to the frequency of pulmonary signs in typhoid. The temperature in acute miliary tuberculosis is much more irreg- ular as a rule and may intermit entirely, and tends to marked remis- sions, the respiration is hurried, the face anxious, and there is an omi- nous cyanosis. Osier states that " leucocytosis is more common in miliary tuberculosis than in typhoid, in which leucopenia is the rule." The typhoid bacillus can be cultivated from tlic stools or the blood. Persistent anemia, or especially chlorosis or neurasthenia or dys- pepsia, are so often tlie initial symptoms of tuberculosis, and so many incipient cases are treated for these diseases, that the possibility of tuber- culosis should be kept in mind. Chlorosis is so often accompanied by slight fever and so often precedes tuberculosis that the view of some that it is really a tuberculous condition seems reasonable, and the use of tuber- culin justified. In neurasthenia and dyspepsia the thermometer is valuable, and the all too common custom of explaining away a cough that cannot be stopped as a " stomach cough," and of treating it with anodyne cough mLxtures, cannot be too strongly reprobated. If a cough exists it has some physical cause, which in the large majority of cases can be discovered and removed, and no physician is doing his duty to his patient who fails to make a thorough physical examination into its cause. ON THE RECOGNITION OF STAGES 361 ON THE RECOGNITION OF STAGES If the results of the study of tlie SA'mptoms and signs of our cases are to be utilized in widening our knowledge of this disease, if the observations of many separated observers are to be correlated into a complete whole, it is essential that we have a system of classification for our cases by stages which shall be used by all physicians in their work. Many such S3'stems have been suggested (Petruschky, Brehmer, Koniger, etc.), but that put forward by Turban in the A'ear 1899 has been generally recognized as the best and most practical, and it forms the basis of the classifications in use to-day. In Europe the Inter- national Anti-Tuberculosis Association has modified it by adopting part of the scheme of Gerhardt ('01), and in this country the iSIational Asso- ciation has used it as the basis of their classification, but has modified it by adding to it certain clinical data, while Trudeau has a system of his own in which also he combines anatomical and clinical facts in classi- fying his cases. It is probable that the system of the International Anti- Tuberculosis Association, more or less modified, will finally be universally adopted, and hence it should be familiar to all workers in this line. While retaining the anatomical basis of Turban's scheme almost entirely, this so-called Turban-Gerhardt scheme modifies it by noting the condition of each lung separately, and makes one or two other slight changes. Kay- serling, speaking of it, says that " this is a material improvement, as one thereby gets immediately a plastic image of the case in hand ; especially in studying results is it a great advantage that we know of each case — which side of the lung is diseased, and to what degree — for only thus is it possible at a reexamination to determine if the cure is persisting." While in Turban's original scheme the first stage was limited to changes of the volume of one lobe or two half lobes, in the new it is limited to changes reaching to the level of the clavicle in front and the spine of the scapula behind, save in cases of unilateral trouble, when the second rib is taken for the lower limit. Further, in the new classification the presence of considerable cavi- ties places the case in the third stage, and the stage of any cases must be judged by the condition of the most seriously afl^ected lung. The jS'ational Association for the Study and Prevention of Tuber- culosis ap))ointed a committee to arrange a classification, of which Y. Y. Bowditch and, later. Ij. Brown were chairmen, and this committee has reported a classification which has been generally adopted in this coun- try, and which, while based on the scheme of Turban, is imjiroved and amplified by the addition of certain clinical data without which they considered his scheme scarcely comprehensive enough. Below I give the classifications of Turban-Gerhardt, of the Xational 25 362 DIAGNOSIS Association, and of Trudeau in parallel columns for ease of comparison. In looking over these the excellence of Turban's idea is evident, and it is not remarkable that it has been popular, but the clinician in using it will find himself hampered by its failure to take notice of the clinical condi- tion of the case, which is of such paramount importance in classifying it. The anatomical condition alone cannot by itself give us a complete idea of the state of the case; daily one sees patients with quite extensive signs, who are yet in excellent general condition and with practically no symptoms, while some very severe cases can have very scanty phys- ical signs. Indeed, were we obliged to use only one or the other, I believe we would find that symptoms are usually a safer guide to a patient's condition than signs, and I do not believe that any classifica- tion for general use can omit certain clinical data from its plan. If the physician will use a proper system of classification he will find it an easy matter to divide his cases into three stages, botli in the commencement and at the end of treatment, and it is earnestly to be hoped that all physicians in reporting cases in the medical press will be careful to classify them in this wav. Turban-Gerhardt Disease of slight se- verity, limited to small areas of one lobe, that, for instance, in case of affection of both apices, may not extend beyond the spine of the scapula and the clav- icles; in case of affec- tion of one apex, fron- tal, beyond the second rib. National Association 7. Incipient (fnvorahle) Slight initial lesion in the form of infil- tration, limited to the apex or a small part of one lobe. No tuberculous com- plications, slight or no constitutional symp- toms (particularly in- cluding gastritis or in- testinal disturbances or rapid loss of weight). Slight or no elevation of temperature or ac- celeration of pulse at any time during the twenty-four hours, es- pecially if at rest. Expectoration usually small in amount or ab- sent. Tubercle bacilli may be present or ab- sent. Trudeau 7. Incipient Cases in which both the physical and ra- tional symptoms point to but slight local and constitutional involve- ment. ON THE RECOGNITION OF STAGES 363 Turbax-Gerhardt // Disease of slight se- verity,' more extensive than I, but affecting at most the volume of one lobe; or severe disease,^ extending at most to the volume of one half lobe. National Association 77. Moderately Advanced No marked impair- ment of function, either local or constitu- tional. Localized con- solidation, moderate in extent, with little or no evidence of destruction of tissue. Or dissem- inated fibroid deposits. No serious tuberculous complications. Trudeau 77. Advanced Cases in which the localized disease proc- ess is either extensive or in an advanced stage, or where, with a comparatively slight amount of pulmonary involvement, the ra- tional signs point to grave constitutional impairment or to some complication. 777 777. Far Advanced III. Far Advanced All cases extending beyond II, and all such with considerable cavi- ties. Marked impairment of function, local and constitutional. Local- ized consolidation, in- tense or disseminated areas of softening, or serious tuberculous complications. Cases in which both the rational and phys- ical signs warrant the term. • By disease of slight severity is to be understood: disseminated ff)ci manifested by slight dullness, impure, rough, feeble, vesiculobronchial or bronchovesiciilar breathing, and fine or medium riiles. 2 By severe disease is to be understood: compact infiltration, recognized by great dullness, very weak bronchovesicular or bronchial breathing with or without rales. Considerable cavities, to be recognized by tympanitic sound, amphoric breathing, and extensive coarse consonating rales, come under Stage III. Pleu- ritic dullness, if only a few centimeters in extent, is to be left out of account; if it is extensive, pleuritis should be especially mentioned under tuberculous compli- cations. The stage of the disease is to be indicated for each side separately. The case as a whole is to be classified according to the more diseased side. For example, R II, L I = Stage n. 364 . DIAGNOSIS CONDITION ON ARRIVAL AND ON DISCHARGE (National Association) A. On arrival: 1. Extent of Disease. (Pvit here Turban's scale or Turban-Gerhardt.) 2. How long sick? 3. General condition : (a) favorable; (h) unfavorable. 4. Digestion: (h) unimpaired; (y) impaired. 5. Pulse (rate). G. Temperature: (E.) 101° F. or over; (F.) 99° to 101° F.; (N.) Normal. 7. Bacilli: (+) present; (0) absent.' 8. Tuberculous complications. 9. Other complications. 10. Classification of case. (Here put National Association classifica- tion.) B. On discharge: Progressive. (Unimproved.) All essential symptoms and signs un- abated or increased. Improved. Constitutional symptoms lessened or absent, physical signs improved or unchanged, cough with bacilli usually present. Arrested. Absence of all constitutional symptoms, expectoration with bacilli absent or not, physical signs stationary or retrograding. This for at least three months. Apparently cured. All constitutional symptoms with expectoration and bacilli absent for three months, signs of healed lesions. Cured. Same for two years under ordinary conditions of life. (Also note A 3 to A 9 inclusive.) 'Wilson of Baltimore has well suggested A'^, " no sputum examination made," to cover the large number of cases in which this has been neglected. filOcfj/teJ /rvm ^/ovsse/ Figs. 84 and 85. — Suspect Case in Anemic, Slender Youth. No fever. Slight cough. No expectoration. (Case E. Z.) TVToc// ^/eJ from tJocss-ef 6.k^. 'OS" ?r)/o^SSC/. Figs. 86 and 87. — Incipient Case. Four months' course. BacilH present. General condition favorable. Digestion unimpaired. Temperature normal. Pulse 80. (Case C. D.) 365 IVTodi 1^ leJ from (Joessc/ C.IM- 'oS" 7n<>t////'eJ /rem \/oesse/. Figs. 88 and 81). — Incipient Case, Chiefly Posterior, Extent I. Note slight pleurisy under left scapula. (Case Y.) ■ TVod i f leJ from cfoessef CLM. 'OS" Figs. 90 and 91.— Stage I. (Case G. B.) 363 Tnodi/ifi /rtm Joesst TVTod i f leJ from fJoGssel ' CA-M- 'o^ Figs. 92 and 93.— Stage I. (Case F. K. S.) JVod I f leJ from tJoQSSel C.i-M. 'OS" ?noj,/ieJ /ior» Joeae/. Figs. 94 and 95, —Incipient Bilater.^l Case. (Case X.) 367 TVTod I f led from tJoGS-^el ' C.l^l 'OS- /ne„„, Joesse/ * Figs. 102 and 103. — Stage II. Of Long Duration with Retrogressions and Exacerbations. (Case J. L. W.) 369 TVTodifieJ fronx.fjoessel C.ZA/. v^r. Figs. 104 and 105. — Stage II. Beginning Softening, Later Excavation. (Case W. G. B.) ^o»ni Joesif/. CIM. '05" Figs. 120 and 121. — Acute Miliary Tuberculosis. Three months' duration. Just before death. (Case Mrs. S.) ON RECORDING FINDINGS If we are to classif}' all our cases carefully it is very important that there sliould be some uniformity in recording our findings. For this purpose the physician should have good outlines of the anterior and posterior aspects of the chest on which graphically to record the con- dition of the lung, as well as charts of the mouth, nose, and larynx for recording the condition of tlicse parts. It is better to have these all on one sheet of paper, on the other side of which are spaces for the facts noted on inspection, palpation, and mensuration. Personally I prefer three chest outlines — one for fluoroscopy, one for percussion, and one for auscultation — since this gives ample room ; but if, as Trunk advises, we use the pencil for recording percussion and the pen for recording auscultation, both can be recorded on one diagram ; hut fluorosco]jy needs a separate one, on which shadows, limitations of outlines and of motion, etc., can be noted. The chest diagrams here given I have based on the standard ana- tomical works of Poirier-Charpy and of Joessel. The upper inner apex outline is better given as concave above and convex below, rather than as in the charts, but any such small details can easily be changed in ON RECORDING FINDINGS 375 an}' diagrams for which the?e charts serve as a basis, and from experi- ence I can recommend them as not onl)' correct, but conveniently large, tlie fault of using too small a diagram, and thus crowding our findings, being one to be avoided. The facts to be noted under inspection are : General build ; nourish- ment, complexion, and skin; eyes, hair, and nails; teeth, gums, and tongue, dyspnea; glands, heart, stomach, respiratory motion, form of chest — its length, breadth, and depth. Under palpation, vocal fremitus in the different parts of tbe chest, and the condition and rate of the pulse and the apex beat. I'nder mensuration should be noticed degree of the temperature, height, weight, and vital capacity, and tape meas- urements, and there should be a line on each side of wliich to lay out the lead-tape tracings of the two halves of the chest. There should also be on this chart the condition on arrival and on discharge, according to the scheme of the Xational Association, as already given. So much for the physical examination chart. Turning to methods of recording the findings, the graphic method is now so generally used that its advantages need not be dwelt upon liere. Enough to say that it gives at a glance the condition of the physical signs, enables us to compress much information into a small space and to localize the various signs far more sharply than can be done if we try to describe them in writing. Probably the l)est-known system of signs is that of Sahli. But desirable as it is that all should use a similar notation if possible, this system has some faults and has been variously modified by different clinicians. Probably every man, whatever plan he follows in the main, will modify it in particulars to suit his own ideas, and the system I have devised, while being both simple and convenient, is given chiefly as a suggestion to others in developing their own systems. It is based in part on that of Sahli, and especially on the excellent plan of Trunk. Whatever signs we use must be capable of being easily and quickly drawn, must be unlikely of confusion with other signs, and must not be too complex. The percussion findings are noted by shadings of various intensity, the limit of dullness being marked by a heavier line, but I have added " Slit." for short percussion note and " Impd." for impaired resonance, neither of which can be indicated by shadings, and both of which are of diagnostic importance. Under auscultatory signs I have adhered to the rectangle of Sahli, the vertical limb representing inspiration, the horizontal, expiration; but as in hasty drawing it is very easy to miscalculate the length of the base line, and thus to make expiration appear prolonged when it is not, I have added a hypotenuse to the right angle, so that any pro- longation beyond the normal is quickly seen and easily indicated. More- over, since the heaviness of the lines is used to indicate the intensity 376 DIAGNOSIS of the breatli sound by some, the thickness of this hypotenuse can serve as a standard of thickness, and any increase or decrease of the tliickness of the other two lines can be noted by comparison with this. Tiie plan of indicating the pitch of the expiratory and inspiratory sounds by the angle made by the lines with the horizontal, which, as far as I know, was first used by Page, has advantages, but cannot be well combined with Sahli's right angle, and as the other is simpler and easier of use I have adopted it. To indicate feeble breathing by light lines is unadvisable, since mistakes can be made in drawing the line, so that I use an F inscribed in the triangle for this purpose as clearer; but to indicate puerile breathing I use a triangle with all three sides very heavily marked, which cannot be mistaken. Absence of breath sounds is very easily indicated by a zero inscribed in the triangle. Sahli's division of rales is that of Skoda, which is used in Ger- many, but which has not Avon acceptance in this country or England, and I have therefore adhered to the plan of dividing rales into dry and moist — as they are given, for example, among others, by Cabot. The part of the respiratory murmur in which the rale occurs can be indicated, if desired, by a vertical line at the side, indicating in- spiratory rales, or a horizontal one in the same location to indicate expiratory. To indicate whether the rale occurs only on deep breath or only after coughing, a d or an ! can be written at the side. To indicate whether the rtde is musical (resonant, consonant), a circle (moist ride) with a tail to it, like a musical note, is used by Trunk, with an m at the end of the tail if it is metallic. While one who is not used to employing such signs might sup- pose them to be complex and troublesome, a short experience of them will convince anyone of their ease of application and conven- ience, while their import can be understood fully as quickly as the written words. A good point made by Trunk is the use of pencil to mark per- cussion findings and of the pen to mark auscultation findings. Pen and pencil ai^ always at hand and are more satisfactory than the red and blue pencils recommended to distinguish percussion findings by Sahli — blue for dullness, red for flatness, with mixtures for intermediate de- grees. Preceding the scheme of signs for recording physical findings will be found a few typical charts to exemplify their use, as well as to show the different stages according to the Turban-Gerhardt classi- fication. SIGNS FOR RECORDING PHYSICAL FINDINGS Percussion Signs (to be made in pencil) T^ r J n sht. Short note. Degrees or dullness. • (Xote lower or upper linnt, ^^'^' Impaired resonance. of dullness by heavier line.) h. R. Hyperresonance. Flatness. c . p. " Cracked-pot ' ' resonance. T Tympany. fMotion of base. |, IK ^ (Amount can be noted in Uches.) (g) Wintrich's change. ' (3 Motionless base. |\ Vesicular murmur. |\ Puerile breathing. A Feeble breathing. |\ Absent breath sounds Auscultation Signs (to be made in ink) Vesiculobronchial. Bronchovesicular. Bronchial. ^ Cavernous. |v^ 1^ Rough (granular, "rude"), k ^^^^^^.^ ^^.^^^^.^^ \ Prolonged expiration. . k » Inspiratory, expiratory, Heart sounds unduly trans- n mitted. nspiratory and expira- tory harsh breathing. K K Cogwheel (interrupted) I \ i_\ breathing. |\ Inspiration interrupted. Vyp Whispered pectoriloquy. VR + Increased 1 I Vocal VK - Decreased j resonance. \/"R o Absent J A Aegophony. 377 SIGNS FOR RECORDING PHYSICAL FINDINGS— CoTifmuerf Adventitious Sounds Dry Rdles ' \' Dry crackles (isolated crepitations). « .;/.;•;:; Crepitant rales. ^xx** Medium dry rales. xl I x-^\ \ Large dry rales. Inspiratory. I Expiratory. Moist Rdles /o", °Q oo Fine and medium (subcrepitant) rales. qO o ^ o^rk Large moist rales. *] 9 Cj Resonant (consonant, musical). \^^ Metallic. %,0 Gurgles. ojl^ " Mucous click. " s Sibilant rales. 3 Sonorous rales. dl Rales on deep breathing only, f Rales after cough only. Ill Fine friction sounds. Ill Loud friction sounds. 378 ADDENDA 379 ADDENDA Summary of Symptomatology and Diagnosis Presented at the Inter- national Congress, held in Washington, D. C. Landoiizy reported on that form of acute tuberculosis first described by himself as " typhobacillose/" and which has already been alluded to. He distinguishes it from caseous bronchopneumonia and from, acute miliary tuberculosis. No miliary granulations are to be found. There are no localizing symptoms, either pulmonary, cerebrospinal, or abdominal, and, instead of being always rapidly fatal, it usually ends in recovery, so far as the generalized acute infection is con- cerned. In the majority of cases, after three or four weeks of con- tinuous fever, tlie patient convalesces, l)ut only imperfectly. Appetite does not return. Emaciation continues, and finally the localizing signs of tuberculosis appear — usually in the lungs or pleura, or, in cluldren, in the mesentery. Occasionally a good convalescence follows such attacks, but, sooner or later, tuberculous lesions appear. Usuf^lly, how- ever, after the fever sul)sidcs, the patients continue in a state of latent tuberculosis, and in a few weeks, months, or even years after the initial acute septicemia they are found to be tuberculous. He would distin- guish it from typhoid fever by the irregularity of tlie fever curve, which, wliile continuous, shows greater oscillations; secondly, by a lack of cor- respondence between the pulse and the temperature — the pulse being faster than in typhoid fever; thirdly, by an absence of visceral symp- toms; and, lastly, by absence of rose spots. Its diagnosis from typhoid, as which it usually masquerades, can only be made by the use of labora- tory methods, such as the Widal test. Symptoms. — A^on Vnterberger does not consider a small heart as predisposing to tuberculosis, but believes that the rapid enlargement of this organ in phthisis is related to a congenital ])redisposition and is caused by an obstruction to the lesser circulation and l)y the toxins of the bacillus and of the products of metal)olism. He believes that an en- larged heart and liver form a very im])ortant link in the chain of early clinical symptoms. Ullom, as a result of the study of the livers of those dying from tuberculosis in the Phi])))s Institute, notes that miliary tubercles are found in a majority of cases of chronic phthisis. Solitary tubercles were rare, while passive congestion was found in nearly every case, but amy- loid and fatty changes were found in a relatively small number. He does not believe, as tlic result of his observations, that fibrosis or cir- rhosis, due to the bacillus, occurs. J. Anders, in a paper on the symptomatic value of hemoptysis in 380 DIAGNOSIS early tuberculosis, notes that cases of hemorrhage in which all other clinical and laboratory findings are negative are to be regarded as tuber- culous until disprovcn. It is, however, not pathognomonic, but, never- theless, of exceptional diagnostic imj)ortance as a cardinal symptom. In 3,506 cases of tuberculosis, 9.6 per cent hemoptysis was noted at the very commencement of the disease, and in cases of chronic pulmonary tuberculosis hemorrhage was one of the most characteristic symptoms in 25 per cent. II. von Schrotter (Vienna) reported on the occurrence of, usually undiagnosticated pneumothorax without exudate in early tuberculosis. This can best be studied by the use of the X-ray and the spirometer. A deficiency in vital capacity of 1,000 to 1,500 c.c, espe- cially in a case whose normal vital capacity is already known, permits, he believes, a diagnosis of latent pneumothorax, even if other signs are doubtful. Ticry and Eenoux found that the scales of pityriasis versicolor in- oculated into guinea pigs caused tuberculosis, while the scales taken from healthy skin of consumptives or from other dermatoses failed to do so. This, if urefied, would suggest that this skin disease is specifi- cally tuberculous. Metabolism. — Croftan spoke of the increased urinary calcium excre- tion in tuberculosis. This he would explain by an affinity between the calcium and an albumosc which is almost universally present in tuber- culous foci, sputum, culture media, blood, and urine. When rendered calcium-free it has marked fever-producing qualities which it loses when again combined with calcium. The combination he regards as a pro- tective anti])yretic process which would suggest therapeutic possibilities. Diagnosis, — The ophthalmic reaction (Wolff-Eisner, Calmette) was the subject of valuable reports by Calmette, Wolff-Eisner, Baldwin, Malmstrom, Bailliart, and by F. Arloing. Xone of these observers con- sider the test dangerous to the healthy nontuberculous eye, and it is probable that the bad results which have been reported (see text) were due to its use in tuberculous eyes. Calmette, in 6,603 cases, had no serious results, and only 3 of phlyctenular keratitis, 20 of conjunc- tivitis, and 72 slow, persisting reactions. Wolff-Eisner considers it absolutely without danger if contraindications are observed. Baldwin thinks that, used with proper precautions, the danger is slight, and Arloing, Jr., notes that its possible bad effects can be largely obviated by a preliminary instillation of adrenalin, 1:3,000. Diagnostic Value. — The percentage of positive reactions in active tuberculosis was placed by the various writers and speakers at from 70 to 96 per cent. Trimescu placed it at 96 per cent. Calmette, in 2,894 cases, at 92 per cent. Wolff-Eisner stated that 85 per cent will react; Malmstrom, 86 per cent; and Baldwin, from a study of 310 cases. ADDENDA 381 70 per cent. White and McCampbell reported on its use in cattle, and note that, since repeated instillations create a hypersensibility, the result of the first instillation alone should be made the basis of diagnosis. They consider that a proper reaction in ten or twelve hours demonstrates tuberculosis. The views as to its diagnostic reliability varied. AVolff- Eisner held that it will be positive only in the presence of active tuber- culosis, and Calmette stated that a positive reaction to the ophthalmic and cutaneous tests furnishes almost conclusive evidence of the existence of an active tuberculous focus. He found early reactions chiefly in suspected tuberculosis, late or slight ones chiefly in well-developed tuber- culosis, and he, like all others, has found that advanced cases react slightly or not at all. He says that, unlike the cutaneous reaction, it seems to be found chiefly in active or developing foci, and not with healed lesions, and believes that, used in children over one year of age, it shows active tuberculosis. Baldwin considers that the test has some value in confirming the diagnosis in its early stages, but slight value when the symptoms justify only a suspicion. Its value in distinguishing active latent from healed tuberculosis he regards as undecided. He would confine its use to adults, since the cutaneous test is equally valuable for children, and would restrict the subcutaneous test to cases where a focal reaction is desired and where the ophthalmic and cutaneous tests have been negative. Malmstrom considers it diagnostic and useful, but not final ; while F. Arloing regards it as a convenient diagnostic measure whose value is not absolute. Prognostic Value. — Here, again, views vary. Baldwin regards the ophthalmic as unreliable for this purpose, while Wolff'-Eisner considers its prognostic value to be very great and thinks that the failure of the cutaneous and conjunctival reactions is prognostically unfavorable, as is also a rapid (twenty-four hours in all) reaction, while a permanent reaction (seven to twenty days) he considers favorable and occurring chiefly in healed tul)erculosis. Calmette thinks that as bad cases react slowly (forty-eight hours), weakly, or not at all, and light ones strongly, the test has prognostic value. However, he calls attention to tiie fact that since, after five days, hypersusceptibility (anaphylaxis) is estab- lished, which lasts for twenty-five or thirty days, we should repeat the test before the fifth day. He also notes that cases taking tuberculin do not react until one month after the injections are stopped. Trimescu (Bukarest) made the interesting statement that while, as is well known, severe cases are generally negative, they can become positive if the process improves and gets less active. F. Arloing reported that he had found that the reaction is caused not only by the presence of tubercle toxins, but also by those of typhoid, diphtheria, and staphylococcic and streptococcic infections. This he ascribes to the vasodilator effect of 382 DIAGNOSIS these toxins on the vasomotor centers, and considers tliat it shows a state of intoxication of some sort, but not necessaril}^ tuberculous. The reaction in tuberculosis, in his o])inion, shows tliat the organism is intoxicated by tuberculin, and he considers that the intensity of the reaction indicates the degree of immunity of the individual, and hence is prognostically valual)le. As to the physiology of the test, Calmette considers the reaction to be due to the fixation of the tuberculin by the cells rich in lecithin and to the reaction between the two. He believes that the presence of free lecithin in the blood has a close relation to tuberculosis, as the suprarenals are always congested in animals killed by tuberculin, while animals refractory to tuljerculin have no free leci- thin in tiieir blood. Finally, lie very wisely notes that these tests must not be overvalued, but tliat all other clinical and laboratory methods must be cautiously and wisely used. The Cutaneous Reaction. — Von Pirquet believes that from a positive reaction the presence of tuberculosis can be concluded. The reaction, however, does not prove that the patient is sick — i. e., has active tuber- culosis — but possibly only latent trouble, and lie warns against treating a patient for active tuherciilosis on the strength of reaction to his test. It occurs cliiefly in sliglit or inactive tuberculosis, and in Vienna most grown children and adults react. He believes, therefore, that in adults only a severe reaction on the first attempt has any significance, and that in this case it speaks for a new process. Repeated failure to react, in his opinion, excludes tuberculosis. Its chief value, he believes, lies in children from one to five 3'ears of age. Calmette considers it chiefly valuable in cases of calcified and healed lesions and in children under one year of age, of whom about twenty per cent react. After this age the number reacting increases rapidly, and over fifteen becomes sixty per cent, while nearly all adults react, so that he would limit its use to children under one year. A positive reaction to both ophthalmic and cutaneous tests he considers almost conclusive evidence of an active tuberculous focus. LeFetra considers a positive skin reaction in infants almost certain evidence of tuberculosis, and if a careful sputum exami- nation and skin test are l)olh negative, he thinks we can feel safe in ruling out tul)erculosis. Detre, of Budapest, read a paper on his method of differential bovine and human cutaneous tests, with old tuberculin and with l)ouillon filtrate of human and another of bovine bacilli. He reports that ninety-five per cent of all tul)erculous cases react to the human test and that most pulmonary cases are of this class, while in children and in visceral and bone tul)erculosis thirty to forty-five per cent react to the bovine, while a good number react to both. He advises testing the immunity of a case after treatment by a large dose of tuberculin, after a cutaneous test, when he be- ADDENDA 383 lieves that if the case be not immune the cutaneous reaction will reappear. A new modification of the tul)erculin test was advocated l)y Mantoux (Cannes) whicli consists of an intradermic injection of tuberculin, the needle being introduced only into the derma as in cocainization. The reaction consists of a macula surrounded by a bluish zone, and he con- siders his modification universally reliable in active tuberculosis. The percutaneous or inunction method of Moro and Lignieres was a subject of a paper by the latter, but nothing new was brought out. L. Brown reported on the diagnostic value of the ophthalmic, cutane- ous, and subcutaneous tests. He believes the cutaneous method has no contraindications, but regards the conjunctival test as offering enough risk of severe injury to the eye to cause him to be opposed to the use of the method. As to the subcutaneous, he has " used it in a large number of cases for eight 3'cars " and has " yet to see as a consequence anything more than a slight temporary untoward result." He advocates a procedure in the use of these tests which merits general acceptance. " When we wish to apply the tuberculin test to a patient presenting sus- picious symptoms or physical signs of tuberculosis," he advises, " first to use the cutaneous test, and if he fail to react with this, we can with some degree of certainty attribute his symptoms to some other disease. If he reacts we can then use either the conjunctival, when no contra- indications exist, or the subcutaneous method," in which he places still greater confidence. He feels " that the conjunctival test, like the sub- cutaneous test, should be used onl}- when all other means of diagnosis have been exhausted." Further, he notes that he hesitates to say " that a patient does not react to the tuberculin test until the subcutaneous test has been found negative." He believes that the cutaneous test reveals very accurately both active and latent tuberculosis, but, since the recognition of the presence of inactive and encapsulated foci has little clinical significance, the cutaneous test alone to him seems to possess slight practical value. Hamman concludes as to the use of tuberculin for diagnosis that the test must be used with care and that while the reaction is believed to be specific, it must be remembered that a very in- significant lesion may produce tuberculin hypersensitiveness. A negative reaction he considers decisive information, as also a focal reaction. After a consideration of all these different views, it is evident that the conjunctival and cutaneous tests can be regarded as valuable and safe ^ additions to our diagnostic measures and as fully justifiable pro- 1 P. Schnimpf ('08) concludes, against Teichmann and others, that the ophthalmo reaction can lead to permanent and serious lesions of the eye in spite of all measures of precaution. — Editor. 384 DIAGNOSIS cedures in properly selected cases. They iriay at times render un- necessary a resort to the rather more severe subcutaneous method, but which at present they do not seem entirely to supplant. The diagnostic value of the opsonic index also received consideration. Inman uses the test to demonstrate autoinoculation, either spontaneous or artificial (after exercise), by a variation in the opsonic index which does not occur in the nontuberculous. He notes that the tuberculous patient who exercises is elaborating his own tuberculin. A rise of tem- perature goes with a negative opsonic phase, showing autoinoculation, and can be cliecked by absolute rest. Al)sence of variation after hard labor he regards as evidence of arrest, but some of these cases still show bacilli; hence he believes he is justified in assuming that we can have arrest of the disease but persistence of the bacilli. Sanborn holds simi- lar views about the diagnostic value of the opsonic index. Szaboky considers the height of the index of no value, but thinks that lowering of the index shows the presence of tuberculosis. He believes that it gives an approximate idea of the degree of immunity, and hence is a good guide for treatment. He finds it, however, troublesome and not giving uniform results, the personality of the observer having a great effect on the counts. M. Lincoln considers that the great skill needed for its application limits its utility. She finds that eighty per cent of her ophthalmic and cutaneous tests agree with the opsonic test. The opsonic index was positive in seventy-seven per cent of the cases, while the tuberculin test was positive in eighty per cent of the same cases. Other Diagnostic Methods. — Cade advocates the study of the cytol- ogy of effusions (Widal) for diagnostic purposes, in determining the nature of a pleurisy, predominance of lymphocytes speaking strongly for tuberculosis. In other than pleural effusions its value is doubtful except in ascites, where the discovery of a lymphocytosis is suggestive. Caution and control by other methods, however, is desirable. Sondern has examined tlie cerebrospinal fluid in tuberculous meningitis in chil- dren. He considers a high pressure of the fluid and a high number of lymphocytes (eighty-six per cent) suggestive. If bacilli are present a relative polynuclear increase may indicate a mixed infection, while if bacilli are absent a predominance of lymphocytes should encourage further search. M. Solis-Cohen has studied the coagtdal)ility of the blood. Persons with increased coagulability are probably less liable, and those with a decreased coagulability more liable, to hemorrhage. In cases with hemorrhage the bleeding ceased more quickly in those with a short or normal clotting time than in those in whom it was delayed. Bezancon and de Jong have studied the behavior of the cells in the sputum of caseous tuberculous pneumonia, and believe that a tendency to degeneration of the cells (j^olynuclear and young pulmonary epi- ADDENDA 385 thelial cells usually mononuclear) is the most marked characteristic of tuberculous lesions, and is especially marked in galloping consump- tion. They found pycnosis of the polynuclear cells and loss of staining quality. Arneth's method of studying the nuclei of the polynuclear neutro- philes was the subject of a paper by Dluski and Kozpedzikowski. They examined 55 cases and found in all but 2 a more or less marked impair- ment of the blood picture, with displacement to the left up to 75 per cent. In 17 of 21 cases examined several times they found agreement between the picture and the course of the disease. They conclude that tlie method may do good service in the clinical study of the disease along with other methods. Bushnell reports on his use of this method, which he believes to be of distinct prognostic value. He regards it as espe- cially useful in deciding how long it is necessary to keep the patient quiet. " An objective proof that a toxic absorption is present in a degree which constitutes a tax on the resistance of the afebrile patient is one of the great desiderata in the treatment of pulmonary tuberculosis. Arneth, it appears to me, has furnished the means of securing such proof in his method of studying the neutrophylic leucocytes." Sputum Examination. — Much calls attention to the fact that parts of tuberculous nodules in the lungs of cattle, in which the microscope shows no acid-fast bacilli, produce on inoculation into guinea pigs typi- cal tuberculosis, from which cultures can be made. Cold abscesses in human beings where no bacilli can be demonstrated by Ziehl's stain, give cultures by the inoculation method, and by a modified Gram stain the bacilli can be made visible here as well as in the tissues. The more virulent forms of bacilli he finds most easily decolorized by the acid. The importance of this, if it be verified, need scarcely be dwelt on. Physical Diagnostic Measures. — Few new procedures in this line were brought forward. Kuthy noted the frequency of thoracic pain of pleural origin, AA-hich he found present in 60 per cent of 650 cases, and in 85 per cent of these it was on the side of the most exten- sive lesion. Seeking for an objective evidence of this pain, he found it in the " clavicular symptom," as he calls it — i. e., the drooping of the outer end of the clavicle, which Aufrecht has specially dwelt upon. But while present in 80 per cent of the first-stage cases, 63 per cent of these had the droop on the most affected side, and in 20.5 per cent of all cases the droop did not correspond to the affected side. The lessened rise or immobility of the acromion on the affected side he calls the " acromial phenomenon," which he found even in the ear- liest cases; 80.4 per cent of his cases showed it about as often as the " clavicular symptom," but in only 2 of 86 cases did it not correspond Avith the side of the lesion. He concludes that pleural pain or the " cla- 26 386 DIAGNOSIS vicular symptom " indicates the diseased side with al)out 80 per cent of probability, while the " acromial phenomenon '' does this with almost complete certainty. Franeke believes that a pain on pressure in incip- ient tuberculosis to be found where the inflammation is first located — i. e., in the posterior superior aspect of the apices, without relation to respiration — has diagnostic value. He lays stress only upon pain pro- duced by pressure with the fingers or by tapping with the percussion hammer. This early determination of a pleurisy accompanying incip- ient tuberculosis he calls " algeoscopy." The pain also varies directly with the extent, advance, or retrogression of the trouble, its depth from the surface, and its cure. In 77.5 per cent of 200 cases he found this pain. Of these 154 were light, 32 medium, and 14 severe cases. Waller, in a paper on the methods of percussion, dwells on the great difficulty, when both sides are affected, of correctly valuing the percussion find- ings. He divides percussion sounds into several varieties, too elaborate to be here reproduced, disapproves of the customary symmetrical com- parative ^percussion, and advises beginning percussion in regions where normally there is a clear, full percussion note — i. e., in front, in the infraclavicular fossae and behind in the region of the angle of the scapula. Use of X-rays. — Valuable papers by Williams, Ivrause, and Kist w'ere read. The former stated, in agreement with his past attitude, that " X-ray examinations, while not infallible, add to our knowledge of conditions present in the thorax, and give fuller, more accurate, or earlier information than the older methods." Krause noted that, " in the main. X-ray diagnosis merely confirms and completes the clinical findings and is limited to the detection of differences in density in the lung," a conservative view. He considers that infiltration which can- not be determined by percussion can often be demonstrated by the radio- gram, but that a simple catarrhal process in the early stage cannot be demonstrated either by the fluoroscope or by radiography. Later the apices appear dark and do not clear up during inspiration. He con- siders that Williams's sign has no diagnostic value. He also dwells on the extreme value of the X-ray in the diagnosis of bronchial-gland enlargements in children. Rist very wisely emphasized the importance of a thorough familiarity by the physician making the X-ray examina- tion, with the refinements of clinical methods of diagnosis of tuber- culosis, and noted that if clinical diagnostic work is to be in the hands of one man and the X-ray work in the hands of another, serious mis- takes are apt to occur. Prognosis. — Casselberry emphasizes the fact that the prognosis of laryngeal tuberculosis is better than is generally supposed, and that tuberculous hyperplasia can resolve and tuberculous ulcers will occa- ADDENDA 387 sioiially heal iu cases si lowing a good resistance to the disease gen- erally. Craig studied the prognosis in children. This he believes is best estimated first by the amount of lung involvement, next by the pulse- rate, and last by the respiration rate. Older children show slightly bet- ter results than younger, and those treated in sanatoria better results than those treated in dispensaries or hospitals. The results in children if the disease were not extensive were better than in adults, but when it was advanced thev were not so good. PART IV PROPHYLAXIS OF TUBERCULOSIS INTRODUCTION By HERMANN M. BIGGS Questions relating to prophylaxis have come more and more to dominate the consideration of the social, economic, and medical aspects of the great problem presented by the universal prevalence of tuber- culosis. While it is everywhere recognized that great progress has been made in the treatment of the various forms of this disease by the devel- opment of the hygienic, climatic, and dietetic phases of the subject, and while the earlier recognition of the pulmonary form of tuberculosis has, and is still, very largely increasing the percentage of cases of pul- monary tuberculosis, which may properly be brought within the scope of treatment, and while bacteriological researches have contributed much information, which gives promise of ultimate vsuccess -in the spe- cific treatment of tliis disease, yet we are realizing more fully each year that the solution of the prol)lem looks forward to the development of more efficient and far-reaching measures of governmental control. It is the administrative control, with prophylaxis chiefly in view, which is growing most in importance, and a very hopeful sign of the times in this respect is the increasing acceptance by sanitary authorities of a broader conception of their functions and duties with reference to this disease. Of course, in the ultimate analysis the prophylaxis of tuberculosis is connected with all those fundamental problems which have to do with the lives of the lower and middle classes of society; those relating to the hygienic conditions obtaining in their homes and workshops, such as lighting. h(>aliiig. ventilation. jiUimbing, and the air space; the relative width of the streets and the height of the build- ings; small parks and open spaces; the purity and character of the food- supplies; the regulation of the hours and condition of labor, matters relating to school hygiene, and numerous other similar considerations. The questions relating to immediate prophylaxis as connected with the infection possibly surrounding the affected individual have to do primarily with his education and with the development of a sense of responsibility in him for (he adoption of precautionary measures, as well as the growth of an intelligeul demand on the part of the well, (hai fhey shall be subjected to no needless exposure becaus(> of the care- 391 392 PROPHYLAXIS OF TUBERCULOSIS lessness of the sick. With this, too, there must come a more general recognition of the duty of the sanitary authorities to exercise more strict police surveillance over tuberculous individuals, and, when necessary for the protection of others, to insist on the forcible removal to insti- tutions of persons who are unable or unwilling to take these precautions which are necessary to render them free of danger to other persons. It has come to be pretty generally recognized as the duty of the authorities to provide sufficient facilities for the treatment of these patients in dispensaries, hospitals, sanatoria, day camps, etc. As long as the problem of prophylaxis is so intimately associated Avith the fundamental conditions of life of the masses of the population, we cannot hope for any early and complete eradication of this disease, but we may very properly hope for and expect that there shall be a fairly regular and continuous decrease in the prevalence of tuberculosis in all well-regulated communities. The time is not far distant when the lack of proper measures of precaution in any community will be regarded as proof of negligence and incompetence on the part of the sanitary authorities and gross indifference to their own welfare on the part of the general public. CHAPTER I IXDIVIDUAL TROPHYLAXIS By EDWARD R. BALDWIN MEASURES FOR THE HEALTHY INDIVIDUAL The efficacious prevention of tuberculosis involves the protection of the healthy individual from needless exposure to the infection, so far as is possible. Since, however, complete annihilation of infective material cannot be contemplated in a generation or two at least, measures to minimize the danger by reducing the amount and frequency of expo- sure on the one hand, and to increase the resistance of the healthy individual to the inevitable exposure on the other hand, must be de- pended on at present. These measures can hardly be less important in causing the gradual extinction of tuberculosis than those directed toward the control of the consumptive individual himself, considering the pres- ent state of civilization. The protective measures must also be viewed as to their importance in inverse proportion to the age of the individual. Precautions which are of the utmost importance for young infants become almost super- fluous for adults, when we consider the greater relative resistance of the latter to infection. Infancy. — Xontuberculous Pabentage. — The most enlightened opinions as to the danger of infection to the youngest infants justify every precaution that can be taken in the isolation and feeding of the new-l)orn, whether the parents are apparently free from tuberculosis or not. Unsuspected tuberculosis in the parents is very common. If the mother has had a latent focus, there is no time more propitious for it to become active tlian during parturition and lactation. Consequently, obscure ailments in the mother or wet-nurse, especially when accom- panied by fever or cough, should be the signal to discontinue breast feeding if tuberculosis cannot be excluded. Milk. — The necessity for artificial feeding involves infinite care to insure against the danger of conveying tubercle bacilli in the milk. The ideal conditions are to have the absolute assurance that tuberculin- tested cows constitute the only source of the milk, and that, in its 27 ' -.m 394 INDIVIDUAL PROPHYLAXIS handling or transportation, no tuberculous person is employed; further- more, that exposure to dust or insects does not occur. When these con- ditions can be fulfilled no danger can be apprehended from the use of raw milk, but in the complexity of city life few can have these advantages. Hence, sterilization in some form becomes the only safeguard. Pasteurization leads among all methods for accomplishing this end. The suspicion that milk has been exposed in public places should be reason enough to have it pasteurized; nor should it be forgotten that it may be contaminated after pasteurization if carelessly exposed, and that cream requires the same precautions. The heating should be done in a closed vessel, otherwise the surface layer will not be sterilized. The addition of antiseptics, such as formalin and boric acid, cannot be jus- tified either on the ground of efficiency in killing the bacillus or of harm- lessness. The least objectionable method is that of adding hydrogen peroxid (Budde). The modifications introduced by De Waele, Sugg, and Vandevelde, and also Much and Roemer (" perhvdrase"), by which the HoOo is decomposed by a blood enzyme after acting as an antiseptic, have thus far had insufficient trial to prove their reliability. Tuberculous relatives or other members of the household, such as nurses, servants, visiting guests, or boarders, should be prevented from coming into close contact with infants if these persons have open tuber- culosis. They should avoid kissing the infant and coughing when near it. They should neither be permitted to prepare nor taste the food, nor offer it in the same cups, glasses, or spoons which they are themselves in the act of using, as is so frequently done among the poor. The ever-ready handkerchief forms a dangerous weapon with which to wipe the infant's hands and mouth, and the custom is widespread among otherwise cleanly women of expectorating into handkerchiefs. The unwashed fingers of relatives too often find their way into the infant's mouth, or during the teething period contaminate its fingers and toys, thus indirectly carrying infection obtained elsewhere. Like- wise pets, especially dogs, who are in the habit of lying on the sidewalks and steps, may become soiled with sputum and convey infection to the nursery. Overshoes, walMng hoots, and sl-irts should not be neglected as pos- sible sources of danger to the creeping infant, and they should not be cleaned in any living room. It is of the greatest importance to have the floor of the nursery frequently cleaned and covered, if at all, with movable rugs and matting. Traveling in public conveyances with infants probably involves less danger of tuberculous infection than is popularly supposed, inasmuch as the chance contact is of short duration. Infants should not be seated MEASURES FOR THE HEALTHY INDIVIDUAL 395 in coaches where" antispitting ordinances are not enforced and where dusting of clothing is permitted, if such exposure can be avoided. Visiting public resorts and houses where tuberculous persons reside is to be discouraged on general principles, though the danger to infants is conceivably far less than from other diseases. Public halls, waiting rooms, and amusement places in general are likewise to be avoided so far as possible. The monkey house of the zoological gardens is a place of danger by reason of the frequency of the disease in these animals. Diseases, especially the exanthematous infections, which give favor- able times and places for the reception and development of tuberculosis, should not be dealt with lightly by the laity. Whooping cough, diph- theria, and tonsillitis present all the favoring conditions for infection through the air passages, while gastroenteritis gives the opportunity for its entrance by way of the intestine. The gradual extinction of the acute infections by efficient quarantine and sanitation will doubtless go far toward decreasing tuberculosis, which would often fail to develop when the infection is feeble but for them. Extra precaution should be taken with children known to have ade- nitis that they shall not be exposed unnecessarily to children's diseases, or under the instruction of a tuberculous teacher or governess. En- iarged tonsils, whether faucial or pharyngeal, are a menace of tuber- culous infection either actual or potential, and removal is indicated in nearly all cases. It is highly probable that the gateway of infection is thereby sealed in many cases by timely operation. In any case, mouth- breathing is to be remedied if it has resulted from these causes. Carious teeth should be removed and the gums protected from ulceration. Digestive disturhances are frequently caused by careless feeding of children. They should be restricted as to sweets, and taught to avoid unripe fruit and gluttony. The presence of intestinal catarrh or gas- tric dyspepsia paves the way for infection otherwise unlikely to gain a foothold. Accidents. — Falls on the head, blows, or concussion of any kind should be guarded against, for the popidar idea of their connection with a subsequent meningeal joint or bone tuberculosis has considerable foundation in clinical experience. Inoculation tuberculosis from scratches is sufficiently common to require care in covering eczematous patches on the skin of infants, and to observe scrupulous cleanliness with their hands and toys during the period of teething. The possibility of conveying tubercle bacilli by means of insects should be guarded against by screening sleeping in- fants. Vaccination has no longer any reason to be charged with the inoculation of tuberculosis where calf virus is used. Only the grossest 396 INDIVIDUAL PROPHYLAXIS carelessness and neglect could produce such a result. The same may be said of circumcision. Tuberculous Parentage. — \Mien one or both parents have tuber- culosis, there are numerous precautions to be taken if complete isolation of the infant is not feasible. Isolation: ^Vhen NeceKmry. — Even with the most minute attention to details, the presence of open tuberculosis in a mother almost inevi- tably involves some danger of infection to her infant when it is under her care. The tuberculous father can readily avoid close contact with his child ; not so the mother, who, though she may not nurse the babe, must pi-epare its food and attend to its wants because there is no other person to do it. Complete isolation is, therefore, logically the ideal for the infant with a tuberculous mother who is expectorating bacilli. If the disease is latent or already healed, there can be no danger for the infant, though the wisdom of breast feeding by the mother for her own and the infant's interest must be a question in every case. The possibility of obtaining the infection directly from the milk is very remote even where active tuberculosis exists, unless the mammary gland is involved, but the nipples are readily soiled by the mother's fingers under these conditions, and may thus indirectly convey the bacilli. Besides the conveyance of infection in the milk, the possibility of transmission of a specific susceptibility to the disease is to be re- garded, though actual proof of this is not easily obtained. Where the tuberculous parents must of necessity associate closely with the infant, the danger can be reduced to a minimum by avoidance of coughing in the immediate vicinity of the infant, carefully shielding the mouth dur- ing the act, and by careful attention to all the other details of personal hygiene elsewhere mentioned for tuberculous individuals. Special measures directed toward increasing the resistance of the infant are of the utmost value, and the most important is care in feed- ing. Proper modification of cow's milk, suited to the age and capacity of the nursling, as well as regularity in feeding, should be secured. In this way frequent gastrointestinal catarrhs may be avoided which doubt- less favor the lodgment of tubercle bacilli, when otherwise they would not gain entrance. Constipation is only second in importance in favor- ing infection and must be combated with mild measures. Immunized Milk. — The possibility of conveying antibodies from immunized cow's milk which shall avail to increase the resistance of infants has received some experimental support. Figari, v. Behring, Eoemer, and Much have demonstrated increased agglutinative power for tubercle bacilli in such milk and its transference to offspring. The activity of this and other hypothetic antagonistic substances, neverthe- less, appears to be rather restricted, since it has been found (Eoemer) MEASURES FOR THE HEALTHY INDIMDUAL 397 that only during the first eight days after birth are proteid substances absorbed unchanged by digestive action. The advantage resulting from the employment of such milk for infants is largely theoretic at present. But little application has been made of the principle, and it is prema- ture to venture an opinion of its possibilities. Active immunization of infants by means of feeding tubercle bacilli or their products, made innocuous in various ways, has a promise of appli- cation in the future since success has been obtained with suckling calves and guinea pigs, in the experiments of Calmette, Guerin, and Morin. General Hygiene, Climate, etc. — Much can be done by intelligent care to strengthen infants against infection by keeping them out of doors in all weather except the most severe heat and cold. The morning nap may profitably be taken on a sheltered veranda in cool weather, where safety and quiet can be assured, or in a cold room if this is not available. Catarrhal colds may be warded off by cool sponging and friction to the neck and chest, suiting the temperature to the growth and daily condition of the infant. Favorable climatic conditions, if possible, should be secured for the offspring of tuberculous parents. Those who are congenitally delicate and persistently under-nourished thrive best in Southern California or the southern Atlantic States in winter, especially among the pines and on the coast. Infants with nor- mal assimilative powers are better in the highlands of Colorado, Xorth Carolina, or the Adirondacks, both winter and summer. Childhood. — The same recommendations can be made with more insistence for children over two years of age, because the opportunity for outdoor life is greater with increasing age and invigorating meas- ures are more effective. Food. — With the weaning of a breast-fed infant begins whatever opportunity for food infection there may be from other sources. So far as evidence has been adduced, there is little danger outside of milk and its products, butter and cheese. The contamination of food is, however, easier with the greater freedom of movement enjoyed by the child. Bread, cakes, fruit, and confectionery are occasionally handled by tuberculous persons at the shops, and often soiled by dirty hands. The child plays on the floor or sidewalk, handles door knobs and latches, public cups, and innumerable other things used in common which may convey infection. Fortunately these sources do not constitute a great danger in nontuberculous families. Attention to cleanliness is the prime factor of safety here as in all else that concerns prophylaxis. The food should be abundant and especially rich in fats and proteids for children of tuljerculous parentage. The butter- and cream-eating habit should be encouraged in such children. A liking for cod-liver oil is not infrequently acquired by children with advantage. 398 INDIVIDUAL PROPHYLAXIS Clothing. — When children are congenitally malnourished, it must not be thought that their clothing is an indifferent matter. They require more underclothing than the better-nourished children, preferably wool next the skin in winter, and especial care to prevent wetting the feet. Bare legs and arms in cold weather are certainly irrational measures for the purpose of hardening most children, however successful with some. Head covering in hot sunshine should always be provided for children. The neck and chest should not be confined tightly nor bun- dled warmly except in coldest weather. Bathing and Exercise. — A morning sponge with cool water and a warm tub bath twice a week at night, merit constant attention for deli- cate children ; the habit is then formed early and increased resistance to changes of temperature is acquired. The question of sea- or fresh-water bathing in the open is an impor- tant one for the physician to decide for each individual. No rules can be laid down except the general ones that the time spent in the water should never be long enough to produce cyanosis and pronounced chilli- ness, and also the warning against entering the water when overheated or directly after meals. Injury has often resulted from neglect by par- ents and physicians in this matter, by which the foundation for a future pulmonary tuberculosis is laid. Exhaustion from overrunning and excessive play is a frequent source of illness and debility in delicate children, especially those of active mentality, not unusual among children of tuberculous parentage. Violent games should be discouraged for any child suspected of latent lymphatic, bone, or joint tuberculosis. On the other hand, calisthenics and the respiratory exercises recommended by Knopf are very important in developing weakly children. Sleep. — Children under fifteen years of age require from ten to twelve hours sleep daily. Some are benefited by an after-luncheon nap, but this leads to the temptation to keep a wide-awake child up later in the evening. Delicate children must be prevented from frequent attendance at evening parties. Unless suffering from recent colds or diseases, chil- dren should sleep in cool rooms, with at least one window open. Night clothing of flannel, with foot covering, is desirable for cold weather. Habits. — No time can be better spent for the prevention of tuber- culosis than in teaching cleanly habits to young children. It should be the constant aim of parents and teachers to keep the hands and nails of children clean, to prevent picking of the nose and scratching of abraded surfaces, herpetic or eczematous patehes, etc., which may thus 1)6 the source of inoculation tuberculosis. The sanitary instruction now being introduced into public schools promises much in the furtherance of prevention. MEASURES FOR THE HEALTHY INDIVIDUAL 399 The follo'wiiig brief presentation of simple health rules was made by the Hawthorne Club, a group of tenement-house children in Boston : HEALTH RULES FOR SCHOOL CHILDREN 1. Health is wealth. 2. Do not put pins in your mouth. 3. Do not hold money in your mouth. 4. Do not put your fingers in your mouth. 5. Do not put pencils in your mouth or wet them with your lips. 6. Do not wet your finger in your mouth when turning the leaves of books. 7. Do not put anything into your mouth except food and drink. 8. Never spit on your slate or on the floor or sidewalk. 9. Do not pick your nose or wipe it with your hand or sleeve. 10. Keep your face, hands, and finger nails clean. 11. Keep the interior of your body clean by allowing nothing to go into it excepting pure food and pure drink. 12. Do not keep your rubbers on in the schoolroom. 13. Do not sit with wet feet or damp clothing; resort to the stove or register until they are dry. 14. Do not swap parts of apples, candy, chewing gum, half-eaten food, whistles, or anything that is to be put in the mouth. 15. Xever cough or sneeze in a person's face. Turn your face to one side and hold a handkerchief before your mouth. 16. When drinking, rinse out the cup, and empty what water you leave into the wash basin or sink. 17. Breathe only fresh air day and night ; simply avoid draughts. 18. Breathe, sit, stand, and walk correctly. In so doing you will do more to prevent consumption than all the physicians combined. A good pair of lungs is the most efficacious barrier to this disease. 19. Go to bed early, rise early, and take plenty of " physical culture," helping father and mother, before and after school, with the " chores." 20. Study the physiology — to know how to use rightly and take proper care of every part of the body. Schooling. — The amount of strain which schooling brings to a child must be considered carefully, particularly with children of tuberculous parentage, whether they are already infected or not. Apart from the danger of infectious diseases likely to be acquired at school — especially measles, whooping cough, scarlet fever, and diphtheria — the well-known precocity and intellectual keenness of many such children is a reason for restraint rather than stimulus in study, and the family physician may properly err on the side of overwillingness to grant certificates asking for shorter hours and absences to these children. Work at home or elsewhere, when it restricts outdoor life and the normal development, should be abolished by law. 400 INDIVIDUAL PROPHYLAXIS An excellent scheme for keeping children out of doors in cities is the roof garden devised and successfully used by Dr. Northrup in New York (see Fig. 122). Youth. — Period of Puberty. — With the advent of sexual conscious- ness, a period of danger arrives in relation to tuberculosis. It is chiefly with those children who have already become infected that the fear of an outbreak should be greatest, for the actual danger of primary infec- tion is probably less during the years of adolescence when active outdoor life is the rule. Rapid growth and instability of the nervous system tend to favor the spread of latent disease, and the suspicion of any focus of this kind should lead to constant watchfulness. Periodic examina- tions by the physician are strongly to be recommended, and much de- pends on his care and tact with delicate youths. Avoidance of mastur- bation can be taught best by the family physician, and its debasing moral and physical effects j)resented in a judicious way, supplementing the generally desultory efforts of parents and teachers. Signs of chlo- rosis or markedly irregular menstruation in girls call for increased vigilance in reference to latent tuberculosis. Overstrain has been the bane of modern life for adolescents. Ex- hausting wheeling trips and racing of all kinds are common. Athletic contests and overtraining are associated Avith the development of tuber- culosis with sufficient frequence, even in the robust, to justify constant restraint. The presence of latent tuberculosis has often been unsus- pected by physical directors, and more care is required in obtaining the previous histories of candidates for college teams. Mental and nervous strain is to be prevented quite as much as physical overexertion, for the latter naturally concerns the strong, while overstudy and nervous excitement oftener affect the less vigorous. Late and irregular hours, insufficient sleep, excessive smoking, eating, and drinking, combine to undermine the resistance of many college youths who have inherited or acquired susceptibility to the disease. Moral training is especially important for venereal prophylaxis, and has been sadly wanting in the past. Fortunately, educators and publi- cists are now endeavoring to supplement the efforts of physicians in this direction, and a potent factor at the root of much tuberculosis is being grappled with. Nevertheless, the most effective work is that which may be done by the personal influence of the physician. Adult. — Promotion of Good Physique. — When full growth is at- tained and the life work entered on, individuals with delicate constitu- tions are the first to contribute to the harvest of tuberculosis, which is always greatest at the threshold of married, business, and professional life. The open-air life of youth is abandoned, and responsibilities accu- mulate which tend to lower resistance by their demands on the physical MEASURES FOR THE HEALTHY INDIVIDUAL 401 aud mental powers. Xor can it be forgotten that the strongest some- times succumb. Xone can be excluded in the application of rules of hygiene. Good muscular vigor should be furthered b}' walking, deep breathing, and open-air sports generally. Golf is one of the foremost useful games for sedentary persons, while driving and boating are especially good for those more actively employed and required to stand Fig. 122. — Playground on Roof of Residence in New York City. (Dr. Northrup). much on their feet. It is often important that otherwise desirable indoor recreation be replaced by outdoor work, such as gardening. On the other hand, mental recreation is highly important to maintain vigorous intellectual power and, indirectly, a stable nervous system, so often lack- ing in persons predisposed to tuberculosis. Habits. — Regularity and temperance in all things are requisite for the maintenance of good resistance in the strong, and doubly so in 402 INDIVIDUAL PROPHYLAXIS persons predisposed to tuberculosis. Even moderate dissipation may arouse a latent infection into activity, so that alcohol, tobacco, and late suppers can be dispensed with by such individuals. Temporary exhaus- tion from excesses of any kind is readily forgotten until a breakdown occurs, so that constant warnings are needed. Carefulness in dress so as to avoid chilling and wetting, in diet and eating that the necessary time is taken for proper mastication, and in sleeping that fresh air is obtained, should be insisted on specifically and often by the family phy- sician; otherwise gradual neglect of simple hygiene commonly prevails in most families. Occupation. — In the choice of an occupation everyone should have the advice of a physician familiar with the physique of the family, if Fig. 123. — Sleeping Balcony. (Private house, Saranac Lake, N. Y.) possible. Too often necessity drives ill-nourished, thin-chested indi- viduals, and those who are physically under-developed, into an indoor trade or behind the counter. Practically all the " light " occupations are indoors, so that the problem is not what occupation to select which will give the individual an outdoor life, liut how one can be adjusted to it so as to get the most time in the open air and have healthful work- ing conditions indoors. Dusty employment should not be permitted for persons predisposed or those already the victims of latent tuberculosis, nor should trades that involve exposure to wetting, steam, vapor, and MEASURES FOR THE HEALTHY INDIVIDUAL 403 extremes of temperature, like confectioners, bakers, and plumbers, be selected by any person who may be predisposed to tuberculosis. Clerical and professional pursuits, involving as they often do great mental strain, ought not to be undertaken by very excitable, nervously constituted individuals. Where possible, such persons should be guided into agri- cultural or allied occupations. The transportation, mail, and express services offer many desirable places for open-air employment. Dwellings. — Modern urban life is inexorable in its crowding, with consequent restricted light and air. It should be the aim of families which have had tuberculosis among their members, or which, for any reason, are predisposed, to secure a suburban house isolated from others so that all sides may receive light and air. No unlighted hallways, basement rooms, or damp cellars should be permitted. Houses in swampy regions should be abandoned for higher and drier locations. Heating furnaces or radiators should be furnished with water evapo- ration tanks to prevent undue dryness. Dry sweeping should be for- bidden. Living rooms in winter should not be warmer than 68° F., and the windows should frequently be opened at the top. A sleeping room with balcony or with provision for a bed practically out of doors is very desirable for any family, but especially for the one with a deli- cate member who is predisposed to pulmonary disease. Much attention should be given to a spacious veranda to make it available for both summer and winter as a place for rest and comfort (see Fig. 123). Houses with sleeping porches entering into the building plan are being constructed more and more. They are worthy of imitation. The two adjoining plans may be more suggestive (see Figs. 124 to 127). rresr flooe plan sax»n FLOoe plan Figs. 124 and 125. — Cottage Showing Arrangement for One Sleeping Porch. (First and second floor plans.) (Scopes & Feustmann, architects, Saranac Lake, N. Y.) Marriage. — The question of nuirriage, in relation to the danger of tuberculosis, is not often first referred to the physician, yet serious 404 INDIVIDUAL PROPHYLAXIS danger might be averted in some cases by his wise counsel. The things most important to consider for the husband are his physical ability to bear the strain of supporting a wife and children by his own efforts, m K I , I I , 1 BEDROOM •I& PORCH FIRST TUoaH PLAN SECOND TL002. PLAN Figs. 126 and 127. — Cottage Showing Arrangement for Two Sleeping Porches. (First and second floor plans.) (W. E. Scopes, Architect, Saranac Lake, N. Y.) if that is to be required of him by necessity or choice. If he is deli- cately organized, and has a struggle before him, there is a real danger that tuberculosis may claim him, yet if life is comparatively easy, and the wife strong, the union may be free from serious objection. The children may also acquire excellent constitutions in spite of the paternal weakness, unless syphilis or some other taint is added. On the other hand, a delicate woman must undergo grave danger of tuberculosis from child-bearing if latent disease is present or the conditions of life in- volve exposure to it. Each case must be decided on its individual indi- cations and contraindications, consideration being given to the tem- peraments, social status, and prospect of greater or lesser hardships in the married state. MEASURES FOR TUBERCULOUS INDIVIDUALS Closed Tuberculosis. — Numerous cases of closed (latent or healed) tuberculosis have come to light in recent years owing to the greater attention given to early diagnosis and the use of newer diagnostic aids, especially tuberculin. Many tuberculous families are now being system- atically examined, and luedical inspection of school children, combined with special tuberculosis dispensaries, promise to reveal an enormous number of infected individuals. Adequate public and private preventive MEASURES FOR TUBERCULOUS INDIVIDUALS 405 agencies will not fail in the future to take more and more note of latent tuberculosis. All that has been mentioned in the preceding pages on prophylaxis applies especially to these dormant tuberculoses which may often be prevented from spreading further by good care. Scrofulosis. — Every effort should be made to prevent suppuration and ulceration of scrofulous glands. Bone and Joint abscesses under modern surgical treatment can often be prevented from rupture and secondary infection. If rupture occurs and drainage becomes necessary, it must be kept in mind that the pus contains tubercle bacilli and that the discharges from the sinuses must not be neglected simply because it is not easy to discover the bacilli in them. Closed Pulmonary Tuberculosis. — This may so readily become open, witliout warning symptoms, tliat it is wiser to provide for this con- tingency by observing the rules for the care of the cough and ex- pectoration, if present. If these precautions were more generally carried out, " locking the door " after the harm is done would be less common. Open Tuberculosis. — Care of the Sputum. — There is no doubt about the advantages of asepsis over antisepsis in dealing with tuber- culous sputum. Eeliance on disinfectants begets uncleanliness in handling cuspidors or other receptacles. Hence, with the most efficient germicides less is accomplished than with a liberal use of soap and water and the destruction of expectoration by fire or boiling heat. Moreover, most of the useful disinfectants have a disagreeable odor, coagulate the sputum, and injure the skin, besides being poisonous. Ilandkerdiiefs. — The use of washable handkerchiefs should be strictly forbidden, and cloth, gauze, or paper handkerchiefs substituted for all purposes. The repeated use of the same handkerchief or cloth for sputum is absolutely unhygienic, in that the hands will be unavoid- ably soiled and flakes of dried mucus are soon formed and scattered from the cloth. If handkerchiefs have of necessity been used, they should be burned or soaked in boiling soapsuds or some alkaline dis- infectant, such as a two-per-cent chlorinated lime solution or a two-per- cent lysol solution before being laundered. The ordinary soiled clothes bag is not a sanitary place for any handkerchiefs. A l)etter plan is to collect all handkerchiefs in a covered slop jar during the week and pour boiling suds on them before removal to the laundry. Cloth or bandage rolls for receiving the sputum are objectionable because the fingers become soiled in rolling them. Pieces of gauze and paper handker- chiefs should also l)e folded several thicknesses for the same reason. Paper bags are the most satisfactory receptacles for sputum cloths. Rubber pocket linings are less available and require cleansing, whereas the baffs are to be burned. 40G INDIVIDUAL PROPHYLAXIS Cuspidors. — Those made of paper are now in general use, and are preferable to metal or glass ones because no cleansing is required. This consideration applies to all forms of cuspidors, whether for the pocket or stand. There are, however, several excellent metal and glass pocket cuspidors, such as Knopf's, Kny-Scherer's, and Dettweiler's, which can be tilled partly with a disinfectant when in use. Floor and wall cuspidors should he abolished as fast as the pocket receptacles can be introduced to take their places. Portable cuspidors in great variety are to be had which are quite sanitary. Only such should be permitted as have a cover, so as to prevent the access of flies. Paper cups should be placed in frames of sufficient weight to prevent their capsizing or being blown about by wind. Cuspidors of agate ware or china should be cleansed with strongly alkaline soap and hot water, the sputum having been burned, or after disinfection poured into a water closet (see illustrations in Appendix, pages 832-839). Disinfection. — It should be a constant aim to burn all sputum where possible. Admixture with sawdust, paper, and cloth greatly facilitates the burning, but care should be taken that the fire is sufficiently strong to completely destroy everything. Boiling is also efficient, but not ordi- narily feasible, outside of institutions. The alkaline disinfectants are the best, but have an objectionable odor in most cases. A two-per-cent solution of chlorinated soda and lime is most economical but more volatile than lysol (3 per cent). Caustic soda (10 per cent) is satis- factory for public cuspidors, but requires careful handling to avoid injury to floors, etc. Mercuric chlorid (0.1 per cent), phenol (5 per cent), and formalin (3 per cent) are coagulants which act too slowly for most purposes, but may be useful where sputum has been accident- ally spilled on a carpet or floor. Cuspidors require more careful wash- ing when these have been used. Fornuilin fumigation should be relied on for the disinfection of garments, rugs, and other nonwashaljle objects. Where a public fumigatory is not available, a closet or room can be utilized and the formaldehyde generated by the fireless method.^ Cough Discipline. — A well-trained and conscientious consumptive can do much to minimize the danger from accidentallv coughed-out ' For each 1,000 cubic feet of space disinfected take 3 ounces of commer- cial sulphuric acid, add it to 1 pint of water and pour into 18 ounces of com- mercial formalin in a vessel of crockery or agate ware. This warm mixture is then poured quickly on IJ pounds of fresh unslaked lime, broken into small lumps in an agate or iron kettle, and placed on the floor protected by papers. The formalde- hyde vapor is rapidly generated so that it is necessary to close the door at once, all openings having previously been pasted over with paper. The door is then sealed for twelve hours, after which the room may be opened and the contents removed for airing and cleaning. MEASURES FOR TUBERCULOUS INDIVIDUALS 407 spntuni .spray hy repressing the cough and covering the mouth when coughing. This can be cultivated to a marked degree by resisting the tendency until the sputum can be raised without effort. Fraenkel's mask was introduced for the purpose of arresting the cough spray, but it has found but little favor. Simpler measures are the only ones likely to be carried out in practice, and the habit of covering the mouth with cloth is readily acquired. Hawking and sneezing should be suppressed if possible, and the mouth and nose especially covered during these acts. The head should always be turned away during the act of cough- ing and raising in the presence of other persons. It is surprising how many persons forget hygienic breeding, or lack alertness in practice ! The patient should endeavor, as far as possible, to do his coughing in his own room or out of doors, repressing it elsewhere. Personal Cleanliness. — The whole law and gospel of properly trained tuberculous patients are contained in the expression " Be ye clean." This is of paramount importance and needs intelligence to be carried out consistently. Patients who gargle and wash their mouths carefully, yet swallow their sputum consciously or unconsciously, are endangering the intestinal tract. Likewise, those who brush their teeth carefully, but wear drooping mustaches or a beard often smeared with sputum, are not fulfilling the law. Effective cleanliness begins with mouth-washing ^ and gargling after the morning cough has dislodged and raised the sputum. Nothing should be swallowed until this has been accomplished to as great a degree as possible. The teeth are then to be brushed and a nasal spray or douche used if much catarrh is present. An alkaline cleansing spray is also desirable for a catarrhal larynx and important when this is tuberculous. These procedures prevent to some degree autoinfection or reinfection of the ears, nose, larynx, and intestine, while frequent and plentiful use of soap and water for the hands and face avoids much chance of conveying infection to others. Mustaches and Ijeards are difficult to maintain in a state of sanitary > Mouth Wash. I^ Olei gaultherise vr\^ xxxvj 2.3 gm. Olei eucalypti xxi xxx 2 " Mentholi gr. xx 1.3 " Thymoli 5 j 4 " Acidi benzoici 3 iv 16 " Acidi borici 5 j 30 " Sodii bicarb 5 j 30 " Extr. baptisiae tinctorise f 3 iij 12 " Alcohol O iij 720 " Aquie O v 1200 " M. With eqviai parts of water. S. Use as mouth wash. 408 INDIVIDUAL PROPHYLAXIS cleanliness unless closely trimmed, and should be shaven when the expectoration is profuse. Patients should be cautioned against hand- ling articles used by children, leaving cloths or handkerchiefs in books, overcoat pockets, bureau drawers, and closets, and also against permit- ting glasses, spoons, pipes, cigar butts, and toothpicks to lie about and get dry. However insignificant taken singly, all these precautions are in the aggregate justifiable and reasonal)le. Care of Other Excretions. — The urine and feces are to be con- sidered secondary in importance to the sputum, but soiled undercloth- ing and bedding should be soaked before being handled in a laundry, and especially where renal, vesical, or intestinal tuberculosis is known to be present. Abrasions of the genital organs, especially of the female, should be kept surgically clean in the tuberculous. Duty of Consumptive Individual to Society. — Every tuberculous per- son owes a duty to his fellow human beings to the extent of protecting them so far as possible from his disease. He cannot rightfully scatter infection about because it is some trouble and sacrifice for him to avoid this, and because he may have acquired the disease through no fault of his own. Xay, more, he may not justify carelessness if his disease is the direct and acknowledged result of public neglect. The rule must apply here as in all infectious diseases, although restraint of freedom beyond recognized limits is very much less justified. Quarantine of a tuberculous patient cannot be upheld unless he is sho\ATi to be viciously dirty and knowingly careless. Isolation for the tuberculous insane and imbecile or the hopelessly ignorant and depraved patient is logically demanded, but not for the intelligent and obedient in the present state of society and widespread prevalence of the disease. On the part of the patient, voluntary isolation cannot be expected, yet it is desirable that he should avoid undue publicity in manifesting the symptoms, which may cause him embarrassment and increase the prejudice of the inconsiderate public. This is especially true of ad- vanced cases with severe cough and hoarseness when in public places, such as street cars, waiting rooms, theaters, churches, hotels, and espe- cially restaurants. Duty of Society to Consumptive Individual. — The careful, cleanly consumptive has a right to associate with other people in the ordinary pursuits of business and pleasure. He also should have the right to consideration and sympathy as well as charitable aid when in need. He can justl}^ meet the demands of society for his isolation or abandon- ment of occupation by the counter demand for a place of retreat or another occupation. Society, through government, should provide in- struction to the afflicted individual in the means of prevention and cure, and not greatly restrict his liberty provided he obeys these instructions. ADDENDA 409 Phthisiopliohia has been an increasingly serious matter for several years, and the popular lecturer on tuberculosis cannot avoid conveying exaggerated ideas of the dangers of infection. When the public is told that a dirty consumptive is dangerous, the inference that all consump- tives are dangerous is irresistible to many persons. Argument and sta- tistics do not accomplish much to counteract this unjust impression, and it behooves all right-minded physicians to throw the weight of their per- sonal influence against exaggeration. Marriage should not be contracted by tuberculous persons until two years after their recovery, except under special conditions. Where a complete arrest of the disease is obtained, though not a clinical cure, marriage and procreation may sometimes be permitted with safety under favorable conditions of life in other respects. Circumstances arise wliere the marriage of consumptives is quite justifiable, but in nearly all of these cases the procreation of offspring should be forbidden in a consumptive wife. The interest of the mother and child alike demand this course, yet if pregnancy occurs, the induction of abortion becomes a question to be decided in each case and not by rule. When the hus- band is consumptive, the interest of the mother and child are less en- dangered, but usually sufficiently so as to preclude procreation. Con- siderations of a nonmedical character must frequently determine the decision and remove the matter from the physician's control. ADDENDA Summary of Individual Prophylaxis, Presented at the International Congress, held in Washington, D. C. While no fundamentally new contributions have been made to methods of individual prophylaxis, a great number of investigations of tuberculosis in childhood have again emphasized the necessity of pur- poseful efforts in early childhood. The enormous number of infected children is only recently becom- ing realized and emphasized by the results of examinations. Miller and Woodruff found 51 per cent in 150 children of tuberculous parentage. Floyd and Hawes in 900 children found 66 per cent distinctly tubercu- lous, the majority of whom were exposed at home. Lowman and Sachs have also found similar conditions. Suggestive as regards the attempted immunization of children by feeding them with milk from immunized animals is W. J. Butler's finding that opsonic substances are practically absent in milk of healthy women. CHAPTER II PUBLIC MEASURES IN THE PEOPHYLAXIS OF TUBERCULOSIS By S. ADOLPHUS KNOPF Historical Review. — The possibility of the transmission of tubercu- lous diseases, particularly pulmonary tuberculosis from man to man, was known to some of the ancient Greek and Arabian physicians. Galen (131-200 A.D.) was the first to write of the possible contagiousness of the disease, and Avicenna (980-1037 a.d.), the founder of the Arabian school of medicine, speaks of the contagiousness of phthisis pulmonalis in his " Arabum medicorum principis " and the " Canon medicinge." The first scientific demonstration of the transmission of tul)erculosis from man to animal was given by the French physician Villemin, in 1865, and the infectiousness of tuberculous meat and milk from tuber- culous cattle was first shown by Gerlach and Klebs in 1870. The first official act pronouncing tuberculosis a contagious disease, giving directions for the disinfection of apartments, furniture, and per- sonal effects used by a consumptive, making it at the same time obliga- tory for the physician to report cases of consumption to the authorities and prescribing the punishment for failure to do so, was the celebrated royal decree issued in Naples, September 20, 1782. With the beginning of the nineteenth century, however, it was no longer enforced. After that, for nearly a hundred years, there were only individual efforts on the part of some public officers or local governments to recog- nize in tuberculosis a communicable disease. A new impulse toward the recognition of the necessity of taking proper precautions and edu- cating the public in regard to tuberculosis as an infectious disease, was given through the epoch-making discovery of the tubercle bacillus by Robert Koch in 1882. Soon after that laws were made and official regulations issued in various countries with the object of the prevention of tuberculosis in men and animals. The first society for the prevention of tuberculosis in the United States was founded in 1892 by Dr. Law- rence F. Flick, of Philadelphia. France had its first " Congres pour I'Etude de la Tuberculose ehez riiommc et cliez les animaux " in 1898, Germany held a congress at 410 HISTORICAL REVIEW 411 Berlin in 1890, and England followed with one, international in scope, in 1901. There was a similar congress held at Naples in 1906. A truly international congress on tuberculosis convened in Paris in 1905. At the closing session of this congress it was decided to hold the next one in Washington in the autumn of 1908, under the auspices of the Na- tional Association for the Study and Prevention of Tuberculosis. This, the first congress of its kind ever held in the United States, must be considered one of the most successful scientific gatherings which ever convened. Mr. Theodore Poosevelt accepted the presidency of the congress, Koch of Berlin. Williams of London, and Landouzy of Paris were made honorary presidents, the governors of the various States of the Union acting as honorary vice-presidents; representatives from all civilized nations were sent, and the attendance was very large. Many valuable communications were presented at the section meet- ing. There were seven of these sections: Section I, "Pathology and Bacteriology," Dr. William H. Welch, president; Section II, "Clinical Study and Therapy of Tuberculosis — Sanatoria, Hospitals, and Dispen- saries," Dr. Vincent Y. Bowditch, president; Section III, " Surgery and Orthopedics," Dr. Charles H. Mayo, president ; Section IV, " Tuber- culosis in Children," Dr. Abraham Jacobi, president; Section V, "Hy- gienic, Social, Industrial, and Economic Aspects of Tuberculosis." Mr. Edward T. Devine, president; Section VI, "State and Municipal Con- trol of Tuberculosis," Surgeon-General Walter Wyman. president ; Sec- tion VII, " Tuberculosis in Animals and its Relations to Man," Dr. Leonard Pearson, president. The meetings were held in the new National Museum, which the L^nited States Government had placed at the disposal of the congress. The tuberculosis exhibition was held in the same building, and it can be said that it was the most instructive ever presented. The exhibition consisted of charts, photographs, maps, models, diagrams, and all sorts of appliances for the prevention, study, and treatment of tuberculosis. Exhibits were shown from 15 different countries, and from 200 asso- ciations and individuals. All in all the exhibition included nearly 5,000 units. Numerous awards, prizes, and honorable mentions were given. There were nearly 7,000 inscribed congress members. Some of the distinguished foreign delegates delivered special addresses in Wash- ington and other cities of the Union. The section meetings lasted from September 28th to October 3d, and the social functions of the congress were as interesting and gratifying as the scientific work. At the concluding session, over which Secretary Cortelyou presided, Presi- dent Roosevelt made an interesting and inspiring address. The dele- gates present decided to accept the invitation from the Italian Govern- ment to hold the next coTi An interesting and novel method of educating the public visiting a tuberculosis exhibition was inaugurated by the New York State Department of Health. A large phonograph for which a well-trained voice had given a record embodying a short, concise and comprehensive popular lecture, was put in motion at certain intervals. The people usually gathered around and listened attentively to what the phonograph had to say. TUBERCULOSIS EXHIBITS, ETC. 425 accounts or misrepresentations of what the lecturer lias said, it is ad- visable to have a statement carefully prepared for the press to be given to the reporters who may be present at the lecture. Next to the press the clergy can certainly do much to help the medi- cal profession in the crusade against tuberculosis. The clergymen of all denominations should see to it that their churches are hygienically constructed and well ventilated. Fixed carpets should not be used in places of Avorship where so many people congregate. Catholic priests in charge of large congregations may do well to follow the example of a great Koman divine, the Bishop of Fano, in Italy. In a circular re- cently issued Ijy him, he asks the priests of his diocese to comply with the following rules: (1) In every church the floors must be regularly cleaned with sawdust, saturated with a strong sublimate solution. This thorough cleaning should take place particularly after holidays when great masses of people have visited the church. (2) Every week all ordinary chairs and confessional chairs must be thor- oughly cleaned with moist rags. (3) The grate of the confessional chairs must be washed every week with lye and then polished. It might he of advantage if such articles of adoration as crosses, statues, or, as in Greek churches, pictures which are often kissed by devout people, be included in the periodical disinfection. Kissing the Bible when taking an oath should be discouraged by jurists and divines. Some ministers may not feel that they have either the knowledge, the ability, or the inclination to deliver a lecture or sermon on the pre- vention of tuberculosis. In such a case they will do well occasionally to invite a physician to occupy the pulpit, as was done recently in Rochester, X. Y., to preach a dignified sermon which will arouse the I^eople to an interest in the antituberculosis crusade and help them to see their duty toward the poor consumptive who is their fellow man. Tuberculosis Exhibits, etc. — Tuberculosis exhibits are most impor- tant factors in the education of the public concerning this disease. They should be objective presentations of the history, distribution, varieties, causes, cost, prevention, and cure of tuberculosis. This means models, photographs, charts, diagrams, circulars, etc., whereby hygienic and un- hygienic methods of living, proper and improper care of consumptives, are graphically shoAvn. Besides the evening lecture, which should always be a feature of a tuberculosis exhibition, there should be a person in constant attendance, able to explain and give information to the visitors. Children from ten years upward should be given admittance to the exposition as well as adults. The accom])anying illustrations of parts 29 426 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS of the exhibits of the last International Congress ('08) (see Figs. 128 to 130) give a good idea of the apjjearance of such an exhibition. This exhibit was shown in New York. To show the composition, scope, and result of such a traveling ex- hibit, the writer may be permitted to quote from the above-mentioned report, sul)mitted l)y the secretary, Mr. Paul Kennaday : The effectiveness of the tuberculosis exhibition has been in the nature of a discovery. This has been so with others, who in many widely scat- tered parts of the country have shown the exhibition of the National Asso- ciation, and most assuredly has it been true in New York City. It seems Fig. 128. — Exhibition of International Tuberculosis Congress, 1908. (Transferred to New York.) more than probable that it is a plan of operation that has come to stay and to spread; it may, therefore, serve a useful purpose, if there is here given some detailed account of the manner in which these Committee exhibitions were handled. The Committee's Traveling Tuberculosis Exhibition is made up of 249 frames of photographs, charts, etc., 13 models, and 10 pathologic specimens, all divided into three classes, as shown more particularly by the four-page programmes which are liberally distributed at all the exhibition halls. The first division reads, " Tuberculosis is a preventable disease," and here are the principal part of the Board of Health exhibits: A large chart showing the reduction of the death-rate from tuberculosis in New York City from 4.92 in 1881 to 2.66 in 1905, a series of printed instructions for consumptives and those living with them, and diagrams and photographs illustrating generally the educational and preventive work carried on by TUBERCULOSIS EXHIBITS, ETC. 427 the department. The work of the National Consumers' League, of the City Tenement House Department, the State Factory Department, and of the Fig. 129. — Exhieitiox of International Tuberculosis Congress, 1908. Tenement House Committee and the Committee on the Prevention of Tuberculosis of the Charity Organization Society, are shown here by mod- els, photographs, diagrams, etc. Fig. 130. — Exhibition of International Tuberculosis Congress, 1908. Perhaps most striking of the exhibits in this section, if not in the whole exhibition, are the full-size models of a dark interior bedroom, dirty 428 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS and crowded with furniture, typical of the rooms in which many a poor man develops tuberculosis, and the adjoining front room with open win- dows and clean cot, spread with blankets between w^hich have been sewed newspapers as a cheap and at the same time warm covering, representing the changes wrought by visiting nurses and charity visitors. Under the second division, " Tuberculosis is a communicable disease," is a collection of nine human lungs, presenting the healthy lung, the nor- mal city lung pretty Avell spotted with dust and dirt, and lungs showing the process of healing and in A^arious stages of disease. As a part of the pathologic exhibit, and placed around these specimens of lungs, are the Board of Health signs prohibiting spitting, diagrams and photographs illustrating the methods of infection through spitting and coughing, and an exhibit of dry brooms, feather dusters, wet paper, moist sawdust, etc., illustrating the right and wrong way to sw^eep and clean. To still further enforce the practical value of this division of the exhibition, there are dis- tributed at this point simple instructions in relation to sweeping and dust- ing, printed on small cardboards in English on one side and on the reVerse side in Yiddish, Italian, German, and Bohemian. The third and last division of the exhibits is, " Tuberculosis is a curable disease," under which comes the illustration by means of photographs and models of the work of all of the city tuberculosis hospitals and special tuberculosis dispensaries. Here, in the same way, are shown models of the Sea Breeze Hosjiital for Children, of the lean-tos from Loomis Sanatorium, of the White Haven shacks, and photographs from the Adiron- dack Cottage Sanatorium, from the Boston Day Camp, and from a num- ber of other places outside of New Y'^ork City. The exhibits are all labeled, and throughout there is the attempt to make the lesson so plain that it will be readily understood by all, while lectures and demonstrations alike try to translate for the practical application of the average man \;he graphic representation of tuberculosis, preventable, communicable, and curable. With the amount of material that is shown, ease and rapidity of instal- lation is all important, and, therefore, models, picture frames, and cases are all so made that they may be handled with the least possible delay and without unnecessary labor. For the setting up of the exhibits, taking from two to three days, is but a small part of the work necessary in connection with each exhibition. After the arrangement of the definite preliminary itinerary, the substitution of other exhibition places for those which have dropped out, and perhaps the complete rearrangement of the whole sched- ule, it is time to hold a series of conferences, about a month in advance of each exhibition, when the cooperation is sought of the local physicians, settlement workers, school teachers, clergymen, and generally all those who are identified with the social work of the particular neighborhood in which the exhibition is to be held; after this, a schedule is arranged for the attendance from ten o'clock in the morning until ten o'clock in the even- ing of persons competent to explain, in turn, to small groups of people the meaning of the different exhibits and the purpose of the exhibition — phy- sicians and nurses are usually asked to do this part of the work, those TUBERCULOSIS EXHIBITS, ETC. 429 from the region in which the exhibition is to be held being called on as far as possible, each member of the group selected for demonstration for each exhibition being asked to volunteer for three periods of two hours each. The Board of Health, realizing the large possibilities of these exhibitions, ih addition to loaning much exhibition material and department wagons for moving the exhibition from place to place, regularly assigned two phy- sicians for the daily instruction of the school children, and thus the task was much lightened of obtaining volunteer instructors in sufficient number to be on hand eight and more hours a day for an almost unbroken period of five months. On the whole, the attendance at these exhibitions has been most satis- factory, running from about 3,000 in the smaller halls to 49,000 in three weeks at the Educational Alliance, a large Hebrew educational and social betterment institution in the congested lower East side of the city. In five months there has been a total attendance of over 82,000 persons. The most promising single feature of the scheme has been the intelli- gent interest shown by the children of twelve years of age and upward who, under arrangement with the Department of Education, have been sent to the exhibitions in charge of their teachers by their local principals as a regular part of their school work. For the instruction of these chil- dren the Department of Health has regularly assigned a Department Inspector, Dr. Anna C. Judkins, who in a plain, simple, and practical manner explained the exhibits to the children and answered their many questions. While speaking of tuberculosis exhibitions, it is but right to mention one of the latest features in the line of pictorial demonstrations of value in the antituberculosis crusade — the open-air lantern exhibit, Avhich originated with Dr. Oscar H. Rogers, of Yonkers. The New York Health Department made immediate use of Dr. Eogers's admirable sug- gestions. Thus, during last summer, in twenty-five of the small parks of the city, and at five recreation piers on the river fronts, there were shown, before crowds varying in numbers from several hundred to two or three thousand, a set of stereopticon slides giving in short sentences easily understood advice in relation to tuberculosis. Along with these sentences pictures were thrown on the screen which showed the wa3's in which the bacilli causing tuberculosis are transmitted by the cough and expectoration of those who have it, by dust and air filled with particles of dried sputum. They showed the effect of the disease on the lungs; how overcrowded, dirty, badly ventilated rooms and tenements cause and spi-ead il ; liow llu'se conditions are being remedied ])y new building laws; how the DepariiiKMit of Health renovates rooms infeeled with the germs of consuinplion by fumigation and the removal and dis- infection of bedding and fiiniisliings ; how it cares f-ODd Food and Re KEEP YOUR . k) • ioeU-T or t Altfvttj lUnmber ABLE diMAM ud lh« y Cotan«y ot Siege! Cooper Co.) ^^fi".^j;,;'cs. I Fig. 131. — An Effective and Inexpensive Method of Tuberculosis Propa- ganda. Free advertisements of New York Tuberculosis Committee on back of street-car transfers. Duty of Consumptives; Tuberculosis is Curable; Administrative Con- trol; The Department of Health; The Department of Public Charities; Bellevue and Allied Hospitals; The Tenement House Department; Other Administrative Activities; Dispensaries; Sanatoria and Other Private Agencies. In order that the patient may choose for his dispensary the insti- tution nearest his home, a map of the Manhattan districts, with Eoman TUBERCULOSIS CLINIC 435 letters showing ti:e locality of the dispensaries and hours when they are open, is reprodii.^ed on the last page of these circulars. A unique way of s;ireading the knowledge concerning the prevention of tuberculosis is to utjjze the back of street-car transfers (see Fisr. 131). .; Circulars of information may have to be varied to suit the locality in which they are to be distributed, and the people to whom they are to serve as guides, and the circulars and leaflets given in the Appendix are by no means expected to suit all purposes, all classes, nor all com- munities. From a circular intended for physicians only, which was recently issued by the ISTew York City Health Department on the subject of bacteriologic examination of sputum, are quoted the following conclu- sions which may prove helpful in the crusade as far as the profession is concerned : First. Incipient tuberculosis tends to recovery. Second. Advanced tuberculosis, with or without mixed infection, tends to a fatal issue. Third. In all coughs which last more than a few weeks, and which are not associated with asthma, emphysema, or cardiac disease, tubercu- losis is to be suspected as a cause. Fourth. Successful treatment and prophylaxis demand the earliest possible diagnosis. Fifth. The diagnosis of incipient pulmonary tuberculosis, properly so called, is made positive when tubercle bacilli are found in the expec- toration. Sixth. Repeated examinations of the expectoration are frequently necessary to demonstrate the presence of the tubercle bacilli in incipient cases of pulmonary tuberculosis. In order that bacteriological examinations of the sputa may be at the service of the physicians in all cases, the Health Department is prepared to make such examinations, if samples of the sputa, freshly discharged, are furnished in clean, wide-necked, tightly stoppered bottles, accom- panied by the name, age, sex, and address of the patient, duration of the disease, and the name and address of the attending physician.^ Tuberculosis Clinic. — In the larger centers of population, in fact, perliaps, in all larger communities where there are a considerable num- ber of poor or relatively poor people, the tuberculosis dispensary, or at least a special tuberculosis class in an ordinary dispensary, is one of the most important factors in the crusade against tuberculosis. > I have found Dr. Hart's improved wooden box with a dark iiniiornieable lining the most suitable for sending sputum specimens to the laboratory for examination, (See Appendix.) 434 PUBLIC MEASURES IN THE PROPHYLAXIS OF TT„^^^,.^ „„_„ 'The object and purpose of a tuberculosis clinic, as it/ , , p ,, in the first report of the Clinic for Pulmonary Disf^ ^^ ^j jjg^ith Department of the City of New York, may be set r,^j^ ^^ follows : It was early recognized that the establishme;^ ^^ ^ municipal clinic or dispensary would be of great assistance in ;^^ attainment of the fol- lowing desired objects : l.The Early Recognition and Accuv^^^ Diagnosis of Pulmonary Tuherculosis.-It is now generally admitt^'^ ^^^^ tuberculosis is frequently a curable disease, and that incipient tr^^^^^j^^.^^ ^^^^^ favorable condi- tions, tends to recovery; but to msi^^^ ^^^^ ^.^^^^^^^ ^^^^ diagnosis must be made at the earliest possible mo^^^^^ ^^^ ^^^^ ^^^^^^ ^^^^^^^ ^^^^_ ical examinations be made, togey- .,, , , , • +• ^ . ^ Aier with repeated sputum examinations, as required in connection with/, t •• i i,- 4. -u t- ■ i r + - ^1,^^ ^ -/the clinical history, but m addition, when necessary, the tuberculin test, /S ^ ■ ^- j j- „ i,„ ,,/' , , . /±loentgen-ray examinations, and radiography should be employed to assisj. . . , , ■, , ■,• ^^. ^ . 2 m arriving at an early and correct diagnosis. ■ . . Ill- ypervision of Patients under Treatment. — This , ' . -ide not only hygienic and medical treatment, but also the furnishing /j. ■ ^ j? • r ^- • • i „ „^ /T? r 1, n yof circulars of mtormation 111 various languages (English, ^erman,^^.^^.^j^^ Italian, Chinese, Ruthenian, Polish, Hun- ^ ' lAi)' containing information as to the nature of the dis- ease, and carefuj- . ^^. ,xi x- u. -u ^. ^ A instructions as to the precautions necessary to be taken ./ infection of others. Paper sputum cups, paper handker- ' proper food (milk and eggs) should be supplied to indigent . and needy, 3 ta'''^'^': ■ 'e Continued Observation of the Homes of Indigent, Needy, and . tint Cases, Including all those Discharged from the Public Insti- yns of the City. — A special staff of trained nurses should visit the ,/ients at their homes to see that the instructions given are observed, .hat the sanitary surroundings are satisfactory, and to afford such assist- y^ance as is required. Suitable cases should be referred to the various / charitable organizations for food, fuel, ice, etc. Special attention should f be paid to the children in the families of tuberculous persons, and every effort made to prevent their infection. 4. The Removal of Cases Requiring such Care to Hospitals or Sana- toria. — These cases fall under four heads : (a) Advanced or bedridden consumptives, with profuse expectoration, who will not or cannot take the necessary precautions against spreading the disease, and whose pres- ence at home is a menace to others in the family; (b) consumptives who are able to get about, but who are unable to Avork and are entirely depend- ent upon their earnings for their livelihood; (c) incipient cases, who stand a good chance of recovery if removed to sanatoria outside of the city; (d) consumptives living in lodging houses and those having no home. 5. The Provision of a Municipal Institution to lohich Cases of Tuber- culosis may be Referred. — (a) By physicians (indigent patients, etc.) ; (6) by institutions (on the discharge of consumptive patients from hos- pitals or sanatoria) ; (c) by the various charitable organizations through- TUBERCULOSIS CLINIC 435 out the city which keep tuberculous cases under observation; (d) by other persons doing individual charitable work who may come in contact with such persons; and (e) by other city departments. 6. The Extension and Strengthening of the Sanitary Control of Tuber- culosis among the Poor by the Department of Health. 7. The Care of Laryngeal Cases. — The involvement of the larynx is one of the saddest complications of pulmonary tuberculosis, and the pain, distress, and discomfort of the patients are great. While the prognosis in these cases is extremely grave, yet under proper treatment recovery takes place in some instances, and in most the distress of the patient can, in some degree at least, be relieved. Special attention should be paid to such cases in a fully equipped throat clinic. In a city like New York, where ground is expensive, it is often dif- ficult to procure the desired plot for the erection of a municipal build- ing, particularly for the purpose of treating tuberculosis. One has, then, to contend with the objection of neighbors gviided by selfish mo- tives, by phthisiophobia, fear of depreciation of value of neighboring property, etc. The ideal dispensary should be placed on elevated ground, in a locality where there is relatively little traffic, yet easy of access, and where the air is as pure as can be found M'ithin the city limits. Xot all such ideal conditions existed when the Xew York Health De- partment decided, in 1903, to establish its first municipal tuberculosis dispensary. For obvious reasons, the name " Clinic for Communica- ble Pulmonary Diseases " was de- cided on. The lot being narrow and between high structures, and all the available ground space being re- quired, windows could only ])e had on the ends. The building (Fig. 132) was therefore limited in heiglit to one story, with a cellar below, in order that each room could be lighted by a ventilating skylight. To insure further ventilation, square openings were cut high up in the walls of the various rooms, connecting them witli each other and with tlie halls, and electric fans were installed in suitable places. As will be seen in the plan (Fig. 133), the subdivisions are as fol- lows: (1) Entrance; (2) registration room in which all applicants are received, their history taken, and all records filed; (3 and 4) waiting rooms for male and female patients, each with its toilet; (5 and 6) dress- ing rooms for physicians and nurses, each containing a closet for cloths, Fig. 132. — Exterior of Tuberculo- sis Clinic of New York Health Department at 965 Sixth Avenue. 436 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS a washstand, and toilet; (7) throat clinic, with complete outfit, includ- ing compressed-air-spray apparatus, electric sterilizer for instruments, instrument cabinet, and a full stock of all necessary instruments and apparatus; (8) Eoentgen-ray room, the equipment of which consists of a twelve-inch coil, with electrolytic breaks and mi- crorheostatic control, Crooke's tubes of several patterns and sizes, fluoroscopes (15 X 18 inches), tube stands, examina- tion table, supply and appara- tus cabinet, etc.; (a dark room for the immediate development of radiographic plates is being constructed in the basement of the clinic, beneath the X-ray room) ; (9 and 10, 11 and 12) nuile and female examination and patients' dressing rooms, containing desks, stools, etc., also a pneumatic cabinet for compressed- or rarefied-air treatment; and (13) drug room, containing in enameled metal cabinets a full supply of all medicines furnished by the drug laboratory of the Department of Health. The floors are of ce- ment, and all corners and angles are rounded to prevent accumu- lation of dust and dirt; all fur- niture is enameled metal. In the basement lockers are placed for physicians' and attendants' gowns, individual stethoscopes, etc. The supplies (blanks, cir- culars, cards, etc.) of the clinic are also stored there. Large signs indicating that spitting on the sidewalk is pro- hibited are placed at the en- trance door of the clinic, and TUBERCULOSIS CLINIC 437 the following signboard (Fig. 134) in four languages greets the patient on his arrival in the waiting room : Donor spit on the floorbr in ^nythin^ except the brown pap^r " envelope furnistied for thepiOrpose. When you cough. hMitet^^ piece of musfin given to voii bj^fore your inouih.Use the rausltf^ aiso for wiping the nfiouth dlrijvose afterispitting w.^ ;:;3Tie^^t1n^. Men are forbidden to smoke or wear- i^fl^eir hats while ifl the cihic. ' :; f%-- h •'^'^5 iet i>erbotcn cwf ben ^o0tn gu sp(jcrcn:fopiirfen Gte in Ckis A braunr^Pcj^icr(£om>ert h>dcfe©ie Jbeim^Eintritl crNten ^Hhtu) ' I iSe \mm ctrr n i e sf n iKtlte n (Sie ba$1[ccisse WuslmtttclV^' »s^l30r ten57?unO 6onntr>isclbch (5ic Vi\xxi^ «uc 9Jqsc mlt tems^eJben Xutl) ab.Das Hciucbcn istter ^cr^ei^iif, '9;iannermii»»enif)i*e^utealbi;iehmea^^^^^ ; §§^^'-^^4; Hon sputate per terra nealtrovemaggltaTito nella busta color, marrorffl Che vi viene fornita a qoesto scopo! Quando tossite ten^tevi davanrffe alia bocea il pezzo dl m«s$Qlina cha vi yiene dato •espres'samenf^ri ' "''Jela stessa mussoiinaper aseiugarvj la boc(^a o il naso dppQ ' f sputafo starnutato. E proibifQ agli uomini di tenere.II CappeJIo , ;3po e di fumare quando vefenq alia clinjca, /A.iiMTC, ' iim I I III Fig. 134. — Signboard for Dispensary Waiting Room. The New York Health Department, with the aid of the Dispensary Association, has undertaken the examination for tuberculosis of all the children of parents who frequent the tuberculosis clinics. The work is still in progress, and thus far, strange to say, only a relatively small number of tuberculous children have been discovered. Another inter- esting feature which has recently been inaugurated by the Tuberculosis Committee of the Charity Organization Society of New York is the 438 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS examination of certain professions; thus, for example, every individual belonging to a certain printer's union has been examined for tubercu- losis. It must be evident that through such methods of examining thousands of children and adults, where the presence of tuberculosis may be suspected, a number of early or incipient cases will surely be discovered and a considerable number of lives saved. In view of the time and care it takes to examine individuals sus- pected of tuberculosis, and to investigate their home environments and social conditions, it is almost impossible to do justice to all the cases which apply to the dispensary in a large city. Advice and Care Stations. — To supplement the work of the dispen- sary, there have been recently established in Berlin, Germany, a number of advice and care stations for the tuberculous (" Auskunft und Fiir- sorge Stellen fiir Tuberkulose") which do excellent work, both in the medical and social combat of tuberculosis as a disease of the masses. In these advice stations patients are not treated, but only examined and advised what to do and where to go. Investigations of home environ- ments, social conditions, and the presence of other tuberculous members in the family are carefully made. A very important feature of these advice and care stations is that they examine not only adults, but children as well. Thus, for example, according to the latest report of Dr. Kayserling, the general secretary of the central committee, no less than 6,924 children, 5,689 women, and 3,033 men, a total of 15,646 persons, were examined in the five Berlin stations within one year and seven months. Dr. Arnold C. Klebs, who has visited these stations and investigated their work, says : To my mind these advice stations are of fundamental importance in the fight against the disease, provided they are similarly run to those in Berlin. They are more important than the dispensaries because they have a much wider radius of activity. In a fight against a disease which is so closely dependent on social conditions the institution Avhich exerts a widespread influence is the most important. Everything else has its use- fulness and its importance, but viewed from the standpoint of the masses and their health, I put the advice stations ahead of everything. The writer agrees with Dr. Klebs that such advice and care stations might with advantage l)e established in some of our large American cities which desire to fight the white plague according to the most modern and efficient methods. It must be evident that through such institutions, combined with the dispensary work outlined above, the proper cases for sanatorium treatment can be more easily selected, the necessary isolation of hopeless cases accomplished, centers of infection SEASIDE AND INLAND SANATORIA FOR CHILDREN 439 removed, unsuspected tuberculous cases discovered, unhygienic environ- ments improved, and, last but not least, the children of tuberculous parents protected in time from contracting the disease. The necessity for the timely care of children of tuberculous parents who may have inherited a tendency to tuberculosis or acquired it through unhygienic environments, has been demonstrated in France by the admirable work known as " L'(Euvre de preservation de Tenfance contre la tuberculose," inaugurated by tlie late Professor Grancher, of Paris. This work, as instituted in Paris, consists in the main in removing the children of poor tuberculous parents from the center of infection, either to good sanitary private homes in the country or to seaside or inland sanatoria. There is no time limit; the children may stay away until, in the opinion of the supervising physician, they are strong enough to resist tuberculous invasion. The removal of these children is, of course, always done with the consent of the parents. The first complete report of the work of the society was given out at the recent tubercu- losis congress at Paris, and showed most gratifying results. The sooner an improvement is made in the predisposed child's unh3'gienic environ- ments, the greater are the chances for ultimately conquering his pre- disposition. In placing children in country homes the greatest care must, how- ever, be exercised to see that the infants or children do not enter Avorse hygienic conditions than they had left. Experience has shown that there are families in the country who make boarding such children a profitable business by confiding their care to the invalid of the family who is not able to do anything else. It must be evident that the invalid, if he or she is tuberculous, may thus frequently become a source of infection to the little ones. Seaside and Inland Sanatoria for Tuberculous Children. — Children with tuberculous bone, joint, or scrofulous lesions seem to do best in seaside hospitals and seaside sanatoria. The statistics from European sanatoria, and of Sea Breeze Sanatorium at Coney Island, bear out this assumption (Fig. 135). However, institutions of this kind situated in mountainous regions and sometimes even in lowlands have also been productive of much good. As evidence of this may be mentioned the excellent work done by W. S. Halsted ('05), of Johns Hopkins Hospital, at Baltimore. All such institutions must, of course, have school facili- ties attached to them so that the mental development of the children may keep pace with their physical improvement. Where there are many children strongly predisposed to pulmonary tuberculosis or afflicted with the disease, special schools have been suggested. Outdoor instruction, whenever possible, should be the main feature of these schools. 440 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS Such a fresh-air school has recently been established in Providence, E. I. It was formally opened on January 27, 1908. The school is con- ducted indoors, with great swinging windows on three sides of each room, besides which an extensive system of ventilation affords an abun- FiG. 135. — Open-air Treatment of Surgical Tuberculosis at Sea Breeze Coney Island. Spine cases treated with modified Bradford frame. dance of cold, pure air, fiee from germs. The idea of establishing the school was first suggested by the Rhode Island League for the Sup- pression of Tuberculosis, which had heard of the satisfactory results obtained by schools of the kind in Europe. The pupils do not remove their outer wraps unless the weather requires closing the large windows. The teaching force of the institution has been selected largely from experienced instructors, and is under the direction of a corps of experts who have made a special study of the subject. The dispensary and the advice stations will always have to serve as a clearing house. Day Camps (Walderholungsstatten) . — As an intermediary between the dispensary and hospital sanatorium there were established in Ger- many so-called day camps (Walderholungsstiitten), situated in city parks or near-by forests. There ambulatory patients spend the greater part of the day, enjoying the open air, resting on reclining chairs or taking walks, all under careful medical supervision. Many such stations also provide good substantial lunches. In the United States the first day camp, or day sanatorium, was established CLASS METHOD AT HOME 441 near Boston on Parker Hill under the auspices of the Boston Associa- tion for the Kelief and Control of Tuberculosis. The camp furniture is of the simplest sort, consisting of reclining chairs and a few cots for such patients as may be feverisli. The patients come regularly, and are brought up the steep hill to the camp each morning, between 8 and 9.30 A.]\[., in a barge which meets them at Koxbury Crossing. Between 5 and 6 p.m. they walk slowly down the hill to the electric cars on Huntington Avenue, and return to their homes. A substantial hot dinner is served in the mess tent about noon, also a lunch on arrival in camp, and again just before leaving. New York's Ferryboat Day Camp. — In Xew York City the estab- lishment of near-by day camps on land is practically out of the question, owing to the distance the patients would have to go. The only availal^le site for such an undertaking would be far up in the Bronx, and the tire- some journey by the sul)way or elevated railroad would offset any benefit that would be derived during the period spent at the camp. The Committee on Tuberculosis of the Charity Organization Society therefore gladly accepted the offer to utilize for that purpose one of the city ferryljoats out of commission. Moored out at the end of the pier at West Sixteenth Street is the old Staten Island ferryboat South- field, New York's newest day camp for consumptives. Pronounced unseaworthy, the old boat is still doing its part in the service of the city, and its decks, once thronged with an impatient crowd going to and from their work, now afford rest, fresh air, and sunshine for those who are battling with disease. The patients sent there from the dis- pensaries by private physicians (usually from fifty to one hundred in number) pass their days there, reclining in the sunshine and being benefited by the fresh river breezes. The camp is under the supervision of a trained nurse with a suf- ficient number of assistants. The patients have the use of steamer chairs and present quite a cheerful gathering. There has been a gain in weight of nearly all the patients sent to this unique day camp. The routine day begins with the taking of temperatures and weighings. Ail the nourishing food that can be given is eaten. There is an abun- dance of fresh eggs and milk. Each patient eats from three to eight eggs a day and drinks from three to eight glasses of milk. Some of the patients bring light luncheons themselves, although bread, butter, and coffee are served on the boat at the expense of the society. Regular visits are paid by physicians who are medical members of the tubercu- losis committee. Class Method at Home. — Another way of taking care of the con- sumptive poor who must be treated at their homes is the so-called class method, which owes its origin to the zeal and devotion of Dr. Joseph 442 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS A. Pratt, of Boston. To define tlie class methods with treatment of tuberculous patients, one might say a number of patients, who for one reason or another cannot be under institutional treatment, are placed under the care of a physician or nurse or a friendly visitor, and the sanatorium treatment at home is applied throughout the year in order to obtain improvement or cure. The patients may sleep outdoors in tents on roofs or extensions, and when this is not feasible a window tent, an aerarium, a sleeping canopy, or some similar device can be installed. If these are not available the windows of bedrooms are left wide open. Patients spend the greater part of the day outdoors, at rest, or taking careful walking or respiratory exercises. Patients keep a record of their daily doings, including tem- perature, cough, etc. They meet weekly to report to their physician and for the purpose of social intercourse. They are visited daily by the nurse or friendly visitor who devotes all her time to that piirpose. Before anyone is admitted to such a class, a promise of cessation of work and implicit obedience to the rules of the class is exacted. Such classes should never be larger than from 10 to 25, for more are hard to supervise by one nurse. To relieve the feature of possible pauper- ization, a small fee or membership due should be charged to all patients able to pay. The Emanuel Church Tuberculosis Class of Boston charges for this $2 per month. Since Dr. Pratt's successful venture with this method a number of cities have installed the class system, all with grati- fying results. Special Relief Work of Tuberculosis Committee of the C. 0. S., New York. — Another matter of great importance which will help in taking care of the consumptive poor has been taken up by the Charity Organi- zation Society's Tuberculosis Committee, which under the supervision of a subcommittee on relief work helps patients to come under the observation of the society's agents. The following is taken from the society's report of 1906, referring to the work done by the committee for the year 1905-1906: That suitable cases might leave their families to enter hospitals and sanatoriums, there has been given to 15 persons relief in the form of " wage loss,'' the term used to denote the amount paid in to con- sumptive families to make up the wages lost by the consumptive through ceasing work in pursuance of advice given. Twenty-two other families have been moved into better rooms, the committee paying moving expenses and excess of the new rent, as the case might be. Rent has been paid for 36 others in their former apartments, where these rooms were suitable and where also there was a separate room for the consumptive. RELIEF WORK OF Tl^BERCULOSIS COMMITTEE OF THE C. O. S. 443 For 18 others beds have been supplied, so that the patient might have a separate bed in a separate room. Special diet, usually in the form of milk and eggs, has been pro- vided in 139 cases, where the residence of the patient was so far re- moved from a dispensary or diet-kitchen station that he was practically cut off from this needed form of treatment. Clothing has been supplied to 55 patients and sometimes to their families, and is a regular method of relief by the committee in cases going to hospitals. This form of relief will, of course, become more frequently necessary to patients exposed to the cold weather of the winter months while taking the " fresh-air cure." Through the aid of the Committee on Employment for the Handi- capped, 4 consumptives have been provided with employment of a char- acter suitable to their physical condition, such as doorkeepers, etc. Ten young girls and children were maintained in whole or in part at pay sanatoria for periods averaging one and a half to nine months. This was done because such treatment, though expensive, seemed the only method available of effectually returning these patients to wage- earning power, and the refusal to give such treatment seemed likely to lead to unavoidable physical decline along with the possibility of infec- tion to others of the patient's family. Seven patients through the instru- mentality of the committee were sent to the Xew York State Sana- torium for Incipient Tuberculosis at Ray Brook, and provided with clothing or such other assistance as was necessary. In one of these cases, of a young girl of seventeen years, whose parents were continually insisting on her working to add to the small family income, the family was prevailed upon to let her stay at the sanatorium for six months by the payment to them each week of $5, the amount the girl was earning before being taken out of work by friends who brought the case to the committee's attention. In another case the mother of five children was enabled to go to this same institution in the x\dirondacks after her children had been sent to a reliable home in the country, where their board was paid by the committee for five months. Seventy })atients were sent to the country for stays varying from one week to five months, and lasting in 33 cases for three months or more, in 25 cases for two months and a fraction, in 9 cases for one month and a fraction, in 2 cases for half a month, and in 1 case for one week. Tuberculous patients in the first stage of the disease, able and obliged to work, but who, by reason of their poverty, are forced to sleep in unsanitary and overcrowded homes, may be helped toward the cure of their disease by providing for them what might justly be called Night Camps. Here they could receive at least a good supper and a good breakfast, could be instructed in the hygiene and prevention of 444 PUBIJC MEASURES IN THE PROPHYLAXIS OF TI'BERCULOSIS tuberciilosis, and be assured of a good night's rest in a well-ventilated room, tent, or shack. Any city could arrange for such a night camp on empty lots within or in the suburbs of the town, and a great deal of good would be accomplished thereby. The special hospital should be located at not too great a distance from the city, and should receive the seemingly hopeless or more ad- vanced eases. If any of the latter should improve they can easily be sent to a sanatorium. The sanatorium stands, of course, for what its name implies — a healing institution.^ Maternity Sanatoria. — Besides the sanatorium for consumptive adults and tuberculous children, there should be in every large com- munity either a special maternity sanatorium or a special ward in an existing maternity hospital where tuberculous mothers could be received a few months previous to their confinement, and surrounded by the best hygienic and dietetic care. They should remain in the sanatorium for some time after childbirth. It is only by taking away these mothers from their unsanitary tenement homes, and placing them under con- stant medical supervision in such an institution, some time before and after their confinement, that the fearful mortality among tuberculous mothers after childbirth can be reduced. The beneficial effect on the woman's and child's constitutions that might thus be accomplished can hardly be overestimated. Leaving aside the physical well-being thus largely assured to mother and child at a period when their organisms need the most tender care, the hygienic training which the mother will have received in such an institution will be of lasting utility to herself, to the family, and to the community. These maternity sanatoria need not be situated at a great distance from the city. All that would be essential is that they should be erected on good, porous ground, preferably somewhat elevated, and in a locality where the atmosphere is as pure as possible. The buildings should be constructed in accordance with the principles of modern obstetric sci- ence and modern phthisiotherapy. The physician in charge should be experienced in both these branches of medicine. 'The vvord sanatorium is used in preference to the word "sanitarium" for the following reasons: Brehmer, the founder of the first institution of that kind, called it "Heilanstalt, " which means a healing institution; and the word "sanatorium," from the Latin sanare, to heal, gives certainly a better equivalent to the German word than the word "sanitarium." This latter word is derived from the Latin sanitas, health, and is usually employed in this country to designate a place con- sidered as especially healthy, a favorite resort for convalescent patients, or an institution for the treatment of mental or nervous diseases. The word sanatorium for institutions for the tuberculous is now almost imiversally accepted, and the United States Government has officially accepted it by calling the government institutions by that name. SOCIAL MISSION OF THE TFBERCrLOSIS SANATORIUM 445 Medical Mission of the Tuberculosis Sanatorium. — The modern and ideal sanatorium for the treatment of consumptives has a medical and a social mission. The medical mission is manifold. By the admission of a patient to an institution, a dangerous center of infection is sup- pressed and the patient is given the greatest possible chance of cure. If in the advanced stage, he is made as comfortable as lies in the power of human skill with all the modern therapeutics at command. The sanatorium teaches that phthisiophobia is as unjust as it is cruel. It shows that the careful and conscientious consumptive is as safe an indi- vidual to associate with as anybody else, and that sanatoria for con- sumptives are not a danger to the neighborhood. It cures the consump- tive whenever his case is curable, and demonstrates the curability of the disease independently of climate. It makes the patient a hygienic fac- tor when he returns to his former environments and demonstrates the preventability of tuberculous diseases. The patient will have been taught the love of fresh, pure air by day and by night, to shun a vitiated atmosphere and the air of the saloon and the crowded meeting place. He will have learned the value of simple, pure, and good food, and how much more advantageous it is for him and his children to spend his money for food than for intoxicating liquors. The sanatoria for children, some of which report as many as seventy- five per cent of cures, prevent many a strongly predisposed child from ever becoming a consumptive in later years or going through life crip- pled or deformed. Social Mission of the Tuberculosis Sanatorium. — In summarizing the social mission of the sanatorium for tuberculous patients, we behold an even greater destiny. The sanatorium teaches true democracy, compas- sion and benevolence to the aristocratic, the rich, and the indifferent. It teaches the fallacy of a belief in alcohol as a food or specific for tuberculosis, and thus combats alcoholism. It teaches the disorderly to become orderly and offers to the uneducated an opportunity for edu- cation. It teaches love for fresh air, personal and general cleanliness, and thus indirectly prevents not only tuberculosis, but many other dis- eases whose origin must be traced to lack of fresh air, to filth, and to unsanitary habitation and habits. The young medical man, entering the sanatorium as assistant, is given an opportunity to become a trained diagnostician of incipient tuberculosis, and thus he will be most helpful in the solution of the tuberculosis problem. It has been asked what shall become of the numl)er of sanatorium buildings when tul)erculosis will have so decreased as no longer to till them? This is a question tliat probal>ly will not have to be answered for some time; nevertheless, by reason of their location and construe- 446 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS tion, the sanatoria for adults will make admirable homes for the aged and infirm who now crowd the almshouses and poorhouses, and the seaside sanatoria will give to the children and overworked mothers of our crowded cities much-needed vacation homes. Duty of the Municipality toward the Family of the Consumptive. — While it is the duty of all municipalities and philanthropic institutions taking care of the consumptive poor and those of moderate means to be assured that the rest of the family do not suffer, and by privation also become victims of the disease while the breadwinner is in the sana- torium, it is of equal importance to use all possible means to prevent pauperization. A careful inquiry into the financial condition of every patient entering a people's sanatorium is as important as taking down the medical history and making the ph3^sical examination. By a visit to the home of a poor consumptive, after he has left for the sanatorium, much may he learned in the interest of all concerned. If the home is unsanitary, it should be brought to the attention of the respective authorities; if, for no fault of the family, there is want of food, fuel, or garments, they should be provided with these, and everyone who has lived with the patient now in the sanatorium should be examined to discover if there exists tuberculosis, some other disease, or a predisposi- tion to any. By attending to these matters in time the municipality will again save money and lives. All this will be owing to the direct and indirect influence of the sanatorium. Preventatorium. — A rather unique type of institution for the tu])er- culous owes its inception to Dr. Arthur J. Richer, of Montreal, Canada. Dr. Richer conducts, under the name of " Brehmer Rest," at Ste. Agathe des Monts, a charitable institution for the sole purpose of sav- ing adults predisposed to tuberculosis from developing it. The class of patients received at Brehmer Rest are those convalescent from pneu- monia, pleurisy, and typhoid fever, or such as are affected with chronic anemia, chlorosis, or who are so generally debilitated by other causes as to make them fit soil for the invasion of the tubercle bacilli. A sojourn of two or three months at Brehmer Rest usually suffices to over- come the tuberculous predisposition and to train the patient to be careful so that he may never develop the disease. It must be evident that this is a great preventive work. The writer has visited Brehmer Rest and convinced himself of the good which may be accomplished by this method of treating a pretuberculous state, if it may be so designated. He has suggested to Dr. Richer the name of " preventatorium," or preventorium, for the institution, and Dr. Richer thought favorably of it. The name Brehmer Rest hardly conveys the idea for which the institution stands, while the word preventatorium means an institution consecrated to the cause of prevention. COMPULSORY NOTIFICATION OF TUBERCULOSIS CASES 447 It would seem that the preventatorium as conceived by Dr. Eicher is perhaps as essential a weapon to combat tuberculosis in the adult, or to prevent its development, as " L'Qiuvre de preservation contre la tuberculose des enfants," called into life by the late Professor Grancher of Paris, is for the child. One saves children, the other adults, from con- tracting the disease by fortifying the system against the probable inva- sion of the tul^ercle bacillus. Works like that of Professor Grancher and that of Dr. Richer are striking at the very root of the evil, and the more preventatoriums for adults and the more " preservatoriums " for children we have, the more readily shall we master the tuberculosis problem. Agricultural and Horticultural Colonies. — Lastly, for the cured and arrested cases Ave will have to create agricultural and horticultural colo- nies, or other industries whereby the recovered pulmonary invalid may have a chance to make his cure lasting by following a healthful out- door occupation for some time before returning to his old trade or profession. While much has been done, there is more to do, and we in America are far removed from the time when we shall have too many sanatoria for adults or children. The municipal. State and Federal governments should combine with individual efforts more energetically than hereto- fore in the establishment of all institutions intended for the preservation and treatment of tuberculosis. Remuneration of Physicians in Public Tuberculosis Institutions. — There is one point, however, which the municipality must bear in mind. It has been shown, when speaking of the economic value of the cured, individual, that the municipality gains directly financially and indirectly socially. The bulk of the work in dispensaries and advice stations, in treatment of the poor at home, in special hospitals, and sanatoria, must be done by the physician. The latter must devote a great deal of his time to this cause. It is but right, reasonable, and just, therefore, that a physician devoting a number of hours daily to the patients in the dispensaries, special hospitals, and other institutions where the poor are received, should be remunerated properly. When the community is the financial gainer through the physician's work and devotion, the latter must not be the financial loser. Compulsory Notification of Tuberculosis Cases and the Work of the Health Department in Relation Thereto. — A municipality which makes registration compulsory accomplishes but one half of its work when it does not at the same time supply sanatoria and hospitals for cases which cannot be properly treated at home. But where such sufficient provision exists, compulsory notification of tuberculous cases, when tactfully in- augurated and carried out, cannot but be productive of good, and will further the interests of the general practitioner, the patient, and the 448 rUBLIC MEASURES IN THE PROPHYLAXIS OF TIBERCULOSIS community as well. A partially voluntary and partially compulsory notification of tuberculous cases was first inaugurated in New York by Dr. Hermann M. Biggs, of the Health Department, in 1893. Public institutions were required to report cases coming under their super- vision, and private physicians were requested to do so. Under this pro- vision the Department of Health carried on this work for three and a half years, and then adopted in 1897 regulations requiring the notifica- tion of all cases. The following is a card which the Health Department furnishes to the practitioner for him to utilize in notifying the department of a case of tuberculosis. It shows for itself that no interference on the part of the department is intended. REPORT OF CASE OF TUBERCULOSIS New York, 190 Name of Patient Age Sex Occupation Color Nationality Residence Care of No. families in house No. in family Previous cases in family Do you wish an Inspector to visit the premises and instruct the family regarding prophylaxis? Answer Yes or No M.D. Residence Note — Private cases of tuberculosis where tliere is a physician in attendance will NOT be visited by the Department of Health except upon request. The same tact is used in the case of a dispensary patient, and the dispensary assures the department that patients are sufficiently in- structed and supervised. The following is the card nsed for that pur- pose. Institutions which treat a number of cases of tuberculosis receive special cards for the purpose of reporting. DISPENSARY TUBERCULOSIS CARD REQUEST NOT TO VISIT New York, 190 Name of Patient Age Sex Occupation Color Nationality Residence Care of This case is under supervision at home and the Department of Health is there- fore requested NOT to send a nurse or inspector to visit the patient. Notice will be sent of any change of address, or discontinuance of attendance. (Name of Dispensary or Charitable Organization reporting case) Note — This card is simply a request not to visit, and is not a report. All cases must also be reported in tlie regular way: by special institution postal card or by the sending of a specimen of sputum. Private cases of tuberculosis where there is a i)hysician in attendance will not be visited by the Department of Health except upon request. COMPULSORY NOTIFICATION OF TIBERCULOSIS CASES 449 Dr. H. M. Biggs ("04) showed the value of compulsory notification when combined with sanitary supervision and sanatorium and hospital provisions. He says: During the last ten years there has been a decrease of forty per cent in the death-rate in children under fifteen years in pulmonary tuberculosis and tuberculous meningitis, these being the two forms of tuberculous dis- ease in which an approximately accurate diagnosis is likely to be made. It is precisely in this, the youngest element of the population, that one would first look for definite results from the enforcement of measures for the restriction of the disease. It would seem that this remarkable result certainly justifies compul- sory registration. The methods adopted by the Xew York Health De- partment have been looked on as, perhaps, the best and most efficient, and for this reason a description of the routine procedure adopted by the Health Department, as it has been tersely given by John S. Billings, Jr. ('06), is of interest: The sanitary supervision of pulmonary tuberculosis in the different boroughs of the city is carried on by means of the same staff of inspectors who administer diphtheria antitoxin. The staff of nurses is apportioned as follows: Manhattan, seven; Brooklyn, four; Bronx, one, and Richmond and Queens, one. Each nurse has a certain section of the city assigned to her. Cases of tuberculosis are reported to the Department of Health by (1) private physicians, (a) on the postal cards furnished, (b) by the for- warding of specimens of sputum for examination to the Diagnosis Labora- tory; (2) institutions (hospitals, sanatoria, dispensaries), on postal cards furnished; (3) death certificates, forwarded to the Bureau of Records; (4) complaints from lay individuals or organizations; (5) employees of this and other departments of the city. The various records, files, indices, etc., of cases of pulmonary tubercu- losis center around an alphabetical " name " index, in which the name, age, address, date, case number, and source of report of every living case are entered, together with the name of the subindex in which the record card is filed. The actual record cards are filed in different subindiees according to circumstances, as follows: 1. "Private cases" (p. c. on name card), reported by private physi- cians and not visited by inspectors or nurses. 2. " At home " (a. h. on name card) ; cases at their homes under supervision by the department (i. e., not under the care of the physician). 3. "Hospital" cases (" hosp." in the space for name of institution), reported as having entered a hospital. 4. "Not found" cases (n. f.) ; those not found at address under which reported. 30 450 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS 5. " Dead " cases (name card is destroyed). 6. " Out of town " cases (o. o. t.) ; reported as having left the city. 7. " No case " and " Recovered " (n. c.) ; found on investigation not to be cases of tuberculosis, or reported as recovered. On the receipt of report of a case, from whatever source, it is first searched for in name index. If it is a (previously unreported) case, a record case number is assigned (beginning each January 1), which is written on the original postal card or report card from Diagnosis Laboi'a- tory in red ink. If an old case (a duplicate), the old number is written in black ink. A blue " record " card is then made out, on which all essential facts are entered, and (later) every official action and recom- mendation of the department, dates of inspection and by whom, records of fumigation and renovation, forcible removal, etc., changes of address, entrance into hospital, duplicate reports, etc., are also noted on this card. The original report is then filed in " report card " index, according to date of receipt. Only postal cards and sputum report cards are so filed; all other forms of reports are transferred to a postal card before filing. This index is kept for five years. A record is kept of every case assigned to an inspector or nurse by means of a " tally " index showing exactly what cases are being investi- gated by each inspector and nurse. A small " tally " card for each case is filed under the employee's name, and is only removed on receipt from him or her of all cards, etc., relating to the case. This index is gone over once a week and any delays inquired into. Private cases are not visited except at the request of the attending physician. A letter is sent to the physician acknowledging receipt of report, calling his attention to the necessity for reporting any change of address or discontinuance of treatment on the part of the patient, and inclosing a circular of instruction, which (or its equivalent) the physi- cian is requested to give to the family of the patient or to the patient himself. A card index is kept of the names of all physicians reporting " private " cases, together with the names of cases. The large record card is then filed in the " private " case index according to patient's address. Once a year a letter is sent to the attending physician of every " private " case, asking for information as to outcome of case. If no answer is received, the case is followed up by the department. Such eases, if found (also all "private" cases reported later by institutions), come under the supervision of the department, the " p. c." on name card being stricken out. At home cases are reported by (a) dispensaries and charitable organ- izations, (h) laymen, (c) physicians, with request that they be visited, and (d) hospitals, as having been discharged. Such cases are at once assigned for investigation and report to the nurse in whose district the patient lives. The date of assignment and name of nurse are entered on blue record card, which is mailed to the nurse. If the patient is found, a pink " observation " card is filled out, giving all essential data (if not foimd, that fact is noted on record card, which is returned). Record and COMPULSORY NOTIFICATION OF TUBERCULOSIS CASES 451 observation cards are returned by mail on the day of inspection. Any recommendations (hospital, charitable aid, etc.) are indicated by writing date in proper space on record card. If case is kept under observation, a white " nurse's " card is tilled out and returned, on same being entered all records of w-eekly visits. On termination of supervision (by death, improvement, removal to hospital, removal outside nurse's district, etc.) the nurse's card is returned. Recommendations by nurse during observa- tion or on termination of case (for disinfection, forcible removal, etc.) are made on a special postal card. On receipt of record at borough office, (1) if tuberculosis case was "not found," that fact is indicated on name card and in book for recording number of " not found " cases, and card is filed in " not found " index. A letter is sent to individual who reported the case, requesting correct address. (2) If found, the record card is stamped " observation card " on left-hand margin, and filed in " at home " index. If not to be kept under observation by the nurse, the pink " ob- servation " card is filed with it ; if kept under observation, the pink card is filed in the " tally " index under nurse's name, forming record of cases under her observation. Each week a record is kept of number of cases under observation in each district. On return of white " nurse's " card, it is attached to observation card and record card, and appropriately filed. Cases needing charitable assistance are referred to the Charity Or- ganization Society, Association for Improving the Condition of the Poor, United Hebrew Charities, Brooklyn Bureau of Charities, etc., by telephone and postal card, a card index being kept of all such recom- mendations. Milk, two quarts daily for one month; eggs, three daily for two weeks, are issued in cases where such extra diet is called for as a part of treat- ment. On recommendation of the nurse an order on the nearest depot is issued, a record being kept of all recommendations. The following are the depots: Manhattan Diet Kitchen Association: Raj'mond Kitchen, 423 West Forty-first Street; Rusch Kitchen, 146 East Seventh Street; Freeman Kitchen, 335 East Twenty-first Street; Wickham Kitchen, 137 Centre Street; Gibbons Kitchen, 140 East Ninety-seventh Street; Hackley Kitchen, 26 Barrow Street; Anne Barbara Kitchen, 205 West Sixty-second Street. Brooklyn: Brooklyn Bureau of Charities. 1600 Fulton Street, 191 Marcy Aveime, 69 Sehermerhorn Street, 174 Johnson Street, 98 Sackett Street, 255 Division Avenue. Sputum cups, both pocket and home (metal framed with removal fill- ing), are issued by the nurses. Instructions are given to the patient and his family, both verbally and by means of the " Circular of Instruction to Consumptives and those Liv- ing with Them" (see Appendix), each circular being printed in English and one other language — German, Italian, Yiddish, Ruthenian, Slovak, Polish, Bohemian, and Chinese. Cases of tuberculosis attending the dispensaries of Gouverneur, Belle- 452 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCTTLOSIS vue, Presbyterian, and Harlem hospitals, and the Vanderbilt Clinic, and kept under observation by the nurses of these dispensaries, are not visited. In order to avoid duplication of visits, these dispensaries are furnished with postals to notify the department that the case is being kept under observation. These postals are filed under the name of the dispensary, forming a record. Twice a year this is compared with the records at the dispensary. All cases must also be reported in usual way, but are held two weeks awaiting receipt of special dispensary postal. If not received, patients are visited. All suitable cases are urged to enter a hospital; if consent is obtained, the recommendation is made on proper space on record card, date and name of institution preferred being given. If recommended to Riverside Hospital, the patient's name is placed on waiting list; when vacancy occurs, an admission card is made out and delivered by the district nurse, who obtains information called for on card and reports as to necessity for ambulance, coupe, etc. In emergency cases, when an ambulance is required, the hospital in whose ambulance district the patient lives is requested to remove the patient to Bellevue, whence he is transferred to the Metro- politan Hospital or to St. Vincent's Sanatorium. Ambulance districts in the Borough of Manhattan : Gouverneur Hospital^Houston to Front streets. Bowery to East River. Bellevue Hospital — Houston to Forty-second streets. Fourth Avenue to East River. Flower Hospital — Forty-second to Fifty-ninth streets. Sixth Avenue to East River. Presbyterian Hospital — Fifty-ninth to Xinety-sixth streets, Fifth Avenue to East River. Harlem Hospital — Xinety-sixth Street to Harlem River, Lenox Avenue to East River. J. Hood Wright Hospital — Eighty-sixth Street to Kingsbridge, Lenox Avenue to. Xorth River. Roosevelt Hospital — Twenty-seventh to Eightj-sixth streets. Eighth Ave- nue to North River; Forty-second Street to Sixth Avenue to Fifty- ninth Street. Xew York Hospital- — Fourteenth to Twenty-seventh streets, Fourth Ave- nue to North River; Twenty-seventh to Forty-second streets. Seventh Avenue to Park Avenue. St. Vincent's Hospital — Fourteenth Street to Canal Street, Fourth Avenue to North River. House of Relief — Catherine Street to North River, Canal Street to Battery. All requests for admission to the hospitals of the Department of Chari- ties, and also to St. Joseph's, Seton, and Lincoln hospitals, are referred to the Department of Charities by telephone, by a double card (one half being given to patient and the other being filed in borough office), and by postal card. COMPULSORY NOTIFICATION OF TUBERCULOSIS CASES 453 When the necessary precautions cannot or will not be observed, and when others (especially children) are exposed to infection, a patient may be removed to Kiverside Sanatorium by force, if necessary, even if con- sent of patient or family is not obtained. When patients continue at work and may be sources of danger to their fellow workmen, the employer is visited and notified as to the danger of infection and precautions to be taken. Placards forbidding promiscuous spitting are furnished free, to be put up in the workplace. When it is evident that premises will need renovation after removal of patient, the owner or agent is required to promptly notify the depart- ment when such removal takes place, and also as to new address. A postal card is also left by the nurse with such patients, on which any change of address is reported. All unsanitary conditions (bad drainage, leaky plumbing, etc.) are reported. If occurring in a tenement house, the complaint is referred to the Tenement House Department ; if not, to the Division of Inspectors of the Department of Health. (A tenement is any house containing three or more families.) On death, removal to a hospital, or change of address of a case " under observation," the district nurse is notified by postal to return all cards, etc. When patients are not receiving medical care they are referred to one of the tuberculosis clinics of the Department of Health, a double refer- ence card being used, one half being given to the patient, and one mailed to clinic. Every hospital must report all discharges and transfers of cases of tuberculosis. Every case returning home is at once visited to see if treat- ment is being continued, instructions observed, etc. Each morning a report is obtained by telephone from Seton, Lincoln, St. Vincent's, Metro- politan, St. Joseph's, and Riverside hospitals of (a) all patients discharged the day before and (h) of all cases to be discharged three days later. The former (a) are noted on a "discharge card" and visited at once, as many of these patients remain at home onh- a day or two. The latter (&) are noted on a " nurse's discharge " card, and each case assigned at once by telephone to the district nurse for investigation as to whether patient should be allowed to return home. She reports by telephone within twenty- four hours, her report being entered on card, which is filed, and hospital notified. Should a patient returning to unfavorable home surroundings, or giving wrong address, insist on being discharged, the patient can be transferred to Riverside Hospital. All cases reported by lay individuals and organizations and nurses are classed as "suspected" cases and are visited by the district medical in- spector, who reports results of physical examination and nature of ail- ment on observation card. The original report cards are filed separately until the case has been reported on, when person reporting ease is notified of result. If case proves to be one of tuberculosis the usual routine is followed, except that when inspector recommends that case be kept under observation, the record and observation cards are filed, and a white nurse's 454 PLBLIC MEASURES IN THE PRorilYLAXIS OF TIBERCILUSIS card tilled out and sent to district nurse. If not tuberculosis, it is classed as " no case," so recorded in name index, and filed. All complaints by citizens (as to spitting, necessity for hospital treatment, etc.) are investi- gated by a district inspector, who submits a formal report. If there is a physician in attendance, he is visited and requested to see that nuisance is abated, if one exists. All apparently incipient cases seen by nurses and inspectors, or calling at borough offices, are referred by card to a tuberculosis clinic of the department for examination as to their eligibility for sanatorium treat- ment. Very incipient eases are referred to the New York State Hospital for Incipient Tuberculosis. Suitable cases are also referred to the Stony- wold, the Loomis, and the Adirondack Sanatoria. Only in the most exceptional cases are children with tuberculosis allowed to attend school. Such cases are excluded from school by medical school inspectors, pending their examination at one of the tuberculosis clinics of the department, whence a report is sent to the Division of Con- tagious Diseases. Every effort is made to have such children enter a sanatorium or hospital. Every hospital in New York City is required to report all cases of tuberculosis within one week of their admission, using a postal card fur- nished. Each hospital and dispensary is visited once a month and their supply of the various rej^orting cards replenished. The larger hospitals (Bellevue, Metropolitan, etc.) report daily. A weekly record book is kept of the number of cases (new and duplicate) reported by each institution throughout the year. When no report is received within two weeks, in- quiry is made by telephone. The yearly totals are compared with the number of cases given in the annual report of each institution. Twice a year (March 1 and August 1) a census is taken of all cases of tuberculosis in institutions in New York City, a special blank being supplied to each institution. These censuses are compared with the " hos- pital index " — i. e., the cases supposed to be in each hospital — and all discrepancies investigated, the results for each institution being recorded. Every case reported as entering a hospital is assigned to a district in- spector, who recommends the necessary renovation, fumigation, and dis- infection of bedding, such recommendations being recorded in the proper space on the record card by means of the date. (It is also stated if patient will return to premises or not.) According to the condition of the prem- ises, the inspector may recommend: (a) That nothing need be done. This is most exceptional, only obtaining in very clean apartments and those where the patient only spent one or two nights on the premises, (h) That the room occupied by the patient be fumigated with formaldehyde, (r) That the patient's room be thoroughly renovated, the walls and ceilings washed and recalcimined, repapered or repainted, and the woodwork and floors be washed and repainted, the rest of the apartment being fumigated with formaldehyde, (d) That the whole apartment be renovated. Reno- vation of the i^remises (washing of floors and woodwork with antiseptic solution, repapering, painting, and calcimining) is recommended on a COMPULSORY NOTIFICATION OF TUBERCULOSIS CASES 455 complaint blank, which, after being approved and journalized, is for- warded to the Sanitary Superintendent for enforcement. When cancella- tion, extension of time, or modification of order is asked for, the case is reinspected by the original inspector. When there is reason to believe that renovation will be evaded, or where the premises are vacated by the death or removal of the patient and renovation has been ordered, the inspector orders the premises placarded. A paster is then filled out at the borough office, journalized, and forwarded to the Division of Inspec- tions to be put up. When owner or agent voluntarily performs renova- tion, that fact is reported, a yearly record being kept of the number of such voluntary renovations. Fumigation with formaldehyde and disin- fection of bedding is ordered on a card, on which number and size of room, date fumigation is to be performed, etc., are noted. All fumigation orders for the day are entered by inspector on a slip, which is forwarded with the fumigation cards to the Division of Contagious Diseases. In an emergency the fumigation order can be telephoned, but the card is also submitted. All bedding is fumigated before it is removed for disin- fection, for the protection of the department employees, and is returned in twenty-four hours. The tally card of the case is filed separately as a check on fumigation. The fumigation card is returned by Division of Contagious Diseases after its recommendations have been complied with, and the tally card is destroyed and fumigation card is filed according to date, being kept about four months. On receipt of record card from inspector it is filed in " hospital index " alphabetically, according to name of hospital, which is written on a small name card. In cases reported as having moved to a new address or hav- ing left the city, the same routine procedure is followed out. In cases liv- ing in private houses disinfection can be done under the supervision of the attending physician, but he must submit a certificate. Lodging houses are not disinfected, that being the duty of the managers of such houses. When an inspector or nurse reports that no record can be found of a case at the address given, a letter is written to the person reporting the case, requesting the correct address. If this cannot be found the name card is marked " n. f." and the record card filed in the annual " not found " index. These files are kept three years, when the record cards are destroyed and the name cards removed from the name index and filed in an " old not found name index." A daily record is kept of the number of " not found " cases reported. All deaths from tuberculosis occurring during the preceding twenty- four hours are reported daily by the Bureau of Records. The record and name cards are stamju'd " Dc;)d," and the former assigned to inspectors to order the necessary fumigation, etc.. the latter being used as a tally card, and all cards of the case filed in "dead" index for the current year, which is kept for two years before being destroyed. Every previously unreported dead case receives a special serial case number, and a letter is written to the attending physician or institution calling his attention 456 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS to the violation of the Sanitary Code and requesting an explanation. Should no answer be received, a second letter, signed by the secretary of the department, is sent, demanding an explanation on pain of prose- cution. A record is kept under each physician's name of all such unre- ported cases, nature of explanation, etc. (unreported cases of typhoid fever, cerebrospinal meningitis, etc., are recorded in the same index). All deaths from pneumonia are daily compared with tuberculosis records. If case had been previously reported during life as tuberculosis, an in- spector visits the physician who signed the death certificate and obtains an explanation of the apparent discrepancy, submitting a report on special blank. The same is done for all cases of tuberculosis reported as having died from some other cause. The Bureau of Records is also notified of any change of diagnosis and death certificate corrected. Every new case of tuberculosis reported in Manhattan is plotted on a large map of the borough, which shows each house (" not found " cases, of course, excepted). The address is written on a small white card (of private cases, on receipt of postal or sputvim report; of all others, on receipt of inspector's or nurse's report stating that patient did live at address given). In Richmond and Queens the cases are plotted on compo- board map by means of colored pins. All cases are admitted here through the Division of Communicable Diseases, the names and addresses of applicants being placed upon the wait- ing list. When a vacancy occurs an admission card is filled out for the first eligible case. (" Forcible removal " cases alone take precedence.) This is assigned to a nurse for delivery, who obtains data called for on card and leaves same with patient. If coupe or ambulance is necessary, the borough hospital is requested to remove the patient. All patients must reach Reception Hospital, at East Sixteenth Street, Manhattan, by 1 P.M., as the boat leaves at that hour. Walking cases may cross at East 132d Street, whence a boat leaves every hour between 9 a.m. and 5 p.m. No patient is allowed out on pass or is discharged until the conditions at his home have been investigated and found satisfactory. A daily report of cases, deaths, discharges, and admissions is received by telephone each day and added to daily report to Sanitary Superintendent. Every case admitted, discharged, or dead is reported daily on a special card, which is filed according to date. All inspectors and nurses bear in mind that the Department of Health pledges itself not to interfere in any way with cases of pulmonary tuber- culosis under the care of a private physician, except where a complaint is made. Even then the attending physician, if there is one, is first vis- ited. The source of complaint is never divulged. The Inspector-in-Charge examines daily all cards, reports, etc.. for- warded by inspectors and nurses, sees that the various recommendations are carried out, and various records, map cards, etc., are kept. When cards are incorrectly or incompletely filled out the district inspector or nurse is summoned to the borough office. COMPULSORY NOTIFICATION OF TUBERCULOSIS CASES 457 All cases reported as living in other boroughs are reported daily to the office of the borough in which they live. When a patient moves to another borough all cards and records of the case are forwarded to the office of that borough. Inspectors report at the borough office every Monday at 9.30 a.m., bringing with them all cards, etc., in their possession, to be compared with tally index. All inspections are made within three days. Special assignments (forcible removals, diagnoses of suspected cases, •etc.) are attended to immediately. Every enti'y on back of blue record card is dated. An observation card is made out for every case seen, whether tubercular or not, and the result of physical examination written in space " present condition." In ordering fumigation the date on which it is to be done is always given on the card. Unless the premises are in very bad condition it is usually sufficient to renovate the room occupied by the patient and to fumigate the rest of the apartment. Where the entire premises are prob- ably infected, renovation should be complete. In cases where the premises are in very good condition, fumigation of the room occupied by the patient may be all that is necessary. Great care and accuracy are necessary in recommending the kind and amount of renovation necessary, both for the sake of justice to the owner and because an error means a reinspection, probably rescindment of the order for renovation, and the submitting of a new complaint. The floor and position of the premises are always noted on the blue card, complaint, fumigation card, etc. The full name of the owner or agent is given in complaint; if it cannot be obtained, the fact is stated. All cards and reports, without exception, are mailed on the day the inspection is made. The regular blank is used for all reports. To explain the word " forcible removal " it must be said that the Department of Health, having police powers, can remove a patient to tlie Riverside Sanatorium by force, if necessary, even if his consent or tliat of his family is not ol)tained, when in tlie opinion of the authorities the necessary precautions cannot or will not be observed, or when others, especially cliildren, are exposed through him to tuberculosis. It may be interesting to know something of the ultimate behavior of patients under such enforced removal. The writer has been tlie senior attending physician ever since the institution was opened live years ago, and vouclies for the fact that in nearly every instance the patient, hav- ing usually l)een removed from a dark, dreary, overcrowded tenement, from an unclean room and bed, where very often he had insufficient nourishment, into a clean bed in a briglit, cheery, airy, and well- ventilated ward of the Riverside institution, where he receives plenty of good I'ood and considerate treatment, was glad to remain. 31 458 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS In l)nt two instances was dissatisfaction sho'ivn or an attempt made to escape. Compulsory Registration in the United States Considered by a Lay- man. — The compulsory reporting and registration of tuberculous cases in the United States has been made the subject of a careful study by Mr. William H. Baldwin ('06), of Washington, D. C, a layman, but deeply interested in the problem, and a director of the National Asso- ciation for the Study and Prevention of Tuberculosis. From his admir- able article on this subject (New Yorl- Medical Journal of December 8, 1906) are reproduced tables giving the jjresent status of compulsory registration of tuberculosis in the United States and some of Mr. Bald- win's personal comments : Since tuberculosis is known to be an infectious and communicable dis- ease, it might be expected that the first step to be taken toward controlling it would be to require each case to be promptly reported to the proper authorities, as is done with other communicable diseases; but when this course was first proposed it met with many objections, due partly to the lack of knowledge among the public as to the nature of the disease and partly to the fact that it differs in some important respects from other communicable diseases. These objections came mostly from physicians, who are naturally con- servative, and who opposed such reports on the ground that they inter- fered with the confidential relations of patient and physician; that they would be made public, and so cause patients to leave physicians who made such reports and go to those who refused to make them; but such patients would be injured in various Avays by allowing others to know they had tuberculosis, and that a stigma would also be placed on the family in which the disease existed. Experience where such reports are made has shown that these objec- tions are not well founded; and in order to bring this experience up to the present time an inquiry was made in the last part of 1905 and the first part of 190G as to such reports in all cities of the United States hav- ing, according to the census bureau, a population of 48,000 or more in 1903, of which there are eighty-six. The health department or board of health in each city was asked, among other things: Whether the city had any ordinance or regulation requii-ing the report and registration of all eases of tuberculosis; whether or not such reports were kept private when made; whether any difficulty was experienced in keeping them private; whether there was now any serious objection on the part of physicians to making such reports. Eeplies received show that such reports are required in 53 cities out of the 86, of which 14 require reports of all forms, 16 of pulmonai-y only, and 23 did not state whether reports of other forms than pulmonary were required or not. (See Tables 1 and 2.) COMPULSORY REGISTRATION IN THE UNITED STATES 459 Table 1. — Cities hiiving Compulsory Law for Reports and Registration of Cases oj Tuberculosis, ivilh Population and Date of the Passage of Such Law in Chrono- logical Order. t'lTV. New York Camden, N. J Cincinnati, Ohi.) Elizabeth, N. J Boston, Mass Buffalo, N. Y Rochester, N. Y Trenton, N. J Bridgeport, Conn Lowell. Mass Worcester, Mass Louisville, Ky Atlanta, Ga Oakland, Cal Providence, R. I Hartford, Conn Cambridge, Mass Omaha, Neb San Francisco. Cal ... . Los Angeles, Cal Memphis, Tenn St. Paul, Minn Minneapolis, Minn Reading, Pa Somerville. Mass *Des Moines, la Springfield, Mass Cleveland, Ohio Youngstown, Ohio. . . . Yonkers, N. Y Paterson, N. J *Salt Lake City, I'tah. Grand Rapids, Mich . . . St. Louis, Mo ♦Baltimore, Md fPhiladelphia. Pa. . . New Haven, Conn. . . . fMilwaukee. Wis Fall River, Mass Waterl:)ury, Conn tPittsburg, Pa New Bedford, Mass. . . Columbus, Ohio Erie, Pa Chicago, III Lawrence, Mass Peoria, III Detroit, Mich Holyoke. Mass Seattle, Wash Wilkesbarre, Pa Troy, N. Y Indianapolis, Ind Population, Census 1900. ,437,202 75,935 325,902 52,130 560,892 352,387 162,608 73,307 70.996 94,969 118,421 204,731 89.872 66,960 175,597 79.850 91,886 102,555 342,782 102,479 102,320 163,065 202,718 78,961 61,643 62,1.39 62,059 381,768 44,885 47,931 105,171 53,531 87,565 575,238 508,957 ,293,697 108,027 285,315 104.863 45,859 321,616 62,442 125,560 52,733 ,698,575 62,559 56,100 285,704 45,712 80,671 51,721 60,651 169,164 Date of Law. January 18. 1897. December 27, 1897. August 19, 1898. March 6, 1.S99. May 1. 1900. 1900. 1900. January 8. 1901. April 23. 1902. September, 1902. October 8, 1902. October, 1902. October, 1902. 1902. Januarv 15. 1903. March 4, 1903. March 11, 1903. June 30, 1903. October 27. 1903. October, 1903. 1903. January, 1904. August 26, 1904. September 1. 1904. October 6. 1904. October 28. 1904. November 1, 1904. February 3, 1905. February 6, 1905. February, 1905. March 3, 1905. March 9. 1905. March. 1905. April 7. 1905. April 8. 1905. April 27, 1905. April, 1905. May 15. 1905. June 13, 1905. September 5. 1905. September 10, 1905. November 8, 1905. 1905. January 1, 1906. January 1, 1906. February 19. 1906. February 20, 1906. * State law. f Slate law; enforcement in this cily began at about this time. 460 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS Table 2. — Cities which do not have Compulsory Report Laws for Reports of Cases of Tuberculosis City. Population, Census 1900. City. Population, Census 1900. New Orleans, La 287,104 Lynn, Mass 68,513 Washington, D. C 278,718 Savannah, Ga '. 54,244 Newark, N.J 246,070 Jersey City, N.J 206.433 Hoboken, N. J Evansville, Ind 59,364 59,007 56,987 56,383 51,418 53,321 52,969 Kansas City, Mo Denver, Colo Toledo, Ohio Allegheny, Pa Syracuse, N. Y St. Joseph, Mo Scran ton. Pa Portland, Ore Albany, N. Y Dayton, Ohio Richmond, Va Nashville, Tenn Wilmington, Del 163,752 133.859 131,822 129,896 108,374 102,979 102,026 90,426 94,151 85,333 85.050 80,865 76,508 Manchester, N. II Utica,.N. Y Kansas City, Kan San Antonio, Te\ Duluth, Minn Charleston, S. C Norfolk, Va Harrisburg, Pa Portland, Me Houston, Tex 55,807 46.624 50,167 50,145 44,633 Schenectady, N. Y Fort Wayne, Ind 31,682 45,115 In six cases the date when the law was passed was not given, but in the others it took effect as follows : Year. Cities. Year. Cities. 1897 1898 2 1 1 3 1 1902 1903 6 7 1899 1904 1905 Three months of 1906 6 1900 1901 17 3 This shows a decided awakening to the necessity of such reports. The total population of these eighty-six cities by the census of 1900 was 17,270,126, nearly one quarter of the population of the United States. The fifty-three which require reports had a population of 14,030,381, or 81.2 per cent, while those not yet having such a law contained 3,239,745, or 18.8 per cent. In the large cities this proportion is still greater, for of the twenty largest cities, sixteen, containing 10,953,081, or 91.5 per cent, have such a law, and four, with 1,018,325, or 8.5 per cent, do not; so that consider- ably less than one tenth of the population in the twenty largest cities do not have this regulation, and such reports are required in all the thirteen largest. As to privacy, nine cities do not state whether the reports are kept private or not, two say that no one has asked to see them, seven that the reports are kept private, and thirty-one that they are " kept private with- out difficulty " ; while in only three — Seattle, Des Moines, and Wilkes- barre — it is stated that the reports are open to the public. This furnishes COMPULSORY REGISTRATION IN THE UNITED STATES 461 conclusive proof that such reports can be kept private, as they should be, and that the objection of harm to the patient or his family by reason of publicity from such a report is without force. The information as to the attitude of the medical profession in the different cities is a little more difficult to classify, as circumstances vary, and, as the dates given show, the laws in twenty cities have been in exist- ence but a year or less, and in some were apparently not yet vigorously enforced; but the substance of the replies was as follows: Cities in which there is no objection, or practically none 34 Cities in which there is little objection 11 Cities in which physicians object 5 Cities which do not state 3 Total 53 One of the cities objecting is Detroit, Mich., where an attempt to enforce the penalty resulted in a lawsuit, which was carried to the Su- preme Court of the State and was not decided at last accounts. Pend- ing this no attempt is made to enforce the ordinance, which still stands. It is apparent, however, that opposition is decreasing with the increase of knowledge on the subject, and in New York City, where the law has had the longest and most thorough trial, it is said that there is now " no objection whatever." The records show that in more than ninety per cent of all deaths from tuberculosis in that city the case has been previously reported to the health department. In many of the cities it is difficult to determine from the replies just what proportion of all cases is reported. Some cities are evidently lax in the enforcement of the law, but the greater number make an honest effort to secure reports of all cases, and one declares that, so far as is known, they get them all. The results indicate an increasing efficiency on the part of the authorities commensurate with the growing interest in the subject. The laws differ somewhat as to the action to be taken by the health authorities when a case is reported, but many of them follow very closely the course of procedure in New York City. In case the attending physi- cian requests that no action be taken, nothing is done except to record the case, as it is not intended to interfere in the relations of physician and patient where the physician assumes the responsibility. If, however, the case is in a tenement house where close contact endangers other peo- ple, or if the physician does not request that nothing be done, the health department inspects the place and takes pains to see that proper sanitary rules are observed, and that the patient and others are informed as to what precautions are to be taken to prevent infection. If the patient is unable of himself to secure proper food or proper nursing, measures are taken to provide the necessary care and nourishment. A report of the removal of any patient to another dwelling is required, and upon such removal, or upon the death of the patient, disinfection of the premises is insisted on. 462 PUBLIC MEASl'RES IN THE PROPHYLAXIS OF TUBERCULOSIS Enforced in this manner, with due regard to the relation of the physi- cian who assumes the responsibility in all private cases, but supplement- ing and making up for any lack of medical attention or any carelessness where others are endangered, it has been found that there is no reasonable objection to such a regulation. Dr. Hermann M. Biggs, who for years has been the chief medical officer of the Department of Health of Kew York City, says: " The notification of a case of tuberculosis does not require any action on the part of the authorities, if it seems reasonable to assume that such action is- unnecessary. The very fact that tuberculosis is notified by the attending physician as a communicable disease has the greatest educa- tional value, and justifies the assumption in those instances in which the case is under the supervision of a private physician that reasonable and necessaiy precautions for the protection of others will be taken. "... Experience has shown that the obstacles are largely imaginary; that the harmful results which were predicted as certain to follow have failed to materialize." — Medical News, Februarj^ 20, 1904. It is because of this extended experience in ICew York City, which is confirmed by that of other cities which have since adopted similar laws, that the sentiment in favor of such regulations in the cities of the United States is growing so rapidly. In this inquiry but two instances were found in which any hard- ship had been suffered by the patient on account of lack of judgment on the part of inspectors of the health department, but in order to I^revent this it is important that the law be worded properly. From a study of all laws obtained from the different cities, Mr. Baldwin sug- gests a hill which should be suljmitted for tlie passage in sucli State legislatures which have not yet any provision for compulsory notification of tuberculosis cases. (This bill is reproduced in the Appendix, p. 811, as it may serve as a guide to physicians desiring to promulgate such a law in their respective States.) Mr. Baldwin concluded his very instructive article with the follow- ing significant phrase : From all this it will be seen that the growing knowledge of the nature of tuberculosis, and the increasing interest taken in the subject, are hav- ing their influence in adding to the number of cities requiring compulsory reports and registration of all cases of tuberculosis, and that the wisdom of what is logically the first step to be taken in the control of the disease is confirmed by experience, where it has been attempted in the proper manner. All communications referring to a patient's disease, in which his name and address are given, should be made in closed letters and never sent by postal card. A number of health boards use postal cards giving CARE OF TrBERClLOrS INSANE 463 full name and address and stating whether a small or large nuinl)er or no bacilli have been found. In small communities, as well as in large ones, such open communications may prove disastrous to the unfor- tunate patient concerning whom the report has been made. Care of Tuberculous Federal Employees. — The care of the tuber- culous must, of course, also include the tuberculous individuals in the army and navy, and other tul^erculous government employees, inmates of prisons, reformatories, insane asylums, etc. The tuberculous sailors of the United States Marine Hospital Service are taken care of at Fort Stanton, N. M., the tuberculous men of the United States Navy are sent to the United States Naval Hospital at New Fort Lyon, Col., and the tuberculous soldiers are cared for at Fort Bayard, X. M., now trans- formed into a sanatorium. To assure a timely diagnosis in the cases of our sailors and soldiers the writer would suggest a periodical examination, at least every six months, of the chest of every soldier and sailor. Only by such methods will it be possible to weed out from the barracks or the war ships the tuberculous individuals and give them the best possible chance for an early recovery. President Eoosevelt issued the first executive order with a view to preventing the spread of tuberculosis among the employees of the Gov- ernment (especially of post offices) in February, 1906. The recent discovery of tive cases of tuberculosis among the employees of the Insular Bureau of the War Department in the State, War, and Navy Building, seems to indicate the necessity of such periodic examina- tions of all government employees, in order that these patients may be treated at the right time and in the right place and before it is too late. Care of Tuberculous Insane. — Dr. A. E. McDonald, Director of the Manhattan State Hospital for the Insane for the Directory of Institu- tions and Societies Dealing with Tuberculosis in the United States, says, in part: It is not proposed to follow here in detail the history of tbe oamp for tuberculous patients. Neither the purpose of this communication nor the limitation as to space will permit of it, and the reader who may desire further information in that direction must be referred to the annual printed reports of the hospital and to special articles by members of the hospital staff which have, from time to time, appeared in the Journal of Insanity and other professional publications. It must suffice to sum- marize results. The isolation of the tuberculous patients has reduced to a minimum the danger of infection of other patients and of employees. The patients themselves have suffered no injury or hardship, but have, on the contrary, been unmistakably benefited. This is shown, among other 464 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS ways, by the decrease in the death-rate from pulmonary tuberculosis, both absolute and relative, and bj' a marked general increase in bodily weight, amounting in the case of one patient to an actual doubling of weight — from 83 to 166 pounds — in fourteen months of camp residence. Mental improvement has, as a general rule, been the concomitant of the physical, not only among the patients in the Tuberculosis Camp, but also in the others, and in the former class this has been somewhat of an anomaly. My experience, and I think that of others, has been that when phthisis and insanity coexist they are apt to alternate as to the promi- nence of their several manifestations — the mental symptoms being more pronounced while the physical are in abeyance, and vice versa. Under the tent treatment we have found a general disposition toward accord in the manifestations, improvement in both respects proceeding concurrently, and some of the discharges from the hospitals which gave most satisfac- tion to us at the time, and most assurance for the patient's future, were of inmates of the Tuberculosis Camp. The mental improvement, even in cases where recovery was not to be looked for, has been a gratifying feature of the camp experiment, and depending largely, as it has, upon the patient's satisfaction with his new surroundings, has served to dispel one of the doubts with which the ex- periment was undertaken. It was apprehended that not only might the patients themselves resent their transfer, but that similar objection might come from their relatives and friends, since innovations, even progressive ones, are apt to be frowned upon by those who constitute the majority of the clientele of a public hospital in a cosmopolitan city. Even at the outset, however, the protests, whether from patients or their friends, were surprisingly few, and latterly they have been more apt to arise, if at all, over the patient's return to the buildings when that becomes necessary. As an interesting incidental fact it may be mentioned that not only the patients, but also the nurses, living in the camp have enjoyed almost complete immunity from other pulmonary diseases. Not a single case of pneumonia has developed in the camp in its existence of over three years, though it caused 131 deaths in the hospital proper in that time. The " common colds " so frequent among their fellows living upon the wards, or in the Attendants' Home, have been unknown among the tent dwellers. The popular idea that the consumptive is a doomed man unless he can at once abandon home and family and business, and betake himself to some remote region, would seem to be negatived by our Ward's Island experience. So also with the strenuous claims for high altitude. The Ward's Island Camp is but a few feet above the tidewater level, its side is swept in winter by winds of high velocity coming over the ice-bound waters of the rivers and the Sound Avhich surround it, and it suffers as much as, or more than, any other part of the city of New York from the trying changes of temperature and humidity which are so characteristic of its climate. If, in spite of all these drawbacks, what has been done can be done, and that for insane patients, what may not be hoped from the extension of the same methods to the ordinary consumptive of sound TUBERCULOSIS IN PRISONS AND REFORMATORIES 465 mind, anxious for recovery and capable of giving intelligent assistance in the struggle? Care of the Tuberculous in Almshouses, Asylums, and Boarding Schools. — Asylums for the aged and crippled, poorhouses, orphan asy- lums, and hoarding schools are very often the seat of numerous early cases of tuberculosis, which, because of a belated diagnosis, finally be- come centers of infection. In all such institutions sanitary supervision as to proper ventilation and periodical examination of the inmates' chests will be the only means to do away with this danger. Tuberculosis in Prisons and Reformatories. — Tuberculosis in prisons and reformatories is a suljject of vital importance in a crusade against this disease. It was the writer's privilege last year, on invitation of the physicians of the National Prison Congress, to address that gathering on the subject of " The Tuberculosis Problem in Prisons and Reforma- tories." It would seem, thus, that the medical men in charge of these institutions are fully aware of the importance of the subject. Yet only a few States have made an effort to separate the tuberculous prisoners from the nontuberculous, and fewer yet have undertaken systematically to treat them. It is hoped that State governments will soon act on the suggestions of the prison physicians, who are almost unanimous as to the necessity of segregating and treating the tuberculous inmates in prisons. In the address above referred to (Knopf, 'Ofi) a plea was made not only for the examination of every prisoner committed to a penal insti- tution at the time of his entrance, and periodically afterwards, but also for examination of individuals in detention prisons. As far as could be learned from visits to detention prisons in New York and other States, prisoners who are simply held for trial or are awaiting removal to the penitentiary, are never examined by any physician unless they are quite ill and in actual need of medical attention, or obviously af- flicted with consumption. It must be evident that in this way a latent tuberculosis has a chance to develop, for even in the better city prisons the usual overcrowding will render the atmosphere vitiated, particularly in winter. Add to this the lack of exercise and the depressing psychical influence of confinement, nostalgia, and worry, one cannot wonder that prisoners arriving, after sentence, at a penal institution are often found to be tuberculous, some even with very active lesions, while they may have entered the prison of detention seemingly in good health. Again, some may have been a little below par, underfed or weakened by expo- sure, and as a result have contracted tuberculosis from consumptive fellow prisoners while in jail. This is not said in disparagement of the heroic attempts made by most of the wardens and physicians to render modern detention prisons 466 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS as sanitary as possible. A good example is the well-kept and modernly built principal prison of New York, The Tombs, situated on Center Street, between Leonard and Franklin Streets. But even here one strongly predisposed or already slightly atBicted with pulmonary tuber- culosis has a good chance to develop the disease to its full extent. It is impossible, with 400 prisoners comprising the ever-changing prison population of the Tombs, that one single physician could examine all prisoners carefully enough to detect the presence of an incipient tuber- culosis. Prisoners awaiting trial stay in the Tombs sometimes six months and longer. They are not occupied with anything. They are allowed to exercise in the open air only once a week and for a])out an hour and a half. It is well known that many detention prisons are not as hygienically built as this one, and that there exist additional depress- ing factors in many of them well calculated to further tuberculous diseases. What can be done to strike at the root of this deficiency in dealing with the tuberculosis problem in prisons? A competent staff of expert diagnosticians should he attached to every detention prison to examine each prisoner for tuberculosis, syphilis, or other infectious diseases. The seeming increase of expense which would thus arise to the community will in the end result in a financial and sanitary benefit to the com- munity at large. Nor is there any reason wiiy the prisoner who has means should not be taxed to defray the expense for a measure from which he himself derives the greatest benefit. If he is himself unknow- ingly afilictcd with tuberculosis, the early recognition may mean to him the saving of his life. If the disease is recognized in one of his fellow prisoners he is protected from contracting it. If prisoners did have to remain in detention prisons only three or four weeks, the enforced idleness with one hour and a half open-air exercise weekly miglit not be very injurious; but when tlieir time of staying in the detention prison is longer than that, a physical, mental, and moral deterioration is almost inevitable. It is at the very beginning of incarceration and enforced idleness that these factors produce the most depressing effects, and if there is any predisposition to tuberculosis it is sure to develop it. Whenever practicable, even detention prisoners should be occupied with something useful and health-sustaining. Lastly, there should be some arrangement in the detention prison to give the prisoner a sufficient amount of exercise in the open prison court to assure his physical well-being — not weekly, but daily. It would thus seem that the first step toward the prevention of tuberculosis in penal institutions should be a most careful examina- tion of such individuals, and the weeding out and isolating of all tuber- TUBERCULOSIS IN PRISONS AND REFORMATORIES 467 culous prisoners detained in jails. The tuberculous patient should remain isolated in the detention prison as well as in the penal institu- tion, and he should bo given the benefit of hygienic and dietetic treat- ment from the first moment he becomes a ward of the State or city. When the time for his transfer comes, the history card of his disease and the recommendation of the physician should be transmitted Avith the other papers of the prisoner to the penal institution. After his arrival at the prison, in which he is to stay for some length of time, the physician will decide whether he is al)le to work or not, and wliat kind of work might be most conducive to his recovery. There is no gainsaying that the ideal occupation for the tuberculous prisoner is agri- cultural or garden work. In a previous communication on prison hygiene as far as it apper- tains to the prevention of tuberculosis, the writer stated that not only should there be a careful examination of every prisoner for tuberculosis when he enters the prison of detention or the penal institution, but his chest should be reexamined periodical!}^, at least once every three months. With this periodic examination a very incipient case, which might have escaped detection during the " entrance " examination, is sure to be discovered before the disease has progressed to any considerable extent. Expectorating, except in proper receptacles placed for that purpose in cells, workshops, chapels, schools, and on the grounds, should be punished by severe disciplinary measures. That there may never be an excuse for violating this rule, there should be provided not only a sufficient number of fixed, elevated, suspended, simple, or self-flushing cuspidors as, or similar to, the ones illustrated in the Appendix, but each prisoner should carry some sort of a pocket flask or receptacle made of metal, glass, or pasteboard, similar to those used in sanatoria for consumptives. A prison is, perhaps, the only place in the world where spitting regulations can be rigorously enforced, and it is but fair that, if we say to an individual, " Don't spit here and don't spit there," we should give him a chance to spit somewhere when he has an excess of saliva, a cold, etc. With such a measure not only would tuberculosis diminish in prisons, but epidemics of pneumonia and grip would be less to bo feared and more easily controlled. It might be recommended as a regu- lation that every prisoner must hold his hand before his mouth when coughing, whether this coughing spell is followed by expectoration or not. Thus drop-infection — that is to say, the expulsion of bacilli with droplets of saliva — will l)e avoided, and since the pneumococcus is so very prevalent, even in the mouths of healthy individuals, this precau- tion may perhaps also tend to the diminution of pneumonia. As an additional measure to prevent drop-infection, it might be well never to 468 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS put prisoners too close together at the work tables. Whenever prac- ticable, there should be a distance of three feet between them. It has been demonstrated that at that distance the droplets expelled during coughing fall to the ground. It goes without saying that the personal and l)ed linen of the tuber- culous prisoner as well as his clothing should be subjected to disinfec- tion regularly. The handkerchiefs of this class of prisoners should con- sist of squares of cheap muslin, which should be burned after use. To judge from the appearance of the various kinds of blankets, comforters, and quilts which were lying on the cots in the prisoners' cells in some of tlie penitentiaries visited by the writer, it seemed that these coverings might become the means of spreading infection, not only of tuberculosis, but of a good many other communicable and contagious diseases. The blankets and comforters are, as a rule, the private prop- erty of the prison inmate. He brings these articles with him, or they are given to him by visiting friends, or by fellow prisoners who have been discharged. In most prisons these coverings, as well as the cloth- ing which the prisoner wears on entering the penal institution, are carefully disinfected. The precaution does not, however, suffice to pre- vent the bed covering from becoming thoroughly infected afterwards, particularly with the germs of tuberculosis. Pulmonary tuberculosis is so insidious in the early stages that the prisoner may have infected his bedclothing long before his disease was discovered by the ])rison physician, unless, of course, frequent and thorough examinations of all prisoners are in vogue. To guard against infection which may arise from blankets, com- forters, etc., having been soiled by tuberculous sputum or other infec- tious material, the writer would suggest that after thoroughly disin- fecting these articles when they are brougbt to tlie j^jrison, they be incased in a covering of light-colored washable material (not neces- sarily white), as one uses a pillow case. By basting the blanket in its " blanket case " it can be manipulated with as much ease as if uncovered. With comforters and quilts the same method should be pursued. There should be two sets of cases, so that the blankets need not remain un- covered while one case is being washed; thus the blankets need never come in direct contact with the prisoner's body. With such a system, and with the injunction that this washing must be done regularly, one factor of transmitting tuberculosis and other infections from prisoner to prisoner will be done away with. Even the prisoner who is only suspected of having tuberculosis should have a separate cell, and, as far as possible, the placing of two prisoners in one cell should be avoided. The bucket system for receiving the dejecta of prisoners during the a ^^ TUBERCl^LOSIS IN PRISONS AND REFORMATORIES 469 night and during the day when confined to their cells, is most deplor- able. It is unsanitary in general, and as far as it permits the emana- tion of odors and gases it is deleterious to the health of the inmate. The individual cell water-closet, with a perfect trap and cover, such as is used, for example, in the New York Tombs and other new prisons, is certainly to be recommended in place of the bucket system. The more advanced cases of tuberculosis, particularl}^ those with constant fever and in whom there is disintegration and corresponding abundant expectoration of bacilli, should be treated in special wards, and in summer, perhaps, in special tents of the prison hospital. In view of the probable indiflFerence to hygienic regulations of the inmates of the hospital, and for the purpose of preventing drop-infec- tion, all patients in the more advanced stages must wear a mouth mask. Patients in a number of European hospitals for consumptives are told to make use of such masks in or- der to protect themselves as well as the other patients. The mask shown in Fig. 36 is known as Professor Friinkel's mouth mask. It is a valuable means to t-, .^^ t. ^ , - • J. ,• 1-1 tiG. 136. — B. Frankel's Mouth Mask FOR prevent drop-mfection, which, ^he Prevention of Drop Infection. with the advanced cases among consumptives, is quite a serious factor in the propagation of the dis- ease. By impregnating the gauze which is held in place by the metallic frame of the mask^ with some medicinal substances, the tuberculous prisoner could be made to believe that the instrument was worn for his own personal benefit instead of for the benefit and protection of others, or, as they might think, as a means of marking them as indi- viduals suffering from a contagious disease. Thus, even the humane arguments against the use of such a mask woukl have no foundation. Where these masks have been used bacilli have been found almost con- stantly on the gauze. Frankel's and Moszkowski's experiments have demonstrated the great value of these protective masks, which can easily be disinfected. The gauze should, of course, be changed as often as necessary, but at least two or three times a day, and immediately be burned after removal. For use at the bedside of consumptive prisoners, Seabnry & John- son's well-known square pasteboard cup with metallic frame or Kny- Scheerer's round pasteboard small cuspidor with cover, or their simple metal spit cup, are most suitable. When filled with sputum these paste- 470 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS hoard receptacles and tlieir contents arc destroyed 1)}' fire. (See Ap- pendix.) The custom of whitewashing a room in wliich ordinary and healthy individuals stay but a short time might be considered a hygienic pro- cedure. When, however, this process has been adopted for the sake of doing away with the danger of tuberculosis, its efficiency may be doubted. In case a cell has been previously occupied ])y a tuberculous prisoner, he has surely infected its walls, if not directly by expecto- rating on them, he has done so by droj)-infection. Whitewasliing is well- nigh useless, since dried whitewash is aj)t to scale off, especially when there are several coats, and it will almost constantly produce a certain amount of dust in a small room like a cell. This becomes irritating to a sensitive lung, and it is not unlikely that it may be an aggravating factor with prisoners who enter the penal institution only slightly tuber- culous or predisposed. The new occupant, if at all debilitated, physic- ally or mentally depressed, is strongly exposed to contracting tubercu- losis in such an environment. The scales of the new coat of whitewash gradually disintegrate into fine dust, unite with the underlying tubercu- lous dust, and make an infection by inhalation par excellence. The method of inhaling tuberculous germs from infected walls has been demonstrated again and again, not only inside of prisons, but in the tenement houses of the poor, and even in the apartments of the rich (Flick, '88). Dr. Eansom expressed himself as follows in regard to the delusion that whitewash is a cleaning and disinfecting agent : Observation and experiment show that whitewash really promotes the spread of tuberculous disease. The fine scales and floating particles that emanate from the dried whitewash when disturbed not only irritate the bronchial mucous membranes, but they are also carriers of infection to the point irritated. To remedy the danger arising from whitewashing small cells, the writer would suggest that the whitewash be replaced by oil paint which can be washed oif with strong disinfecting fluids. The cells should, of course, never be smaller than 500 to 600 cul)ic feet, well ventilated, well lighted by natural light in daytime and by electric light at night (gas illumination absorbing too much oxygen). In the Ohio State prison prisoners with sufficient means to pay for having their walls painted instead of whitewashed can avail themselves of this hygienic safeguard. The injustice of such a rule is evident. On the writers suggestion the painting of all the cells in the Columbus prison has been done since. As to the general sanitation of prisons as far as it relates to tuber- culosis, a prison with all its annexes should be constructed so that there is plenty of light and ventilation, and on a soil that is dry and porous. TUBERCULOSIS IX PRISONS AND REFORMATORIES 471 To avoid the acquisition of a predisposition or the developing of an incipient case, all prisoners should be given a chance to exercise several times during the day in the open air, even if it is only for a short time, and during that time they must not only be permitted, but should be enjoined, to take deep inhalations, or, better yet, regular respiratory exercises. The exercise in the open air should, hovrever, not be limited to week days. According to the prison regulations now in vogue in most penal institutions, prisoners are confined to their cells not only from the hour of five in the afternoon to six in the morning, but also during almost the entire twenty-four hours of Sundays and holidays, and when a holiday follows a Sunday, or vire versa, the prisoners are necessa- rily locked up in their cells for two successive days. That such close long confinement in a small, ill-ventilated cell must be harmful is self-evident. In well-conducted prisons the inmates are required to bathe regu- larly, and their skin is usually in good condition. To the prisoner predisposed to tuberculosis or one whose case is so incipient that con- stant medical supervision is not necessary, permission for daily cold douches should be given. To this class of prisoners, predisposed or incipient, it seems that it would pay the State to give food containing a little more of the nitrogenous substances and the carbohydrates than the regular prison fare now represents. One predisposing factor to tuberculosis in prisons, which seems to have been overlooked in most of the reports on the .subject, is over- working the prisoners. AVhile it is true that in the majority of prisons the hours of work are rarely more than those of the average free labor- ers, we must not forget that the free man, laboring eight to ten hours a day, has a relatively better quality of food, the exhilarating influence of freedom of action, and naturally superior hygiene. The writer does not wish to make this statement in the spirit of criticism, but simply to point out the general likelihood of a predisposed individual develop- ing tuljerculosis more rapidly under conditions of confinement than when in normal environments. The writer has visited a number of prisons where the workshops were very badly ventilated, overcrowded with workers, often overheated, and where there should have lieen dust collectors they were wanting. For example, tobacco workers under the best conditions are prone to tuber- culosis. How much more must tliey he in danger in a prison work- shop constantly dust-laden, where there is hardly elbow room and the air is greatly vitiated? Since it is a very common practice for cigar- makers to paste the final leaf with saliva, it must be evident that no prisoner, even slightly afflicted with tul)erculosis, should be permitted to make cigars, leaving aside the fact that such conditions are sure to aggravate his disease. 472 PITBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS One phase of the subject which appertains rather to the welfare of the conmumity at large is the pardoning of prisoners far advanced in tuberculosis. Whether this practice of restoring the pardoned prisoners to their often poor families is always a wise one is open to question. It is often sad enough that prisoners who have contracted tuberculosis in prison, or whose tuberculosis has been aggravated through prison life, should be discharged at the expiration of their sentence without any regard to where they will go or what they will do. They will invari- ably constitute a source of infection unless they have been prophylac- tically trained and are willing to continue to be careful. Prisoners virtually dying from tuberculosis should not be pardoned and sent home unless the authorities are sure that the unfortunate sufferer will not become a burden to his family nor a source of infection. As to the value of agricultural colonies as a means to employ, treat, and cure tuberculous prisoners in the earlier stages of the disease there can be no doubt. In connection with the care and treatment of advanced tuberculous prisoners the admirable work done at the Texas tuberculosis agricultural colony known as the Wynne State Farm, under the scientific and humane management of Dr. Fowler, should be mentioned. The statistics of four years working of this farm are as follows : Total number discharged 34 pardoned 30 transferred 37 died 46 on hand 33 treated 180 At the conclusion of Dr. Fowler's interesting report he comments on the statistics as follows : I will say that the 37 men transferred are virtually cured, and at least one half of those pardoned and discharged were in good physical condi- tion, and the majority on hand are improving. The labor of the 180 men was practically of no value anywhere else in the prison, as most of them had reached an advanced stage of tuberculosis before their reception at the Wynne Farm. The farm is more than self-sustaining, if the expense of guarding the prisoners is deducted. The men all occupy the same build- ing, as they have to be guarded day and night. From the report it is evident that tuberculosis has been on the decrease in that prison, and there is no doubt that the tuberculous prisoner, cured through the healthful and invigorating agricultural pur- suit, will be returned to society after the expiration of his sentence many times a better member of it than he was formerly. TUBERCULOSIS AND DOMESTIC ANIMALS 473 Tuberculosis and Domestic Animals. — Before taking up the subject of combating tuberculosis in domestic animals, and thus preventing a possible infection of human beings, it is but right that, in Justice to the still existing controversy whether tuberculosis can be transmitted from animal to man and from man to animal, we give the conclusions at which the majority of American, British, French, and German scientists (the Koch school excluded) ^ have arrived: 1. Bovine tuberculosis may be communicated to human beings, and in such cases it is usually children that are aifected. 2. Tuberculosis of other domesticated mammals (hogs, sheep, goats, etc.) may also be communicated to human beings. It is usually, but not always, of the bovine type. 3. The tuberculosis of poultry is not communicable to human beings. 4. Parrots and some other varieties of cage birds may be affected with a type of tuberculosis communicable to human beings. 5. The tuberculosis of human beings, as a rule, is not communicable to cattle, but is communicable to pigs, dogs, and cats. The bacilli in a certain proportion of the cases of human tuberculosis, however, are virulent for cattle and produce in these animals a fatal generalized tuber- culosis. 6. Precautions should be taken to protect human beings from animal tuberculosis by a careful inspection of meat-producing animals at the time of slaughter, and of the cows from which milk, cream, and butter are produced (Salmon).' In a book destined particularly to be of help to the general practi- tioner it would be out of place to give the details regarding diagnosis, hygiene, and treatment appertaining to tuberculosis in animals. On the other hand, it would seem of vital importance that the general prac- titioner, and particularly the one residing in country districts, should be familiar with the latest, best, and most feasible methods of i-epressing tuberculosis in domestic animals, for he certainly Avill be called on, some time or another, as health officer of his community or as an adviser to the Board of Health, for help and suggestions. Some very concise and practical suggestions are given by Dr. D. E. Salmon in the report which appeared in the Bidletin, No. 38, of the Bureau of Animal Industry, the careful perusal of which the ■At the British Tuberculosis Congress, in 1901, Professor Robert Koch delivered an address entitled " The Combating of Tuberculosis in the Light of the Experience that has been (iained in the Successful Combating of Other Infectious Diseases." In this atldress he said that experiments hail been niade by himself and Professor Schiitz, and others of his ])upils, which led him to conclude that tuberculosis was not transmitted from the lower animals to man. — " Twentieth Century Practice of Medicine," vol. xxi, p. 781. 474 PUBLIC MEASURES IN THE PROPHYLAXIS OF Tl^BERCULOSIS writer strongly rocoininends. It can be obtained by applying to the Bureau. Supervision of Slaughterhouses. — It must be evident that no effec- tual prevention of tuberculosis contracted through infected meat is pos- sible without a careful inspection of all animals coming to the slaughter- houses and the condemnation of all diseased ones. This feature of pre- vention is by no means perfected as yet, and will not be imtil there are better laws (Federal, State, and municipal) and a better cooperation between the respective State authorities. This latter feature is par- ticularly important to prevent the clandestine transportation of diseased cattle from one State with good bovine laws, which are strictly enforced, to another State with either less good laws or where good laws are not enforced. Protection against Infection from Tuberculous Milk. — No subject is perhaps more important to the general practitioner, particularly to the one who devotes much attention to diseases of children, than the subject of pure milk. That the procuring of clean, pure milk, free from pathogenic germs, is a very essential feature in the combat of tuberculosis is now generally understood. The battle for pure milk in New York City, which may serve for an example to other cities, dates back to 1843, when Mr. Eobert H. Hartley, one of the founders of the New York Association for Improving the Condition of the Poor, wrote what was then said to be the only volume in the English language devoted to the scientific treatment of milk production. In 1850 it was published in more popular form, entitled " The Cow and Dairy," and was a potent factor in the " swill-milk " agitation and reform that followed. It is due to this association that a milk conference was recently called and a committee, composed of leading sociologists, philanthropists, and physicians, was created. The committee is to be permanent and is to work in cooperation with the Board of Health and the New York County Medical Society, and all those engaged in or related to the production, handling, and distribution of milk. From the first report published we learn that the New Y^'ork Association for Improving the Condition of the Poor was also instrumental in having the law of 18G4 passed, which prohibited the adulteration of milk. Some two years ago a movement was begun to secure more milk inspectors. In the summer of 1905, at Commissioner Darlington's re- quest, the association furnished the Health Department with an inspec- tor who, from April 1st to August 5th, made 2,960 inspections, exam- ined 3,770 specimens, took 264 samples, and destroyed 6,739 quarts of adulterated milk. Fifty-one arrests for adulteration resulted in the conviction of 47 dealers out of 49 tried. The commissioner also trans- PROTECTION AGAINST INFECTION FROM TUBERCULOUS MILK 475 ferred to milk iiis})eclion 150 sanitary oflficers from other fieldri for a time. In 190G the association assisted in obtaining an appropriation which enabled the Department of Health to double its staff of milk inspectors and cooperate with the Evening World in an enthusiastic campaign Avhich led to a marked reduction in infant mortality, saving several hundred lives between July and September. The following are the most important conclusions and suggestions arrived at by the conference: Inspection of dairies and creameries is without doubt regarded as of the first importance. To accomplish this with reasonable speed and thoroughness sixty to eighty inspectors in the country are needed. The milk must be drawn from healthy cov/s under conditions of cleanliness of animals, milkmen, premises, water, utensils, and milk cans; milk must be immediately cooled to at least 50° F., and so delivered at creameries, where it should be handled in a thoroughly sanitary manner, and further cooled. Inspection must then follow it every step of the way to the consumer, protecting it from contamination and never permitting its temperature to rise at any stage above 50° F. The expression was unanimous that nothing can render such inspec- tion unnecessary or reduce its importance. Equally important is it that all cans and bottles shall be cleaned immediately after being emptied, and so sent back clean to the country, where they should be sterilized before being refilled. Closely allied to this is the necessity for improved cans which can be cleaned more easily. The improvement of conditions in retail stores, while in a great meas- ure covered by " insi^ection," involves much besides, such as New regulations as to construction and handling and conditions in stores, all tending to the final establishment of model milk shops. Infants' milk depots are at once of the most vital importance, being directly related to infant mortality, and within the possibility of early establishment. To secure the cleanliness of the vast total milk supply and its proper distribution is a tremendous task; to obtain 10,000 quarts daily of clean milk and place it within the reach of the people, pasteurized or raw, modified, in feeding bottles, with directions from physicians and nurses, as indicated in the report, is no small undertaking, but is within the power of more than one single philanthropist in this city to render pos- sible within a few months. To secure anything approaching the best results to follow such inspec- tion, imi)rovement in shops, and establishment of infants' milk depots, the education of the people must go forward. 47G PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS They must be taught the value of milk as a food and the absolute need of cleanliness in handling after it comes into their hands. Every social, educational, and philanthropic agency in this city should lend its best aid to intelligent efforts in this direction. To render possible the accomplishment of these ends, regulations and legislation must be secured — city, State, and Federal. A constant and unceasing pressure along all these lines, backed by an enlightened public opinion, is necessary to permanent reform. This report Avas signed by Committee on Report : Dr. Rowland G. Freeman, as Chairman ; Mr. John E. Sayles, as Secretary ; Dr. L. Emmett Holt, Dr. Ernest J. Lederle, Dr. Linsly R. Williams, as members of the Committee on Report. What philanthropy in cooperation with municipal authorities can do may best be seen from the work which has been done by a single philanthropist, Mr. Nathan Straus, during the last fifteen years. There were 2,917,336 bottles and 1,222,048 glasses of milk sold or given away this season. The new building Mr. Straus is erecting at a cost of more than $100,000 will be finished and equipped with a large pasteurization plant this winter, so as to be in full operation next spring. The totals for the fifteen years show the dispensing of 18,710,892 bottles and 10,- 089,674 glasses of this milk. Mr. Straus's plan has been copied in nearly 400 cities in all parts of the world. Dr. Goler's ('07) opinion on the regulation of the milk supply of smaller municipalities than that of New York is particularly instructive, and in view of the excellent results obtained in Rochester it may be well worth Avhile to give his conclusions on this most efficient work: There must be a sufficient number of inspectors, really to inspect, and through such inspections to determine that the applicant for the holder of a license is qualified to produce and distribute milk. To such a one only should a milk license be issiied. 1. That adequate inspection may be made, a sufficient number of in- spectors must be employed to collect : a. From each wagon at least one monthly sample for bacteriological and chemical examination. h. At least once in two months a sample from each store offering milk for sale. c. Every city dairy and every store to be scored at least quarterly by the inspector on a score card after the plan of those used by the U. S. Department of Agriculture and the Dairy Department at Cornell University, HOUSING OF THE MASSES, GOOD TENEMENT HOUSE LAWS 477 2. There must be daily inspection of the iiu-ominpc milk at each rail- road station for: a. Condition and housing of cans and bottles of milk in shipment. h. Conditions of empty cans reshipped. c. Temperature of milk. d. Inspection of railroad samples to guard the retailers against fraud on the part of the wholesalers. The territory from which the city draws its milk supply must be mapped, the dairies plotted, the roads examined, the railroad facilities noted, and routes laid so that every farm shipping milk to the city may in the beginning be subjected to a systematic inspection once in two months. No milk must be permitted to enter the city until the seal of inspection has been placed on it by the inspector. When for one reason or another cow's milk of absolute purit}^ and free from tuberculosis germs cannot be obtained, the more extensive use of goat's milk, which seems to be almost always free from tuber- culosis germs, should be encouraged. While the goat ordinarily is looked on as a rather unclean animal, as a matter of fact the milch goat may be tubbed and toweled and thus easily made perfectly clean. For chil- dren's feeding such cleansing is a common practice in certain parts of Europe. Housing of the Masses, Good Tenement House Laws and their Strict Enforcement Essential. — An important feature in the prevention of tuberculosis must, of course, always be the proper sanitation of the home, the school, the workshop, the factory, places of amusement and recreation. The problem of housing the masses, particularly in large cities, is too vast to be dealt with in a work of this kind, but the fearful prevalence of tuberculosis in many of the tenement house dis- tricts of our large cities demands attention. New York's often-described " lung block " on Cherry and Market Streets, had, ten years ago, a death-rate from tuberculosis of 37.5 per cent, w^hile the death-rate in the city at large was only 21.52 per cent; for the ten years from 189-1: to 190-1: no less than 291 cases of tuberculosis were reported to the Board of Health from this block, and since the new tenement house law was enacted 200 violations have been filed with the Tenement House Department against these unsanitary dwellings. Yet in spite of this condition, in spite of the Tenement House Commissioner and the men and women interested in the antituberculosis problem, who have pleaded again and again for the destruction of the block and the conversion of it into a park or playground, the lung block still stands because of the political strength of its owners. Are physicians not often lacking in civic duty by not interesting themselves more in public and political life? 478 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS Tlio lesson tliat tlio lung Ijhx-k loaches is simply that renovation does not pay when tiil)erculosis in any house or hloek has heconie endemic. There are numy "lung hlocks" in New York and in other large cities of the United States. Every collection of dark, foul, un- ventilated tenements is a lung hlock, dealing death to those who, hy eco- nomic necessity, not from choice, must live there and call these disease- breeding houses by the name of home. Such conditions should make municipal authorities and public-spirited citizens everywhere realize the need of better tenement houses, where the laboring population may have homes with light and air in plenty, in addition to modern improve- ments, and at the same time pay no more rent than they had been obliged to pay for unsanitary and uncomfortable quarters in old and dilapidated tenement houses. All the general practitioner can do in this matter is as a citizen to further proper tenement house laws and their enforcement, and as a physician to urge his wealthy clients to help in the building of as many model tenement houses as possible. Viewed even from a purely utili- tarian standpoint, it might be stated that money invested in model tenement houses gives to the investor, as a rule, as high and higher percentage than he is apt to receive from other safe investments. Those desiring information regarding proper tenement house laws are referred to the admirable reports annually issued by the New York Tenement House Department. Parks and Playgrounds. — Parks and playgrounds have appropriately been called the " lungs " of a city, and the phthisiotherapeutist knows only too well what this phrase signifies. The city that has the greatest number of large and small parks and playgrounds or open-air recrea- tion centers, particularly when they are located within densely crowded districts, will always be able to boast of the lowest mortality rate from tuberculosis and other respiratory diseases. Here again is a chance for the physician to direct into a useful channel the practical philanthropy of a wealthy client who may wish to do something for his fellow men. In speaking of the importance of playgrounds in the prevention of tuberculosis, one cannot do better than to quote from an address deliv- ered on this subject by Prof. Henry Baird Favill, President of the Chicago Institute, on the occasion of the Playground Conference wdiich was held in Chicago last year: It is not at all sufficient that the children be protected during their helpless years from danger, but that they be furnished with sturdy, disease- resisting bodies. The problem of tuberculosis involves a deep conviction as to the principles of living which, even though it can be inculcated in their youth, would be as rapidly eradicated by their contact with their elders, unintelligent and fixed in habit, except their knowledge and im- CREATION OF SCHOOLS OF FORESTRY 479 pulse can be kept alive by special advantages and inspirations. . . . Pro- tection of tlie child must be the watchword under which this refnrni will be achieved. The ideal of a healthy body, the obligation to protect the child in its siisceptible years, the willingness to sacrifice for the child in material ways have to come as the foundation for general reorganization. The scope of the playground movement broadens enormously at this point. To provide generously the open spaces necessary to carry on the work is obviously the first duty. To regard this work when done as an end accomplished is scrupulously to be avoided. To learn to regard the playground as an elementary means to a very great end must be the object of our propaganda. Public baths, also baths and swimming tanks in schools, must cer- tainly be considered an important factor in the prevention of tuber- culosis, particularly when they are located in the crowded tenement house districts of a large city. Emigration from City to Village. — Before taking up the subject of the sanitation of the home, as far as its internal equipment is related to the prevention of tuberculosis, it is necessary to speak of the unfor- tunate tendency toward overpopulation in the cities. Physicians, statesmen, and philanthropists who are interested in the solution of the tuberculosis problem, besides working for the better housing of the poor and the creation of special institutions for the treatment of con- sumptives, have an additional mission to perform. The tide of emi- gration from village to city should be reversed. If tuberculosis has made its appearance in a family living in a large city, the physician should exert all his influence to induce especially the younger members to migrate to the country and seek outdoor occupations. Statesmen should protect the interests of the farmer, so that farm- ing will have more attraction to the rising generation than it has had in the last tw^o decades. Philanthropists should aid the statesmen by endowing institutions for instruction in scientific and profitable agri- culture, and also by providing healthful amusements, good libraries, and other educational institutions in country districts, thus making living outside of large cities more interesting and attractive to young people. In short, the love of nature and life in the open air should be more cultivated. In the proportion in which this is done tuberculosis will decrease. But in the cities also open-air life should be more encour- aged and, after the example of many Euro])ean cities, outdoor, healthful amusement places should be established for the masses. The recent estab- lishment of outdoor theaters in some of our American cities must be highly commended by all those interested in the antituberculosis crusade. Creation of Schools of Forestry and the Preservation of Forests. — The creation of schools of forestry in connection witii the j)reservation 480 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS and cull ivat ion of forests in many States where a wasteful destruction of trees is now carried on, would give useful and healthful employment to a numher of people, as well as render the region inore healthful. It would offer attractive careers to young men seeking to overcome heredi- tary or acquired tendencies to tuhereulous diseases. There is no doubt that the preservation of American forests against wanton destruction by greedy speciilators and by the too frequent fires would lead to an improvement of the climatic condition of many regions throughout the country. The question what to do with a patient who is discharged from a sanatorium as a cured or arrested case is an exceedingly difficult one. To allow him to resume his former occupation or to have him return to the unhygienic home environments from which he came means, in many instances, a rela})se, if not a new infection. Everybody agrees that outdoor work, such as farming, gardening, surveying, canvassing, driv- ing carriages or wagons, providing not too much lifting of heavy weights is connected with it, would provide the ideal occupations. For women, suitable outdoor employment is harder to find. There is great danger when too much strain is placed on the system of the former invalid. Even in ease of the most complete recovery he cannot compete Avith a perfectly healthy man or woman. It would seem that the most feasible way to prevent the danger of a relapse, due to the wrong kind of occupation or to a possible over- exertion from too heavy work, would be to have the patient live and work, for at least one year, in an institution which might be called an agricultural or horticultural sanatorium farm, where the kind and the amount of work which the recovered patient is allowed to do w^ould be strictly regulated by an experienced medical supervisor. Experiments in this direction have been made in this country in the Adirondacks, and an interesting article on the subject, under the heading of " The Garden of the Saranac I^ake Industrial Settlement," appeared in Charities and the Commons of December 7, 1007. The idea of this settlement was thought out by students of the sociologic problems connected with tuberculosis. It was established as an experi- ment in May, 1907. During six months of its existence, thirty-one persons have had either temporary or continuous employment ; twenty of these workers have been men, eleven women. The wages paid range from fifteen to twenty cents an hour. The former occupations of the patients were those of laborer, glassworker, machinist, butcher, car- penter, clothing cutter, piano tuner, bookkeeper, lithographer, stenog- rapher, photographer, typewriter, bookbinder, shoemaker, carriage painter, office boy, lady's maid, saleswoman, dressmaker, lawyer, draughts- man, and teacher. The industries thus far established or tried are SANITATION AT HOME 481 gardening, jmultry-raising, leather work, diet kitchen, sewing and mending, and an exchange for the sale of articles made by invalids at their homes. Mrs. William E. D. Scott is the superintendent. The writer of the article above referred to is Curator of the Department of Ornithology at Princeton University, and is himself an enforced resi- dent at Saranac Lake. At the end of nine months he had so far recov- ered his health as to Ije able to direct actively much of the outdoor work planned by the organization which is especially devoted at present to truck-gardening and poultry-raising. In Pennsylvania arrangements are being made by the Department of Health and Charities to send a score of tuberculous patients from the Philadelphia General Hospital to the City Tract at Byberry farm. The change is to be in the nature of an experiment, and if it proves beneficial a greater number of consumptive patients will be removed to Byberry. Sanitation at Home. — The sanitation of the home and its equipment to prevent tuberculosis is, of course, of vital interest to the phthisiolo- gist. The model tenement home should give to its tenants light rooms, good ventilation, perfect plumbing, proper heating facilities, and reason- able security from fire. To make the air in homes as fresh, pure, and sanitary as possible is comparatively easy in summer. The windows and doors can be left open so as to make the air inside as fresh as that outside. The greatest difficulty is experienced in winter. Yet physicians should not fail to urge those in their care to renew the air at least several times a day b}' opening the windows and doors for a few minutes. Against the fear of night air — that nightmare of our ancestors — we should be par- ticularly emphatic. When there is a tuberculous invalid in the famil}' or one strongly predisposed to the disease, and the family is in moderate circumstances, or for some other reason the patient must be treated at home, the ingenuity of the practitioner will be taxed to the utmost by his desire to install the sanatorium treatment. In the Appendix (\'ll) there will be seen a number of illustrations, such as sleeping shacks, sleeping verandas, etc. The poorer the people the more difficult is the problem. If the consumptive sufferer is obliged to sleep in the room which serves as a living room for the rest of the family, there will be naturally strong objections in winter to having the window open day and night. It is for this reason that I devised an arrangement which I call a window tent. A brief description may help the general practitioner to have a window tent manufactured if the device cannot be procured in his local- ity, or if some one in the family has ingenuity and mechanical skill enough to make one. 32 482 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS Window Tent for the Open-air Treatment at Home. — The window tent is an awning which, instead of being placed outside of the window, is attached to the inside of the room. It is so constructed that the air from the room cannot enter or mix with the air in the tent. The patient lying on the bed, which is placed parallel with the window, has Fig. 137. — Window Tent in Use. Note celluloid window. (S. A. Knopf.) his head and slioulders resting in the tent. By following the description closely you will see that the ventilation is as nearly perfect as can be produced with so cheap a device. The tent is placed in the lower half of an American window, but it does not quite fill the lower half of the frame; a space of about three inches is left for the escape of the warm air in the room. By lowering the window the space can be re- duced to one inch or less, according to need. On extremely cold and windy nights there need not be left any open space at all above the window frame. The patient's breath will rise to the top of the tent, the form of which aids in the ventilation. The tent is constructed of a series of four frames, made of Bessemer rod suital)ly formed and fur- nished with hinged terminals, the hinges operating on a stout hinge pin at each end with suitable circular washers to insure independent and easy action in folding the same, the Bessemer rod being hardened to make a stiff rigid frame to insure its maintaining the original form. The frame is covered with extra-thick yacht sail twill, properly fitted, and having elongated ends to admit of their beins tucked in under WINDOW TENT FOR THE OPEN-AIR TREATMENT AT HOME 483 and around the bedding to prevent the cold air from entering the room. The patient enters the bed, and then the tent is lowered over him. Or with the aid of a cord and a little pulley attached to the upper portion of the window, he can manipulate the lowering and raising of the tent himself. Shutters or Venetian blinds, whether they are attached on the inside or on the outside of the window, can be utilized in conjunction with the window tent as a screen to intercept the gaze of the neigh- bors, and in stormy weather as a protection. The bed can be placed by the window to suit the patient's preference for sleeping on his right or left side, so that he has the air most of the time in his face. Another advantage of the window tent is that it will not attract attention from the outside. The bed being placed alongside of the Fig. 138.— Window Tknt Raised, Whi:n Not in Use. (S. A. Knopf.) window will be convenient for the majority of tlie poor who have small rooms. If, however, the bed must be placed at a right angle to the window, this can be arranged as well. A piece of transparent celluloid is placed in the middle portion of the tent to serve as an observation window for the nurse or members of the family to watch the patient if this is necessary. It also serves to make the patient feel less out- doors and more in contact with his family. He can, if he desires, see what is going on in the room. If the window tent must be placed at 484 Pl^BLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS a right angle to the window, the o1jser\ation glass can he put in on the side (see Figs. 137 to 140). It goes without saying that, as a rule, patients should not smoke; when, in exceptional cases, this can be allowed, the danger of the cellu- loid window becoming ignited must be impressed upon them and the greatest caution urged. The writer prefers celluloid to ordinary glass for tliis jmrpose, l)ecause it can easily assume tlie vaulted form of the rest of the tent, and thus even the slightest possiI)ility of an air-pocket formation is avoided. T: f Srl _v J*= Fici. I'.'M. — Window Tknt. \'ie\v I'nua out- side. (8. A. Knopf.) Fig. 140. — Diagram Showing Ven- tilation OF Window Tent. If it is necessary to raise the bed to tlie height of the window sill, it can be done with little expense. If the bed is of iron a few addi- tional inches of iron piping can be attached to the legs by any plumV)er or one handy with tools ; raising a wooden bed can be accomplished with equal facility. If the window tent is to serve the patient only during the night, the tent can be piilled up and the bed moved away from the window during the day and the window closed. Or the tent can be taken from the hooks and put out of the way. The window tent will, of course, be of greatest value to the consump- tive sufferer in winter. If he is feverish, or his stay in bed is advisable, he can spend his entire time in the window tent. If the people are poor, and the room where the consumptive sufferer lies serves as living room for the other members of the family, the fact that the well mem- WINDOW TENT FOR THE OPEN-AIU TREATMENT AT HOME 485 bers need not shiver and yet the patient can take his open-air treatment, is of vital importance in many respects. While the room will not be quite as warm as if the window was entirely closed, it will be much warmer than if there was no tent in front of the open window. Laying aside the economic advantages to a poor family when not being o])liged to heat more than one room, the patient feels that lie does not deprive his loved ones of comfort and warmth, and that lie is less a burden and hindrance to their happiness. The other members of the family, on the other hand, feel that they can give the patient all the air he needs, and that he himself need not suffer for their comfort. In winter the patient's jjed must be covered with a sufficient number of blankets to assure his absolute comfort and warmth throughout the night. Still, this covering should not be so heavy as to press down upon the body and make the patient feel uncomfortable or tire him. The tightly woven blanket is a better protection than the loosely woven one. To the poor Avliose disposal of blankets is, alas ! often very limited, it may be valuable advice to tell them to put several layers of newspapers between the coverings. Outdoor Life (December, 1905) recommends to have a dozen layers sewed be- tAveen two layers of flannel. This will certainly make a cheaj?, light, Figs. 141 and 142.— Woolen Hoods for Outdook Sleeping. and warm covering. In extremely cold weatlier the patient, while sleeping in the window tent, should wear a sweater and protect his head and ears with a wo(den cap, sliawl, or woolen hchiiet (see Figs. 141 and 14:3). Some patients will complain that the bright light awakens them too early in the morning, and that they have difTicuHy in going to sleep 486 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCTtLOSIS again. In such instances I counsel the patient to have some light weight hut dark-colored material (such as hlack lisle thread hose) to put over his eyes. This usually suthces to obviate the inconvenience caused hy the bright light. In the Appendix (VII) there will also be found a number of devices (tents, half-tents, reclining chairs, etc.) to facilitate the rest cure outdoors during the day in the homes of the poor. When there is no garden, no veranda, no roof, which can be utilized for outdoor sleep- ing, the window tent can also be put into service for the rest cure during the day. The lied is moved away and the reclining chair is put in its place. The latter can be raised to the necessary height by wooden blocks or a platform, and with the aid of blankets and comforters the air from the room can be excluded, and the patient being in front of the open window breathes only outdoor air. Dry Air and the Danger from Overheated Dwellings. — Many Ameri- can dwellings and public buildings are heated altogether too much. A temperature of from 65° F. to G8° F. should be sufficient, especially when care is taken that the heat produced by the furnace is not too dry. The excessively dry atmos2:)here in winter in many public buildings and in many city and country homes often gives rise to nasal catarrhs, a condition which everybody, but especially those suffering from pulmo- nary diseases, or prone to them, should be anxious to avoid. Besides keeping the water pan in the furnace constantly filled, there should be in the sitting room and sleeping rooms humidifying arrangements. The humidifier consists of a wooden or metallic box placed with its open side over or before the register. Layers of felt are suspended between two metallic basins containing water; the upper one is the smaller and is placed immediately under the cover of the humidifier, the larger one below. By capillary attraction these layers of felt are kept constantly moist, and the heated air coming from the furnace passing over them is rendered more humid. More simple evaporating devices, however, such as a vessel filled with water and a cloth suspended above it touching the water so as to produce capillary attraction, will answer the purpose of rendering the atmosphere sufficiently humid. Experience has proved that we can be perfectly comfortable in a temperature of 65° F., and even a little lower, provided that the relative percentage of moisture is sixty. If this moisture falls to thirty or to twenty per cent, then the dry throat, dry nose, and dry skin are in evidence. A single direct reading hygrometer (Fig. 42), while not over- accurate, will answer for all practical purposes. Danger from Dry Sweeping. — Dust must, next to the bacilli, be con- sidered the greatest enemy to the tuberculous invalid or to the indi- COMMON HOUSE FLY AS A PROPACJATOR OF TUBERCULOSIS 487 vidiial predisposed to the disease, for we know that even dust free from pathogenic microorganisms, when inhaled frequently or for a long time, will irritate the respirator}' tract and make it more susceptil)le to the invasion of the tubercle bacillus and other microorganisms. There is pul)lishcd an excellent little leaflet in four different lan- guages which the Tul)erculosis Committee of the Charity Organization Society and also the Health Department have distributed at large. It shows how the danger arising from dusting and sweeping in the home may be reduced to a minimum. These simple and comprehensive rules were suggested to our committee by Prof. T. Mitchell Prudden, of Columbia University. The most sanitary and ideal method of cleaning any room is, of course, the vacuum-cleaning method, which, it is to be hoped, will some day be cheap enough to be more generally available. For schools, fac- tories, stores, and public buildings this method should be made ol^li- gatory. To sweep unsprinkled streets and raise clouds of dust should be considered a municipal crime. No sidewalks or streets should be swept M'ithout having been thoroughly sprinkled. Surface street-car com- panies should be compelled to sprinkle their tracks at regular intervals in hot and dusty Aveather. This is done in several cities by cars spe- cially devised for that purpose. Its universal adoption is an urgent necessity. The Common House Fly as a Propagator of Tuberculosis. — An im- portant factor in the spread of tuberculosis is generally omitted in all leaflets on the subject — that is, the common house fly. It would seem that an item showing the danger of this insect as a distributor of bacilli should be inserted. The abdominal cavities of flies caught in the rooms of consumptives often contain the living tubercle bacilli, so also do the fly specks scraped from the walls and windows in rooms where con- sumptives live and particularly where their sputum receptacles do not have any covers. The danger from these infected insects is twofold. They die and crumble to dust, which contains the bacilli, and the microorganisms may thus enter the system through the respiratory tract; or the fly may infect some article of food with its feet or excre- ment, whence the bacilli contained in the deposit iind their way into the alimentary tract of man or animal. It is for this reason that we should insist that all sputum receptacles should have covers and never be allowed lo remain open. The fly, however, may not only be a distrilmtor of pathogenic germs, ])articularly of tubercle bacilli, but it is inimical by its very presence in the sick room. By its interference with sleep in the early morning hours it unquestionably exerts a lowering etfect on the vitality of the tuber- 488 PITBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS culous invalid. Thus, to any of the circulars on the prevention of tuber- culosis one might advantageously add a paragraph relative to the de- struction of the house fly, or it may be even better, after the example of the New York Board of Health, to distribute a separate circular to that effect. 1 copy here the circular relating to this subject recently issued by the Health Department : Keep the flies away from the sick, especially those ill with contagious diseases. Kill every fly that strays into the sick room. His body is cov- ered Avith disease germs. Do not allow decaying material of any sort to accumulate on or near your premises. All refuse which tends in any way to fermentation, such as bedding, straw, paper waste, and vegetable matter, should be disposed of or cov- ered with lime or kerosene oil. Keep all receptacles for garbage carefully covered and the cans cleaned or sprinkled with lime or oil. Keep all stable manure in vault or pit screened or sprinkled with lime or kerosene or other cheap preparation. See that your sewerage system is in good order, that it does not leak, and is up to date and not exposed to flies. Pour kerosene into the drains. Cover food after a meal ; burn or bury table refuse. Screen all food exposed for sale. Screen all windows and doors, especially the kitchen and dining room. Burn pyrethrum powder in the house to kill the flies. Don't forget that if you see flies their breeding place is near-by filth. It may be behind the door, under the table, or in the cuspidor. If there is no dirt and filth there will be no flies. Prevention of Tuberculosis in the School Child. — In the prevention of tuberculosis school hygiene is most important. The writer has en- deavored to point out the great responsibility which we all have, par- ticularly the medical profession, in preventing tuberculosis among the children attending the public schools. If the child has an hereditary pre- disposition to disease l)ecause one or both of his parents has had tuber- culosis or syphilis, been afflicted with marked nervous or mental dis- order, or addicted to alcoholism, the strain of school life not infrequently suffices to bring out or develop the hereditary taint. If the home environments of the child are such that it receives either not enough or insufficiently nutritious food, does not get enough sleep or must sleep in an ill-ventilated room, is insufficiently clad and his bodily hygiene generally neglected, or if, as happens too often, it must contribute by its " child labor '' toward the support of the family, we have additional predisposing factors to tuberculosis. PREVENTION OF TUBERCULOSIS IN THE SCHOOL CHILD 489 As a remedy for existing conditions, the writer suggests that : First, the necessity of giving the child more years to play ; second, more hours of sleep throughout its school term and the abolition of " home studies " ; third, the training of teachers in the diagnosis of diseases, especially in the objective symptoms of early tuberculosis, to a sufficient extent to facilitate the work of the school physician; fourth, small enough classes to enable the teacher to come in close contact with the individual pupil, and classes for the mentally defective and backward; fifth, the abolition of child labor, not only in factory, workshop, and in stores, but also at home; and sixth, the arranging of the curriculum in all schools so that the mental development is not pushed to the detriment of the physical welfare of tlie child. Furthermore to be suggested is the teaching of rational hygiene — physical, mental, and moral — including the teaching of the prevention of tuberculosis, venereal diseases, and alcoholism, to school children according to their age and understanding, by the regular teacher or special teacher or the school physician. School authorities should inaugurate a thorough course of instruc- tion of school girls, the future wives and mothers of the nation, com- prising sanitary and practical housekeeping, including, of course, plain and economic cooking and the art of serving a plain meal appetizingly. The writer also advises the building, equipment, care, and cleaning of the schoolhouses so as to assure the best possible sanitary conditions for teachers and children and the making of large playgrounds or roof gardens and swimming tanks and baths as indispensable equipments in every school. Proper breathing exercises, such, for example, as illustrated in Figs. 143 to 146, and outdoor singing, recitation, etc., when weather per- mits, should prove l)eneficiai, and, whenever possible, instruction in an adjacent school farm or school gardens might form a part of the cur- riculum. The following respiratory exercises have, because of their simplicity, been found most efficacious in the experience of the author: In front of the open window or out of doors assume the position of the military " attention," heels together, body erect, and hands on the sides. With the mouth closed take a deep inspiration (that is, breathe in all the air possible through the nose), and while doing so raise the arms to a horizontal position; remain thus, holding the air inhaled from three to five seconds, and while exhaling (breathing out) bring the arms down to the original position. This act of exhalation, or expiration, should be a little more rapid than the act of inspiration. When the first exercise is thoroughly mastered and has been practiced for several days, one may begin with the second exercise, which is like the first, except that the 33 490 PITBLIC MEASURES IN THE PROPHYLAXIS OF TITBERCULOSIS upward movement of the arms is continued until the hands meet over the head. The accompanying: ilhistration shows the positions which are to be taken during these two exercises. Take the same military i)osition of " attention," and then stretch the arms out as in the act of swinnning, the backs of the hands touching each other. During the inspiration move the arms outward until they finally meet behind the back. Remain in this position a few seconds, retaining the air, and during exhalation bring the arms forward again. This somewhat difficidt exercise can be facili- tated and be made more eifective by rising on the toes during the act of inhalation, and descending during the act of expiration. When out of doors one cainuit always take these exercises with the movement of the arms without attracting attention; under such condi- tions raise the shoulders, making a rotary backward movement during yKi Fig. 14.3. — First and Second Breath- ing Exercise. Fig. 144. — Third Breathing Exercise. the act of inhaling; remain in this position, holding the breath for a few seconds, and then exhale while moving the shoulders forward and down- ward, assuming again the normal position. This exercise (Fig. 145) can be easily taken while walking, sitting, or riding in the open air. Young girls and boys, especially those who are predisposed to con- sumption, often acquire a habit of stooping. To overcome this the fol- PREVENTION OF TUBERCrLOSIS IN THE SCHOOL CHILD 491 lowing exercise (Fig. 146) is to be recommended: The child makes his best eflfort to stand straight, places his hands on his hips with the thumbs in front, and then bends slowly backward as far as he can during the act •::'^..;- 5c -; J Fig. 145. — Breathing Exercise with Rolling of Shoulders. Fig. 146. — Exercise for Children in THE Habit of Stooping. (Knopf prize essay.) of inhaling. He remains in this position for a few seconds, while holding the breath, and then rises again, somewhat more rapidly, during the act of exhalation. Enough school physicians, especially trained for the work and suf- ficiently remunerated, should be attached to every public school to assure the exclusion of cliildren afflicted with contagious and communicable diseases, or otlicr ])hysica] defects, including bad teeth, with a view of curing or correcting the disease or infirmity tlii'ougli either private or public initiative. Tuberculous teachers sliould not be employed in public schools, but if they have contracted tuberculosis in the performance of duty, it is the duty of the municipality to provide for them until their earning capacity is again established. Tlie establishment of municipal seaside or country school sanatoria 492 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS for tuberculous children wliore some of tlie tiil)erculous teachers might also be employed profitably is an urgent necessity. It would also be wise to add a sufficient number of trained nurses as school nurses, whose duty should be: first, to aid the school physi- cian in his work ; second, to visit the homes of the physically, morally, or mentally defective children, in order to learn if home conditions alone are not responsible for the defects in the child. The writer is convinced that hy such judicious cooperation of teacher, physician, nurse, and parents, and, if the case demands it, by the help of an organized charity society, many of the underlying causes of the child's troubles can be lastingly remedied. Substantial school lunches should be furnished by the numicij^al- ity at a nominal ])rice for those able to pay and gratuitously for the absolutely poor. The suppression of child laljor in factories, coal mines, mills, work- shops, stores, and at home is essential if we wish to combat a predis- position to tuberculosis in childbood. The child's organism when en- feebled by labor, by deprivation of sleep and outdoor play, is sure to become an easy prey to the tubercle bacillus, particularly when the under- feeding and unsanitary housing of tlie child of the poor is added to its misfortunes. There is an equal necessity for a law and the vigorous enforcement of it, whereby mothers will not be forced to work until the very hour of their confinement, nor be obliged to resume work until they have regained the necessary strength to do so after their delivery. Sanitation of Workshops, Factories, Stores, etc. — The sanitation of factories, workshoj)s, department stores, and other establishments where people congregate to work, should, of course, be made a matter of State and municipal regulation. To guard against direct infection, spitting, except in proper receptacles (elevated S])ittoons, Proedohl's factory cus- pidor, etc., see Appendix (VII), should ])e prohibited, and any repeated violation of the antispitting ordinance punished by dismissal. The public telephone in such places and elsewhere also may serve as a means of the propagation of tuberculosis. An arrangement such as pictured in the Appendix on page 839 might obviate this possible dan- ger. The thin sheet of paper over the transmitter is removed after each time the telephone is used, and the discarded papers collected and burned every evening. Antituberculosis "Work Among Factory Workers. — There is, how- ever, one feature of antituberculosis work in relation to this that can only be carried out by the physician in conjunction with the employer or owner of the factory, workshop, or store. It is the early detection and timely and proper treatment of tuberculosis among employees. To Franklin T. Fulton, of Providence, K. I., belongs the honor of being the INSURANCE AGAINST TUBERCILOSIS 493 pioneer in this pliase of antituberculosis work. The movement was in- augurated by posting on the bulletin boards of the shops official notices stating that the management of the mill or factory had provided, with- out expense to the employees, a physician to examine anyone who had any suspicion that he might have tuljerculosis, emphasizing the fact that in the very beginning the disease can be cured. Two establishments which took the matter earnestly employed to- gether 5, '^00 men. From these two plants Si operatives were examined during about ten months, 18 of whom were found to liave tuberculosis and were not under a physician's care. Some of the others had symp- toms suggesting the disease, but no definite signs could be detected. It was found that most of these men were living in a very unhygienic way, and their symptoms in several instances quickly disappeared upon their being advised liow to live. Altogether, the work in connection with these two establisliments has been very satisfactory, and wliile tlie number of cases treated has not been very large. Dr. Fulton doubted if there are many sanatoria which show a more marked improvement in as large a percentage of cases and in so sliort a time. The reason for this he cer- tainly does not believe to be due to any advantage that the home treat- ment has over the sanatorium treatment, but to the fact that the cases are detected before they reach an advanced stage. This admiral)le work of Dr. Fulton deserves tlie highest praise, and should be brought to the attention of influential and philanthropic em- ployers that his example may be imitated. Insurance against Tuberculosis. — It is well known that in Germany, owing to tlie compulsory insurance of every Avorkingman and woman against accidents, old age, and disease, including tuberculosis, the anti- tuberculosis movement has made strides such as could l)e made in no other country witliout that provision. These insurance companies are so prosperous, and they have fouiul it of so great a financial advantage to treat their tuberculous policy holders at the right time and at the right place, tliat they have built themselves a number of tuberculosis sanatoria. Some of these are among the best equipped of the land. The Berlin branch of the " Landesversicherung," for e.\am})le, established at Belitz one of the finest and most elaborate institutions of its kind, accommodating no less than 300 tuberculous patients. Aside from all humanitarian considerations, it would seem in the interest of the community at large, the welfare and well-being of the American people as a nation, and in the financial interest of insurance companies, policy holders, and the commonwealth, iliat tlie time had come when Americans should imitate the Gernuui Invalidity, Diseases, and Old-Age Insurance Companies under State supiprvision, including, of course, under insurance against disease, all tuberculous affections. 494 Pl'BLlC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS To combat tuberculosis as a disease of the masses successfully, re- quires the combined action of a wise government (Federal, State, and municipal), well-trained physicians (trained in teaching and practicing prophylaxis in the early diagnosis of pulmonary tuberculosis and mod- ern phthisiotherapy), and an intelligent people, which has learned the value of good health as a prime factor to happiness and realizes that the mutual insurance against accidents, disease, and old age is the safest guard against the possible misfortunes which can come through disease and deformity. The writer closes this contribution on public measures in the pro- phylaxis of tuberculosis with a fervent appeal to the Government to take steps which will place federal regulation of public health on a par with that of the leading governments of Europe. Germany has its ministry for medical affairs, with a cabinet officer at the head, and with the high- est medical authorities connected with the Imperial Office of Health (" Reichsgesundheitsamt "). France has its " Conseil superieur de sante," equivalent in importance and power to the Eeichsgesundheitsamt of Germany. Our Eepublic should have a similar office to guard the health of the nation. The Committee of One Hundred, appointed by Section One of the American Association for the Advancement of Science, has been empow- ered to work for Federal regulation of public health. The time for it seems to be ripe, and what the creation of such a department or bureau of health ^ would mean for the welfare of the people of this country in general, and particularly regarding the combating of tuberculosis, may best be realized by the following extract from an address delivered by President Eoosevelt in Provincetown : I also hope that there will be legislation increasing the power of the national Government to deal with certain matters concerning the health of our people everywhere; the Federal authorities, for instance, should join with all the State authorities in warring against the dreadful scourge of tuberculosis. I hope to see the national Government stand abreast of the foremost State governments. » This department of health is not intended to encroach on the fields of the State boards of health. The thought is rather to arouse the State health boards to redoubled activity. One method of accompHshing this is to make the city of Washington, over which the Federal Government has full power, a model city in hygiene (Irving Fisher, "Federal Organization of Health," Trans. International Cong. Tuberculosis, Washington, 1908). ADDENDA 495 ADDENDA Sumtnari/ of Public Measures in Propliylaxis of Tuberculosis, Presented at the International Congress held in Washington, D. C. Economic Meaning of Tuberculosis.— Some interesting new calcula- tions have been jjre^ented which may prove helpful in stimulating inter- est in preventive efforts against the disease. Y. C. Yaughan figured that from 200,000 to 250,000 inhabitants of this country die annually of tuberculosis. Taking only the lower estimate, it may be calculated that two thirds or three fourths of these die between the ages of eighteen «nd forty-five — that is to say, at a time of life when the earning capacity is greatest. Estimating, with Darlington, the value of a single indi- vidual during the prime of his life at only $1,500, and taking again the lower estimate of two thirds and not the higher estimate of three fourths, the economic loss which accrues to the United States through the un- timely death of these 100,000 jseople is no less than $150,000,000 annually. Another calculation of the cost of tuberculosis in the United States and its reduction was presented by Irving Fisher. He estimates the death-rate from tuberculosis in all its forms in the United States at 164 per 100,000 of population and the number of deaths in 1906 as 138,000, and he concludes that at this rate, of those now living in the United States, 5,000,000 people will die of tuberculosis. The average age at death for males is 37.6 years ; for females, 33.4 years. The " expecta- tion of life " lost (though estimated on a specially high mortality rate) is at least twenty-four years, of which at least seventeen fall in the work- ing period. The average period of disability preceding death from tuber- culosis exceeds three years, of which the latter half is a period of total disability. " The money cost of tuberculosis, including capitalized earn- ing power lost by death, exceeds $8,000 per death. The total cost in the United States exceeds $1,100,000,000 per annum. Of this cost about two fifths, or over $440,000,000 per annum, falls on others than tlie con- sum])tive. An effort to reduce the mortality by one foiirth would be worth, if necessary, an investment of $5,500,000,000. The cost of treat- ing patients at sanatoria is repaid many times over in lengthened work- ing lives. The erection of isolation hospitals for incurables is probably the most profitable method at present of reducing the cost of tuber- culosis." Raising of Funds for Tuberculosis Propaganda. — A ])ra(ti(al sugges- tion toward this end, as well as for the creation of general interest in tuberculosis, is contained in a report by Miss Clara. E. Dyar of a scheme employed in Detroit. By this it was possible to raise in a single day 496 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS $11^000 for the local Societ}^ for the Prevention and Eelief of Tuber- culosis. Badges representing a blue star on pasteboard were sold throughout the city for ten cents each. Great eagerness was manifested by people of all ages and in all classes, and particularly by school chil- dren, to buy and wear the blue-star badges on that day. Collection sta- tions where the blue star was for sale had been established in the prin- cipal office buildings, shops, hotels, and factories. Special Dispensaries. — The importance of tul)erculosis dispensaries was strongly eni|)]iasized, especially by Dr. E. W. Philip, of Edinburgh, the father of the tuberculosis dispensary idea, and Professor Calmette, the pioneer of tuberculosis dispensary work in France. Philip's terse but very comprehensive definition of such a dispensary may be here quoted. " It is a central institution devoted to the guidance, supervision, and assistance of the tuberculous poor. An information bureau. A clearing house. A center for the supervision of home treatment. The connecting link or knot that completes the chain of other undertakings for the prevention of tuberculosis." For Calmette the preventorium or supporting dispensary is the essen- tial instrument of social preservation against tuberculosis. It does not treat patients medically, that function belonging to sanatoria, hospitals, and medical polyclinics. Its mission is to locate, attract, and keep under supervision those among the very poor who are peculiarly exposed to tuberculous infection and those who are already affected. It selects patients suitable for sanatorium treatment ; takes charge of children that are menaced or already attacked by the disease, promoting their proper treatment and cure in the country or in seaside establishments. Patients dangerous to their surroundings are sent to isolation hospitals. Dwell- ings are disinfected and contaminated linen sterilized and washed. Spit cups and antiseptics are distrilmted. What large amount of work can be done by tuberculosis dispensaries with judicious management was well brought out by Alexander M. Wil- son in his report of the work of the Chicago Tuberculosis Institute, which maintains seven special dispensaries in various districts of the city, supplying a nurse to each clinic, and through its central office coordinating the work of the dispensaries, thus preventing duplication. In less than seven months 1,400 examinations were made. Compulsory Examination of Children. — The importance of this was forcibly presented l)y Baumel. He suggests the thorough semiannual medical examination of every child in orphan asylums, kindergartens, nurseries, and schools. He furthermore urges that uniform reports and certificates be transmitted to other institutions to which the child will go, or be handed to the child at the end of the school year. Finally, he very pertinently points out the necessity of having the tuberculous ADDENDA 497 children treated in institutions wlicn the parents cannot have them prop- erly cared for at home. It goes witliout saying that the children's teeth and ears should be included and attended to if found diseased, a point Avhich was also insisted upon by Woodbury. Finding that ninety-six per cent of school children have decayed teeth, he believes that instruction of school children in dental hygiene is of paramount importance in the prevention of tuberculosis. Day and Night Camps. — Although these camps are at present pri- marily intended for treatment, reference to the reports presented may be made here, because of their possible adaptation to preventive pur- poses. A number of day camps are now in operation in various Ameri- can cities. Especially important and gratifying is the work of the branches of the Ked Cross Society, through whose instrumentality day camps in Washington, Schenectady, Albany, and Buffalo have been estab- lished. The Xew York branch is now cooperating with the authorities of the Medical Department of the Columbia T^niversity to establish a day camp on the roof of the Yanderbilt Clinic in the city of Xew York. W. C. White presented his conception of a night camp. He suggests that for many tuberculous patients the night camp would be most valu- able and productive of a great deal of good especially for those needing supervision or for those who cannot get proper care where they live. He distinguislies the three following groups of patients, for many of which the night camp he believes is the " reasonable and most valuable scheme " : I. Those still working, not conscious of their lesion, with (a) open, (h) closed active, and (c) healed tuberculosis. II. Those still working, conscious of their lesion, who from their existing social condi- tion are compelled to work. III. Those not working, conscious of their lesion, yet able to work four to eight hours daily — (a) old sanatorium cases, (h) home-arrested cases. Administrative Control. — Biggs reported in detail on tliis subject, and was able to state that " at the present time there is no other city in the world in which the health authorities have so thoroughly organ- ized the tiiberculosis campaign as in the city of New York." E. Koch's emphatic indorsement of the Xew York methods, which arc in detail desci'ibed in tlie text, deserves mention. Naval and Military Prophylaxis. — Kirsch (German navy) ])ointed out that in order to avoid the more frequent diseases of the respiratory organs in the navy, due to climatic changes, the cut of the uniform sliould be modified so as to afford better ])rotection to the throat and chest. He suggests also that the men whose services keep them below should be brought on deck every day and put through a drill of gym- nastic exercises. Saar (German army) suggests, as guiding principles in the preven- 498 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS tion of tuberculosis in tlie German army: (1) Refusal of recruits sus- pected of tuberculosis. Positive signs of tuberculosis or a history of a for- mer illness of a suspected tuberculous nature, or an inferior physique (habitus paralyticus, thorax pyriforniis, floating tenth rib), to be re- garded as a cause for rejection. (2) Eecruits susjiected of tuberculosis having been enlisted, should be carefully examined (X-ray, subcutaneous and conjunctival tuberculin tests), and if found tuberculous should be at once discharged. (3) Eecruits who steadily lose weight should be care- fully examined and eventually be kept under observation in the hospital. (I) Tuberculous soldiers should be kept in hospitals until the time of their discharge from the army. They should be treated in special tuber- culosis wards. He recommends also for the systematic prevention of dust the treat- ing of the floors of offices and barracks with a dust-binding oil (dustless oil, Westrumit). Furthermore, the hardening of the men by means of regular douching, the introduction of '' naked gymnastics " in the morn- ing after rising, the establishment of light and sun baths in the open air. Rather radical seems his recommendation that if a noncommissioned officer desires to marry, he should be obliged to furnish a medical cer- tificate of his prospective bride, and also that those serving in the canteen must prove that they are free from tuberculosis. Prison Prophylaxis. — To this not sufficiently considered problem J. B. Ransom made an authoritative contribution. He concluded as a result of his observations tliat the large percentage of tuberculous cases in prisons would indicate tuberculosis to be more or less closely allied to crime. He considers the tuberculous prisoner to represent one of the greatest physical menaces to the general social order, insisting on the necessity for a law making mandatory the examination of every pris- oner admitted to a penal institution. The experience at Clinton prison illustrates the advantageous results obtainable from special treatment of the tuberculous incarcerated criminal. The death-rate from tuberculosis during the past fifteen years shows a decrease of seventy-one per cent in the prisons of New York. He advocates also a closer study of the disease in prisons where most satisfactory opportunities for prolonged experi- ment and study are offered. Prostitution. — A study of its relation to tuberculosis was reported on by J. Willougliby Irwin. An examination of 213 prostitutes showed 82 tuberculous — 63 in the first, 18 in the second, and 1 in the third stage (Turban). He believes that it is not beyond the range of possi- l)ility that they acquired, or at least some of them acquired, the disease in tlieir intercourse with men having tuberculosis. Children's School Farms. — Children's school farms, such as are con- ducted in New York under the admirable directorship of Mrs. Henry ADDENDA 499 Parsons, should be multiplied, especially in large, but also in small, cities. Such farms, when located in congested districts, do both pre- ventive and constructive work. Children predisposed to tuberculosis are given an opportunity to spend the greater part of the day doing garden- ing work, learning to love outdoor life and outdoor pursuits, this being cf the greatest advantage to their future ph3'sical welfare. Mrs. Par- son's report made on this subject is full of practical suggestions. She very justly says : " Such gardens, conveniently located throughout the city, would accommodate thousands of such children for six or eight months in the year, year after year, in comparison with the few that can be sent to the seashore, mountain, or sanatoria for short stays. The pos- sibility exists of teaching hygiene within the children's comprehension, by simple experiments with plants in their own plots which will lead them to see why fresh air, cleanliness, and sunshine are absolutely necessary to life and vigor and which will lead them to demand such surroundings in their own homes." Trained Nurses. — The social significance and educational possibilities of the nurses' work in the homes of the poor and rich was dwelt on by Miss Lillian D. Wald. She described the comprehensive organization of State tuberculosis work in Pennsylvania under State Commissioner Dr. Dixon, with nurses and adjuncts in county centers and State sanatoria; also the " follow-up " work of hospital and dispensary patients, includ- ing instruction, interpretation, sending to suitable hospital and dispen- sary, the procuring of appropriate employment, etc., and Avorking for the development of special care of children in public schools. The hospital training schools for nurses give two or three years' education, technically and morally — an excellent preparation. They are drilling the " soldiers in the field," and always exercise the most careful selection of the gradu- ates. The social significance lies in the ability of these " soldiers " to care for the individual victims and to throw light upon the whole sub- ject and the multiple social questions involved. Public Schools, Colleges, etc. — Luther H. Gulick insisted on the im- portance of attacking the tuberculosis problem through the agency of the public schools, which is indicated by the fact that ten out of eleven of all the children of the United States come under the jurisdiction of the public-school system for approximately seven years — namely, from seven to fourteen. G. A. Heron gave an interesting report of the work done in England. Special instruction in elementary hygiene is given throughout the United Kingdom to prospective teachers in the training colleges. The course of training, however, is so adapted as to avoid even the semblance of turning out teachers who might imagine themselves to be specialists in hygiene. The object of it all is to endeavor to secure for the school 500 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS a teacher who is " able to appreciate the conditions, both mental and physical, which unfit a child for school work," and who is so trained that he would be likely to find children who failed to acquit themselves creditably, not because of unwillingness to work, but because of some physical defect or incapacity. William Harmon Norton advocated lectures on tuberculosis in col- leges and university extension courses. He very pertinently pointed out that by so doing hundreds of thousands of young men and women who go out from college to become citizens of exceptional influence in their communities are enlisted in antituberculosis work. Hygienic instruction in schools was also discussed by H. B. Jacobs, who closed his interesting communication with the significant words: " Never will the suppression of the preventable diseases (including tuber- culosis) be secured until the coming generation, rather than the passing one, is instructed in the proper methods to be pursued." Insurance of Workingmen against Sickness. — The new Hungarian law relating to insurance of workingmen is, according to Johannes Bar- tha's communication, doing, and is destined to do, even greater work in the prevention of tuberculosis than the German insurance companies. The municipal regulations adopted against tuberculosis in the Freistadt Kolozovar, East Hungary, has accomplished the following objects with the aid of the insurance companies: The recent revision of the building regulations improving the living conditions of the masses, the early clos- ing of saloons, antispitting regulations, the prohibition to shake out dust cloths on the street. Furthermore, provisions must be brought to market in absolutely clean vessels, baskets, etc. Fruits, pastry, etc., must be protected from flies; confectioner}^ may be exposed for sale only in cases covered with tightly fitting glass lids, and customers are not permitted to finger the wares for the pur})ose of making a selection. Wise abattoir regulations. Eooms occupied by persons who died of tuberculosis, their bedding, and the clothing used by them are disinfected by the city. Resolutions. — The following resolutions were adopted by the Con- gress, and they reflect the new prominence given to the social aspects of the tuberculosis problem, of which the establishment for the first time of a section devoted entirely to those aspects was a most gratifying mani- festation. It was resolved : 1. That the attention of State and central governments be called to the importance of proper laws for the obligatory notification, by medi- cal attendants, to tlie proper health authorities, of all cases of tubercu- losis coming to their notice, and for the registration of such cases, in order to enable the health authorities to put in operation adequate meas- ures for the prevention of the disease. 2. That the utmost efiEorts should be continued in the struggle against ADDENDA 501 tu])erculosis to prevent the conveyance from man to man of tuberculous infection as the most important source of the disease. 3. That preventive measures be continued against ])ovine tubercu- losis, and that the })ossibi]ity of the propagation of this to man be recognized. 4. That we urge upon the public and upon all governments (a) the establishment of hospitals for the treatment of advanced cases of tuber- culosis, (h) the establishment of sanatoria for curable cases of tuber- culosis, (r) tlie establishment of dispensaries, day camps, and night camps for aml)ulant cases of tuberculosis which cannot enter hospitals or sanatoria. 5. That this Congress indorses such well-considered legislation for the regulation of factories and workshops, the abolition of premature and injurious labor of women and children, and the securing of sanitary dwellings, as will increase the resisting power of the community to tuberculosis and other diseases. 6. That this Congress indorses and recommends the establishment of playgrounds as an important means of preventing tuberculosis through their influence upon health and resistance to disease. 7. That instruction in personal and school hygiene should be given in all schools for the professional training of teachers. 8. That whenever possible, such instruction in elementary hygiene should be intrusted to properly qualified medical instructors. 9. That colleges and universities should be urged to establish courses in hygiene and sanitation, and also to include these subjects among their entrance requirements, in order to stimulate useful elementary instruc- tion in the lower schools. PAET Y TREATMENT IXTRODUCTION By EDWARD L. TRUDEAU No generally accepted treatment of ])ulnionary tubej^culopis, beyond the climatic cure, can be said to have existed before Brehmer, in 1859, demonstrated by his sanatorium methods the great value of regulation of the details of the patient's daily life, and instituted the now generally accepted and universally practiced open-air method, in which fresh air, rest, and careful alimentation, with or withoiit specially favorable cli- matic conditions, are the main factors utilized. For the first fifteen 3^ears Brehmer's teachings made but little impression, but during the following twenty years the open-air treatment, whether in or outside of a sanatorium, whether under favorable or unfavorable climatic con- ditions, has been generally accepted and gradually adopted all over the world as giving the best results in the management of all forms of tuberculosis. At present, life in the open air and generous alimentation are uni- versally recommended, but the great value of absolute rest while symp- toms of activity are present, and relative rest at all times, as tending to limit autotoxemia, and the imperative need of the regulation of the daily life for many months at a time, can as yet hardly be said to be generally appreciated, except by specialists and sanatorium physicians. The exact value of climate is still a disputed subject, but it is difficult to understand why climate should l)e disregarded entirely while all other factors which go to make up a favorable environment for the patient are insisted on. No doubt good results could be and are obtained witliout any specially favorable climatic influences, but it seems hardly rational to insist on tlie value of the minutest details of the patient's surround- ings and habits of life, and deny absolutely any influence of climate as a factor in securing the most favorable environment obtainable for the patient. The modern and now generally accepted treatment of tuberculosis by the open-air method aims simply at bringing tlie patient's general health to tlie highest possil)le standard, thus develoj)ing the natural defensive resources of the iiidividiuil. and rendering the soil as unfavorable as possible for the growth and sjjivad of the tubercle bacillus through the system. Successful as this treatment is in nuiny cases, especially where 505 506 TREATMENT the disease is detected in its incipieney or is not of too acute a type, it naturally has its limitations, and from a condition of absolute hopeless- ness and pessimism as to the cure of tuberculosis, the public and the profession are now in danger of forgetting the persistence and relapsing nature of tuberculosis, of exaggerating what can be accomplished by a few months of favorable environment, of underestimating the limita- tions of the open-air method, and especially the time required to obtain permanent results. The arrest or cure of pulmonary tuberculosis by the sanatorium and open-air method requires time, and produces too often but a relative cure, which in a great many cases is maintained only if the patient can return to a mode of life and surroundings which make but little demand on his resisting powers. That a patient whose disease has been arrested in a sanatorium is not fitted to return at once to the trying conditions of life which the modern struggle for existence so often ren- ders necessary, is gradually becoming apparent. What is true in the treatment of pulmonary tuberculosis is equally true in the treatment of all other tuberculous manifestations in the body. The so-called surgical forms of tuberculosis, where the disease attacks the bones, joints, or skin, are best treated by the hygienic, dietetic, open- air method, in or outside of sanatoria, with or without special climatic advantages, but with the addition of conservative surgical measures. If the good results obtainable by the sanatorium and open-air method could be made permanent — that is, if a certain degree of immunity to relapse could be obtained by any method — the work of such institutions would be much more encouraging. The future outlook for progress in the treatment of this disease, as for all other chronic bacterial infections, would seem to be in the discovery of some specific method of limiting the ravages of the bacteria in the living organism, and the light which ex- perimental medicine during the past twenty years has been shedding on the mechanism of infectious diseases, would indicate that success is most likely to be attained by the discovery of some safe method of producing artificial immunity by the inoculation of bacterial vaccines. It has taken many years of tireless experimentation to demonstrate the possibility of producing any appreciable degi'ee of artificial immu- nity to tuberculosis in animals. ^Yith this advance the names of Koch and Behring in Germany, McFadyean, Wright, and Douglass in Eng- land, de Schweinitz, Trudeau, Pearson, and Gilliland in this country, are closely connected. Koch's discovery of tuberculin, and his appli- cation of this suljstance to the treatment of tuberculosis, mark an era in the specific treatment of this disease. The failures and disasters which followed his announcement and brought tuberculin into such disrepute, were evidently due in a great measure to our ignorance of the principles INTRODICTION 507 of artificial immunization, to faulty methods, and to a lack of appre- ciation of the extreme toxicity of this most powerful agent. Of late, with improved methods of application, with a better appre- ciation of the potency and action of tuberculosis toxins, some clinicians are reporting more encouraging results in the therapeutic use of the various tuberculins. The work of Wright and Douglass on the opsonins, and the relation of the opsonic index to artificial immunization by tuber- culosis vaccine, and Professor von Behring's extensive laljors on the pro- duction of artificial immunity in cattle, indicate that the future of the specific treatment of ti;borculosis in man by some immunizing method is full of promise. The prevention of tuberculosis can be advanced by nothing so sureh^ and rapidly as by a successful specific method of curing the disease. When science shall have given us such a method, the control of tuberculosis, with all it means to mankind, will be near at hand. CHAPTER I SPECIFIC TREATMENT By LAWRASON BROWN HISTORICAL INTRODUCTION The discovery of the tubercle bacillus was quickly followed by many attempts to destroy it in the tissues of tlie infected organism by the administration of various substances found to kill it in vitro. The literature of this period abounds in reports of attempts of this kind, and many substances were recommended which, if used in sufficient strength, would have killed the host as quickly as the parasite. These so-called " false specifics " will be discussed elsewhere. The study of the pathology of the disease showed that it was impos- sible in any case to attack the germ in the midst of caseous matter or in old tuberculous foci where there were no or very few blood-vessels. This, however, is no argument against the use of any substance that can be borne by the blood in such strength that it will kill or weaken the tubercle bacillus and not injure the tissues, for the tubercle bacilli in old tulierculous foci are of no danger to the body unless they escape into the blood or lymph stream, where such substances could speedily attack them. While such a body has not been and is not likely to be found, the whole svibject of artificial or acquired immunity rests anatomically on this basis. However this may be, chemistry has long been called on to furnish new agents for use in the treatment of tuberculosis, and it must be acknowledged that it has been overworked. Since the discovery of the tubercle bacillus we have had a means of testing the germicides experi- mentally, and none has proved of any value in treatment. The excellent results obtained by the hygienic-dietetic treatment of tuberculosis is now acknowledged by all, but few realize that its discov- erer (Brehmer) attributed for a long time its beneficial influence to some specific property connected with certain climates, or " immune zones." The idea of " specific climates " has long since given place in discussion to the question of the value of *' climate," but the " specific " value of high altitudes is still recognized by the use of the pneumatic 508 HISTORICAL INTRODUCTION 509 cabinet, and more recently by tbe advocacy of balloon ascensions. There is little to uphold these views. Eobert Koch, in IHUO (*90, A and B; '91, A and B), announced that he had discovered in tuberculin a cure for tuberculosis. Having noted that tuberculous and healthy animals react very differently to a subcu- taneous injection of living virulent tubercle bacilli, he was led to the dis- covery of tuberculin. Tlie first form he experimented with was a non- concentrated broth filtrate from a culture of human tubercle bacillus, now known as bouillon filtre (Denys). Koch considered tliis a weak tuberculin, and discarded it for the stronger, original tuberculin (0. T.). He advised the use of the original tuberculin only in early cases, with a first dose of 1 nigm., which should be repeated until there was no longer any reaction. Then 2 mgm. should be given in the same way, and so on. He believed it so acted on the circulation of the parts about the foci that the diseased tissue died and softened, or was discharged in toto. A failure of reaction was, therefore, due to the destruction and lack of tuberculous tissue, and so healing he believed was accomplished. The avoidance of reactions was not mentioned. This view has long since been given iip by Koch. Notwithstanding these cautions, tuberculin was administered to all sorts of cases, and many a poor, far-advanced consumptive was hurried to his grave. A patient, for instance, was given tuberculin and reacted to 104° F. on the following day, when he received a second dose with sim- ilar results. This was continued in some cases until death ensued. A few observers protested (Guttman and Ehrlich, '91) against this over- dosing, but were unheeded, and finally a storm of indignation arose which reached its climax when Yirchow ('91) stated that he found sof- tening and recent extension of disease in patients treated with tuber- culin and dying of tuberculosis, and the period of " tuberculin delirium " was over. It is manifestly unfair to select pathologic changes occurring in a patient dying of tuberculosis either as proof for or against any line of treatment unless these changes are such as rarely, if ever, occur in un- treated cases. Yirchow later acknowledged that all the changes he had observed do occur in untreated patients dying of tuberculosis. The only accurate pathologic data as to the value of tuberculin would be those obtained from patients treated with tuberculin and dying of an acute intercurrent disease, as Bandelier and Roepke point out. The age of "tuberculin terror" may be said to have begun at this time, and he who used tuberculin was looked on by many as a criminal. A few men (Trudeau, Goetsch, Klebs, Petruschky, von Euck) continued the use of tuberculin, and to them is due the fact that the period of "tuberculin renaissance," which began a few years ago, came to pass. 510 SPECIFIC TREATMENT Much cliemieal work Avas done on 0. T. by many men, who tried to separate a beneficial snl)stance from tliose ca{)al)le oi' injuring tlie patient. Hunter ('91) carefully analyzed tnl)ei-culin, and obtained by precipita- tion with ammonium sulphate a substance (Modification B) which he thought superior to 0. T. Trudeau used the same j^rocedure with the broth filtrate, but neither of these were found of more value than 0. T. Klebs, who was one of the first to work along this line, has consistently adhered to his belief that by treating the 0. T. with bismuth iodid, and filtering off the precipitate, he was able to obtain the beneficial sul)stancc by further precipitation by alcohol (tuberculocidin). This has not been widely used, but some report good results from its oral administration. Koch early recognized tliat 0. T. produced no perfect inmiunity to tuberculosis, and he also tried to separate from the tubercle bacilli the beneficial agent which he believed it contained, for the whole tubercle bacillus when injected subcutaneously produced abscesses. By extraction with sodium hydrate he obtained tuherculin nU-aJinum (T. A.), which on account of its abscess-producing qualities he quickly discarded. Hav- ing observed that at death many tissues failed to contain tubercle bacilli where they had apparently been present, he sought some means whereby he could make the tubercle bacilli more absorbable, for, he argued, had this but occurred earlier in the animals, immunity might have been ac- quired. The results were unsatisfactory, and he finally announced a new tuberculin — tuberculin residuum (T. R.) (Koch, '97) — consisting of an emulsion of pulverized, water extracted, virulent tubercle bacilli. The water extract he called tuherculin ohere (T. 0.), and said it contained the fever-producing substances and should not be used. This new tuber- culin, he believed, should be used so as to avoid all strong reactions, but the results were not satisfactory. Finally, in 1901, Koch ('01) recommended for use an emulsion of tubercle bacilli wliich he said should be given in increasing doses in spite of reactions, first subcutaneously and finally, if necessary, intra- venously, having in view the production of a strong agglutinating power in the serum. This was the beginning of the " tuberculin renaissance," and since this time many tuberculins have been widely used. The work of Goetsch, published in 1901 wifh a postscript by Koch, paved the way in Germany for a wide use of tul)erculin, while in America Trudeau's ('07) work has had the same influence. Denys's work ('07) called attention to the filtered bouillon culture of tubercle bacilli (B. F.) and emphasized emphatically the great care necessary in tlie use of any tuberculin. Trudeau's recent papers have also laid great stress on this point. Like strychnin, arsenic, and many other drugs, tuberculin may be of value when given properly, and is certainly a most potent poison when injudiciously given. SCHEMA FOR TUBERCl'LINS AND TUBERCLE BACILLUS VACCLNES 51 1 From his oracular communications von Behring would lead us to supj)ose that lie had solved the proltleni of making at one and tlie same time the tul)ercle hacilli Ixith ahs^orhahle and unal)le to produce tu- herculosis when injected into man or animal. Proof of this is still lacking. Vaughan (and Wheeler, '07) has, with his split products of the tuhercle hacillns, endeavored to separate the poisonous from the hene- ficial part, and he uses the latter for immunization. It acts, he lielieves, hy promoting bacteriolysis. More recently still Deycke and Eeschad Bey ('07) have obtained from a streptothrix found in lesions of leprosy a waxy substance which they have named nastin. Apparently it has a Itacteriolytic action on the tubercle bacillus Avhen injected subcutaneously, and can only be used, the}' believe, in very early stages, on account of the toxemia that would otherwise occur. Livierato, Klebs, and Maragliano all claim to have obtained some bacteriolytic action. The work of Moeller, Loewenstein, and TJappoport from Belzig, of Turl)an, Schnoeller, and Frey of Davos, of Wright of England, of Mara- gliano of Italy, of von Beln-ing of Marlmrg, and of many others too numerous to mention, has done much to throw light on this most sug- gestive and intricate subject. SCHEMA FOR TUBERCULINS AND TUBERCLE BACILLUS VACCINES The following scliema of tuljerculins and tul)ercle bacillus vaccines is arranged in three large groups, according as use is made of the culture fluid, the tubercle bacillus or both culture fluid and tubercle bacillus. The culture fluid of the first group consists of Koch's original formula, and the various preparations are grouped according to the strain of tubercle bacilli and the amount of heat employed. Tlie preparations of the tubercle bacillus are discussed in a similar manner, but are grouped under four heads — dead l)acilli, living bacilli, extracts of bacilli, and decomposition products. In the third large group of " Culture Fluid and Extract of Tubercle Bacilli," other formulas of bouillon have been used, which is taken into consideration as well as the strain of tubercle bacillus and the degree of heat. I. FILTRATE OF CTLTri^E (TvOCTT'S FOI^MFLA) Filtration through paper or candles (Berkefcld. ('Ii;iiiiberland, etc.). 512 SPECIFIC TREATMENT A. Human Types a. Unhealed h. Heated 1. Unchanged B. F. (Koch, Dcnys, to 60° (". or less Trudeau). 1. To 30° on water hath after 2. Precipitated (^114)280^ Mod. filtration through porcelain B. (Trudeau). (Maragliano). 3. Filtered and evaporated to one 2. Filtration, then concentration to tenth in vacuum (or thermo- one tenth at 57° (Ai'loingand stat at 37° C.) TOA (Speng- Oninai'd). ler's toxoid. h. Heated to 100° C. 1. Fractional distillation under N. (hacillosine, Vaillant). 2. Sterilized, filtered, diluted with 1\S) and glycerin, 10 gms. toxine, Lannoise. B. Bovine Types IJnheated and heated ( tlieoretical). C. Avian Types 1. Unlieated: Unchanged — A. " B. F." (theoretical) Courmont and Dar. experimental. 2. Heated (theoretical). D. Piscine types (theoretical) E. Other " cold-blooded " types (theoretical) F. Acid-fast types (theoretical) II. BA("ILLA1?Y BODIES A. Human types (dead) a. Untreated h. Treated 1. Allowed to (lie (.lousset). 1. By grinding without heat, cen- trifuged and glycerin-treated: T. E. (some extraction with water). B. E. (hacillary emulsion). 2. By lieating to 60° C. (Wright). 3. Extraction with ether. Fat-free bacilli (treated with iodin and KI given internally (Cantacuzene) ). SCHEMA FOR TUBERCULINS AND TUBERCLE BACILLUS VACCINES 513 B. Other strains (dead) C. Human types (living) a. Unchanged h. Attenuated hy Bovo-vaccine (v. Behring). 1. Decomposition. Tauruman (Koch-Schiitz). 2. Heat. 3. Prolonged growth. 4. Chemical means (unsuitable media). 5. Glycerin (Levy). 6. Passing through refractory ani- mals — blindworm ( Moeller ) , turtle (Friedmann). D. Avian types (living) Hericourt and Eichet, McFad3'ean. E. Bovine types (living) Spengler, Klemperer (in man). F. Cold-blooded types (living) Blindworm (Moeller), turtle (Friedmann), frog (Knester). EXTRACTIOXS OF BACILLARY BODIES {Only human types used) a. Unheated h. Heated 1. By alkalies T. A. (Koch). 1. Water and concentrated (100° 2. By water T. O. (Koch). C.) (Maragliano). Watery extract (von Huck). 2. Glycerin and water (150° C). 3. B}^ pressure: tubeivulo-phismin T. D. R. (v. Behring). (Biiclmer and Halm). 3. Fractional distillation at differ- 4. By cliloral hydrate, etc. ent temperatures. Tubcrkidose ) Tuberculol (Landmann). Tulase v (v. Behring). Tulaselaktin ) 5. By cldorofonii and ether (Au- clair). 6. By oil (Siallero). 7. By pure H,.S()„ etc (Tuherku- lotoroidin, Ishigami). 34 514 SPECIFIC TREATMENT DECOMPOSITION PRODUCTS OF BACILLARY BODIES 1. Tuberculinic (nucleic) acid (Ruppel, Levene). 2. Tuberculosin (Ivuppel). 3. Tuberciilosamin (Euppel). 4. Nucleoproteid (3, Levene). 5. Split products (Yaughan). 6. Alkaloid of tubercle bacilli, crystalline toxin treated witb Ca per- manganate — tuberculinum (Baudron). (Not from T. B. Nastin (Deycke-Eeschad Bey). III. CULTURE FLUID PLUS BACILLARY BODIES A. Bouillon — Koch's Formula I. Human a. Unheated (theoretical), h. Heated to 100° C. a^. Old (original tuberculin (tubercle bacilli water bath at 100° C.) boiled in bouillon and evaporated to ten per cent orig- inal volume — Koch). 1. Precipitated by: a-. Alcohol (sixty per cent) — purified (Koch). b^. (NHJ^SO,, Hunter's Mod. B. c^. By alcohol, chloroform, benzol, tuberculinum de- paratum (Klebs) (discarded). d-. Sodium-bismuth-iodid in acetic acid and then by alcohol. Antiphthisin (Klebs) discarded. e-. Alcohol and sodium-bismuth-iodid. Tuberculocidin (T. C, Klebs). 2. Extracted with NaOH (Weyl). 3. Oxidized by HgO, — oxytuberculin (Hirschf elder). h'^. Tubercle bacilli of standard virulence used, bouillon evaporated to eight per cent, filtered and sterilized. Jacobs ('04) tuberculin (T. J.). c\ Heated to 60° C. or less (theoretical). II. Bovine a. Unheated — theoretical. 6. Heated— P. T. 0. (Perlsucht tuberculin) (Spengler). III. Avian a. Unheated — theoretical. b. Heated and evaporated (avian "old tuberculin") (Roux). VARIETIES OF TUBERCULIN USED CLINICALLY 515 IV. Piscine a. Unheated — theoreticaL 6. Heated and evaporated (piscine old tuberculin) (Terre, Ramont and Eavaut, Bataillon, Moeller and Terre). V. Other Cold-blooded Tubercle Bacilli a. Unheated — theoretical. h. Heated and evaporated. Blindworm tuberculin (Moeller, from Dieu- doune). VI. Acid-fast Bacilli a. Unheated — theoretical. ft. Heated — timothy hay, grass bacilli (Moeller), paratuberculin iri- mescu, dung, pseudo-bovine. B. Other Formulas than Koch's I. Human a. Unheated. Tuberculin precipitated by alcohol sixty per cent from glycerinized, nonneutralized, nonpeptonized bouillon, and added to equal parts of precipitated orthophosphoric acid (one per cent) extract of tubercle bacilli of standard virulence, and dis- solved in 20 parts of diluent (Beraneck). 6. Heated to 100° C. 1. More glycerin, no meat extract, otherwise as in 0. T. (Yeseley). 2. Potassium-acid phosphate, ammonium phosphate, asparagin, glycerin, added to bouillon (De Schweinitz and Dorset). 3. More glycerin, neutralized with NaHCOs, not boiled and re- duced in vacuum to eight per cent (Ponzio). II. Bovine, etc. All theoretical. VARIETIES OF TUBERCULIN USED CLINICALLY The varieties of tuberculin that have been most used clinically, to- gether with a brief description of their preparation, include : 1. Old Tuberculin (Koch). — A boiled (for one hour), concentrated (on a water bath to one tenth volume), and filtered (through a Chamberlain filter) " beef broth " (containing five per cent glycerin, neutralized) culture, six to eight weeks old, of human tubercle bacilli, irrespective of virulence or of strain, but usu- ally much attenuated. The finished product contains fifty per cent glycerin. 516 SPECIFIC TREATMENT 2. Tuberculin R. (Kocli). — An imlieated twenty-per-cent glycerin emulsion of living, virulent, pulverized tubercle bacilli, which have first been extracted with water (water extract named tuberculin ohere), containing finally in each cubic centimeter 10 mgm. of solid substance. 3. Bacillen Emulsion, B. E. (Koch). — An unheated fifty-per-cent glycerin emulsion of living, virulent, pulverized tubercle bacilli containing 5 mgm. of solid substance in each cubic centimeter. The coarser particles are removed by centrifugalization. Arlo- ing believes that B. E. affects breathing more than old tuber- culin, the effects of B. E. last longer than 0. T., and that the severity depends upon the virulence of the bacilli in the emul- sion and in the animal. 4. Tuberculocidin (T, C.) and Antiphthisin (Klebs).— The old tuberculin is first precipitated with bismuth (tuberculocidin) or potassium-bismuth-iodid in acetic acid (antiphthisin) and then with alcohol. 5. "Watery Extract" (von Ruck). — Tubercle bacilli are washed with water, then first extracted with alcohol and ether and pul- verized, and finally extracted with water at 50° C. 6. Broth Filtrate (B. F.) (Denys). — The unheated, unconcentrated, filtered (through porcelain) bouillon culture of human tubercle bacilli. Denys believes this is ten to a hundred times as strong as 0. T., but Baldwin has proved 0. T. far more toxic for guinea pigs. 7. Beraneck's Tuberculin. — A twenty-per-cent solution of equal quantities of the unheated precipitate (by sixty per cent alco- Jiol) of a culture of tubercle bacilli of standard virulence on glycerinated, nonneutralized, nonpeptonized bouillon and of an orthophosphoric acid (one per cent) extract of untreated tuber- cle bacilli. It is less toxic and less vaso-dilating than 0. T. Living tubercle bacilli were found at first in T. R. and B. E. by Thellung, in B. E. by von Meissen, and in T. R. by Huber. Many other contaminating bacteria were present at first in some specimens (Baumgarten and Walz). Tuberculase, tulase, and tulaselaktin of von Behring are products of or altered tubercle bacilli, whose preparation has never been made known. No accurate method of standardization of tuberculin has yet been found, though Doenitz, Otto, and von Lingelsheim have all suggested methods, the first two using tuberculous with subcutaneous, the latter healthy guinea pigs with intracerebral injections. CHEMISTRY OF TUBERCULIN 517 Comparison of the strengths of the various tuberculins were made by von Behring on twenty tuberculous cattle, and he found — 1 part T. E. = 3 parts 0. T. 1 part tuberculin purified by partial alcohol precipitation = 4 to 6 parts 0. T. 1 part dried and pulverized tubercle bacilli r= 4 to 5 parts 0. T. 1 part nuclein substance = 3.5 to 4.5 parts 0. T. 1 part tuberkulosamin = 3 to 3.5 parts 0. T. 1 part tuberculinic acid =: 3.5 to 4 parts 0. T. C. Spengler states bovine tuberculin causes a more intense skin and " organ " reaction than 0. T. As Guinard ('02) remarks, there are two principal objects in all the work on tuberculin : ( 1 ) To free the tuberculin of its dangerous constituents and to preserve its useful ones; (2) to obtain more of the latter either by changing the media used for growth of the tubercle bacillus or by employing a better method of extraction. On the whole, the results do not permit us to think that a single tuberculous extract bearing the name of tuberculin is able to be taken as a type or repre- sents a fixed product, constant in its composition and in its effects. All probably contain the specific nucleic acid. What Maragliano said in 1898 is still true to-day : " There is no tuberculous poison entitled to the name because it has not been isolated in a state of purity. They have always been in glycerin or aqueous solutions under different forms of precipitates, dried or redissolved, more or less mixed Avith other albumoses." Guinard also agrees Avith Arloing, who claims that how- ever slightly the microbic products are treated, the active element may be changed. CHEMISTRY OF TUBERCULIN Old tul)erculin, Kuehne found, differed only (luantitatively from the broth-culture fluid. It gave all the proteid reactions, but resisted heat (160° C. for two hours in 50 per cent glycerin solution), so differing from all kno\\7i ali)uinosos and toxalbumins. The largest amount of active substance was precij)itated by 60 per cent alcohol, and tbe crude and precipitated tuberculin contained on an average 18.86 per cent ash, chiefly K and Mg phosphate. Kuehne found in tuberculin by analysis no alkaloids, but (1) an allniminate (nucleoproteid), (3) a peculiar (aero-) albumose, (3) deutcro-albumose, (4) traces of peptone, and (5) trypta- phane, a digestive product. Ruppel, who examined broth filtrates heated only to 30° to 40° C, found no specific substance differing in chemical reactions from the proteids in the original broth. 518 SPECIFIC TREATMENT The niuleoproteids and tubereulinic acid obtained by extracting bacilli with water, with glycerinated water (three to five per cent), or with weak alkaline solutions contained much of the active principle. This substance is probably in proteid combination, and while peptic digestion weakens its activity, tryptic digestion destroys it (Baldwin and Levene) and it is not easily dial3^zable. Tuberculin obtained from the bovine bacilli is strongest, that from the human weaker, while that from the avian is weaker still (Euppel), a fact that Smith explains by the increased alkalinity of the bovine cultures. It has long been held that if only a more virulent toxin co|ild be obtained from the tubercle bacillus, or from its culture fluid, immuni- zation might be possible. Much work by Euppel, Levene, and others has resulted, but no advance has been made along this line for some time, and it is now, for the present, at least, abandoned (Ott, '03). METHODS OF ADMINISTRATION Intravenous. — While Koch at first advised tuberculin to be admin- istered hypodermically, in 1901, when he announced his B. E. and in- timated that it was necessary to obtain a high agglutinating power in the blood to an emulsion of pulverized tubercle bacilli, he suggested that as large doses of B. E. caused, when given subcutaneously, ab- scesses, that these doses be given intravenously. Few, however, now accept the importance Koch at that time attributed to agglutination as the index of immunity and intravenous injection of tuberculin may be said to be almost never used. Eothschild, M. ('06), and Heermann ('05) have reported good results in some patients with this method, and Denys has used it. The dose is one tenth the amount given sub- cutaneously, and the fact that the best immunity has been obtained with living bacilli by this method should arrest attention. Oral. — Tuberculin has been administered in nearly every conceiv- able way. Freymuth ('05) has given it per os in the form of kaolin- coated pills, after neutralization of the gastric juice with sodium bicar- bonate to avoid digestion in the stomach, while Klebs takes no account of this factor. Hubs ("07), who reacted severely to small doses sub- cutaneously (100° F. after 0.00005 0. T.), took 1 gm. 0. T. by mouth with and without neutralizing the gastric juice with a large amount of sodium bicarbonate, and yet, although he had taken 20,000 times the foregoing minimum dose, it had no effect whatsoever. Eecent work on serums has shown that antibodies in serums are absorbed un- changed from the alimentary tract only during the first two weeks of life or when the epithelium is injured, but Calmette and Guerin ('07) have succeeded in vaccinating calves by feeding them tuberculous METHODS OF ADMINISTRATION 519 milk, while Figari and Maragliano claim to have had excellent results in guinea pigs from oral administration of blood clots from immunized calves and horses. The work of Levene, Baldwin, and Kinghorn shows that tuberculin is affected by the digestive processes in the stomach and intestines. Furthermore, it is impossible to gauge accurately the dose by this method (Loewenstein and Koehler) or by inhalation, and consequently severe reactions may occur when least expected and hyper- sensibility result. Inhalation. — Kapralik ('04) and von Schroetter ('04) have em- ployed tuberculin by inhalation in the form of a spray, first suggested by Moeller, a method requiring large doses and incurring, therefore, much expense. Bandelier obtained no results from inhalations, and Huhs thinks them of little value. Jacobs injected tuberculin intratracheally, to enable a large quan- tity to reach the site of the lesion, and was severely criticised by his confreres. Tuberculin in solution is well absorbed from the lungs, but the dosage is inexact, and what can be hoped from saturating with tuberculin an organ which already contains much of it is difficult to see. Dermic. — Administration by rubbing into the skin is only of value in hypersensitive individuals and children. It has marked limitations which Spengler ('03) has noted, and further may be accompanied by disagreeable skin reactions. Spengler rubs into the forearm of patients who are hypersensitive 1, 5, and 10 mgm. at intervals of two to four days. In two weeks the subcutaneous injections can be recommenced. Proper dilutions render this method entirely unnecessary. The rectal and the intrapulmonary injection (Livierato) of tuber- culin need only to be mentioned to be condemned. Subcutaneously. — Tuberculin injected subcutaneously is nearly at once absorbed by the lymphatics. It is of interest to bear in mind that the large mononuclear cells which seem chiefly concerned in the process of immunization in tul^erculosis are probably derived from the endo- thelial cells of the lymph and blood-vessels, which are directly stimu- lated by this method, and stimulated most intensely at a point far distant from the area of infection. Beraneck, however, opposes this view, and believes tuberculin should be injected directly into or imme- diately about the focus. A careful consideration of all these methods unquestionably leads to the conclusion that the subcutaneous method is by far the most exact, the most reliable, the most elastic (adaptable), and the most efficacious. The same arguments apply here that are used in favor of the hypodermic administration of drugs. For tiiese reasons the discussion here is limited entirely to the subcutaneous administration of tuberculin. 520 SPECIFIC TREATMENT DILUTIONS Tuberculin in man}^ instances produces at the site of injection the four classical signs of inflammation — tumor, roboi\ calor, and dolor. It is natural to presuppose that the tissues are less resistant to infection at this point, but care in regard to asepsis always prevents suppuration unless large doses of B. E. have been given, when, in sj)ite of asepsis, local sterile abscesses may occur. All emulsions or vaccines of tubercle l)acilli should always, therefore, be well diluted, but this is not neces- sary with many other forms of tuberculin. Preservation in Dilution. — In all cases, except where large doses of tuberculin are used, it is necessary to dilute the original tuljerculin, as at present few tuberculins are put on the market in a form sufficiently di- luted for the earlier doses. Furthermore, it lu\s not yet been determined how long the high dilutions retain tlieir strength, especially when a small percentage of some antiseptic has been added. High dilutions apparently retain their strength for two weeks, and it is not improbable that they may do so for a much longer period, but until sufficient proof of this is adduced they should be made up fresh every two weeks. Jacquerod says a ten-per-cent solution degenerates only after six weeks. It is best to keep the tuberculin as well as all dilutions in a cool place (ice box) protected from light. In making the dilutions the greatest care should be used not to contaminate the original tul)erculin, which should be in a paraffined, rubber-stoppered, dark bottle. If con- taminations do occur — i. e., if the original tuberculin becomes more cloudy (some forms are never clear) — it should be discarded and not used. With care this is practically never necessary, and no instance of any sort has ever suggested to the writer that the tuberculin he was using should be resterilized. Method of Diluting. — The dilution of tuberculin is a comparatively simple process that demands little previous experience but great exact- ness. If at any time during the process of dilution a question of error arises, it is well to throw aside the dilutions and start anew. The instruments necessary for making dilutions are a 1-c.c. glass pipette, graduated into hundredths of a cubic centimeter, Avith a scale at least 15 cm. long and a long, conical 10-c.c. graduate. These should always be boiled before use, though some recommend keeping them in a disinfecting solution (alcohol, etc.) and rinsing with a diluent before using. A glass syringe with a capacity of 1 c.c, with a long, narrow barrel, graduated into hundredths of a cubic centimeter, is mi;ch easier to use, and, if accurately graduated, is more exact. It matters little, however, whether either the pipette or syringe be accurately graduated, provided that the same instrument be used each time. This syringe DILUTIONS 521 is also the best for use in giving tuberculin. The actual dose is of far less importance than the relative dose. If a syringe be used, it should Fig. 147. — Ix-ti:umextarium for Tubercxtlix Injections. From left to right: Sterilizer, large (1,000 c.c.) and small (100 c.c), measuring cylinders, flask with sterile water, bowl, three small bottles holding tuberculin stock solutions (B. E. and B. F.). On shallow glass dish with hj-podermic syringe, holding 1 c.c, subdivided into lOOths c.c. In front calibrated pipette. be freed carefully from water and rinsed several times in the solution to be diluted (see Fig. 147). Diluents. — The best diluent is probably one fourth per cent phenol in physiologic saline solution. It should be carefully boiled and filtered from time to time. Phenol may be replaced by lysol in the same strength. For emulsions of the tubercle bacillus, which should always be shaken before using, Koch recommended that the diluent should be physiologic salt solution, but the ordinary diluent may be used. Estimating Dilutions. — When a table for dilutions is not at hand, the easiest method is to decide what content per cubic centimeter is desired. For example, if 10 c.c. of a diluent, in which 1 c.c. =: 0.000001 c.c. of the original tuberculin, be required, with a pipette or syringe 0.1 c.c. of the original tuberculin is taken and the diluent added until 10 c.c. is reached. Then as 0.1 c.c. is in 10 c.c, 1 c.c. must contain 0.01 c.c. Repeating this, a solution is obtained of which 1 c.c. = .0001 c.c. of the original tuberculin. The amount desired of the final solution determines how much of this solution should be used. As it is wished 522 SPECIFIC TREATMENT to get 10 c.c. of a solution in which 1 c.c. = .000001, multiply .000001 by 10, obtaining .00001. This amount of tuberculin is contained in 0.1 c.c. of the last solution, which is measured out and diluted up to 10 c.c, which gives the required strength — 1. e., 1 c.c. = .000001 of the original tuberculin. This process may be continued until any required dilution be obtained. By adding diluent until a volume of 100 c.c. is reached, fewer intervening dilutions are necessary. It is unwise to attempt to meas- ure less than 1 c.c. when making dilutions. The accompanying schema, in which grams are equivalent to cubic centimeters, has long been used at the Adirondack Cottage Sanitarium, and has given much satisfaction: Variety Strengt O. T. OR B. F. 1 G. TO 1 C.C. T. R. .01 G. TO 1 C.C. B. E. .005 G. TO 1 r.c. Solu- tion No. To make 10 c.c. of solutions of following strengths — Take Take Take 1 g. to 1 C.C. 10 c.c. Tuberculin. i I .Ig. tolc.c. 1 c.c. Tuberculin. 9 c.c. Diluent. 11 .01 g. to 1 c.c. 0.1 c.c. Tuberculin 9.9 c.c. Diluent. or 1 c.c. Solution I. 9 c.c. Diluent. 10 c.c Tuberculin. III .001 g. to 1 c.c. 0.1 c.c. Solution I. 9.9 c.c. Diluent. or 1 c.c. Solution II. 9 c.c. Diluent. 1 c.c. Tuberculin. 9 c.c. Diluent. 2 c.c. Tuberculin. 8 c.c. Diluent. IV .0001 g. to 1 c.c. 0.1 c.c. Solution II 9.9. c.c. Diluent. or 1 c.c. Solution III. 9 c.c. Diluent. 0.1 c.c. Tuberculin 9.9 c.c. Diluent. or 1 c.c. Solution III. 9 c.c. Diluent. 0.2 c.c. Tuberculin. 9.8 c.c. Diluent. or 1 c.c. Solution III. 9 c.c. Diluent. V .00001 g. to 1 c.c. O.lc.c.Solutionlll 9.9 c.c. Diluent. or 1 c.c. Solution IV. 9 c.c. Diluent. O.lc.c.Solutionlll 9.9 c.c. Diluent. or 1 c.c. Solution IV. 9 c.c. Diluent. 0.1 c.c. Solution III 9.9 c.c. Diluent. or 1 c.c. Solution IV. 9 c.c. Diluent. VI .000001 g. to 1 c.c. 0.1 c.c. Solution IV 9.9 c.c. Diluent. or 1 c.c. Solution V. 9 c.c. Diluent. 0.1 c.c. Solution IV 9.9 c.c. Diluent. or 1 c.c. Solution V. 9 c.c. Diluent. PREPARATION FOR INJECTIONS 523 PREPARATION FOR INJECTIONS Cleansing of Skin. — The area of skin selected should be vigorously rubbed with alcohol both before and after the injection. No other cleansing is necessary, and the use of antiseptics, ether, cotton, col- lodion, etc., is superfluous. In thousands of injections made by the writer, alcohol alone has been used and no infection has ever oc- curred. Needles. — The needles used should be very fine, should be rinsed in alcohol or ether after using and in boiling water before using. They need not be boiled, nor need they be kept in alcohol if they are not used for any other purpose. The platinum-iridium needles used by some (Holdheim) are unnecessary. Accidental Inoculation. — When tuberculin is given to a large num- ber of patients, great care should be taken to avoid ejecting a spray of tuberculin into the air when forcing out bubbles of air, as reactions have been produced in this way. The boiling water used for rinsing the syringes between injections should always be fresh, and graduates or pipettes used for making dilutions should never be placed in this water, nor should the water drawn up into the syringe be ejected back into this pan. The physician, if tuberculous, should always wash his hands after handling tuberculin. Site of Injection. — During the rubbing for cleansing, the site should be examined to see that it is free from indurations left from previous injections. The occurrence of these indurations vary both for indi- viduals and for the form of tuberculin used. The usual site is 4 to 8 cm. from the midline opposite the seventh to the tenth dorsal spines. The skin is usually thick, less vascular, easily movable, and less sensitive in this area. It should be given well under and not in the skin. Beraneck believes that his tuberculin acts more favorably when injected near or directly into the focus in surgical tuberculosis, as it produces an increased phagocytosis and possibly sets free bacteriolytic ferments from the cells. He has not advocated intrapulmonary injec- tions. Crocker and Pernet advise local injection in lupus. The toxin enters, often continuously, into the circulation about the tuberculous foci, and the contiguous cells are constantly stimulated. In tuberculin treatment it is injected at intervals into the lymphatics (subcutaneous), far removed from the disease foci. The latter process may call into play the whole body, especially the lymphatic system, while the action of the former may be limited to the circulatory system, possibly of a limited area. 524 SPECIFIC TREATMENT DOSAGE AND INTERVAL General. — The crucial point in the tuberculin treatment is the selec- tion of the dose and interval. The literature of the period of tuberculin delirium (1890-91) is filled with reports of patients who were excessively overdosed, and in some instances undoubtedly killed by overdosing with tuberculin. The few men who continued to use tuberculin were those who from the first employed much smaller doses than were in current use. To Guttmann and Ehrlich, to Goetsch particularly, to Denys, to Trudeau, and to Wright do we owe the present recognition of the value of small doses. Two men, hoAvever, Denys and W^right, deserve special mention in this connection. Denys in his book, " Le Bouillon Filtre," has given the best exposition of the clinical value of beginning with small doses of tuberculin in all forms of tuberculosis, and Wright, basing his opinion on his studies of the opsonic index, has emphasized the great benefit to be derived from small, repeated, or very slightly increased doses of tuberculin in surgical tuberculosis. The method of administration of tuberculin is far more important than the variety of tuberculin, and he who fails to consider that tuberculin is a most potent poison, is a dangerous man. Too great care cannot be exercised, and carelessness may be equivalent to homicide. A beginner who presumes on his inexperience is likely to have woeful results. Beginning Lose. — The first dose of tuberculin should be so selected that all possibility of reaction is excluded. Koch, C. Spengler, Bande- lier and Roepke, and others have advocated that slight reactions (under 100.4° F.) are necessary for the best results, while the vast majority of observers endeavor to avoid reactions whenever possible, but, in spite of all precautions, slight reactions will occasionally occur during the course of the treatment. In all patients who have recently been sub- jected to the tuberculin test, in all who have a subfebrile temperature, extensive pulmonar}^ involvement, a nervous temperament, or compli- cations, more care about the dosage should be exercised at first. One patient, a well-nourished, strongly built woman aged twenty-four years, with extensive infiltration and slight apical consolidation of the left lung, reacted to 0.0000001 c.c. of broth filtrate (B. F.). and for four months was unable again to reach so large a dose. Another patient, a strongly built male, aged forty, with extensive signs of infiltration in both lungs, was given without reaction a first dose of 0.000005 c.c. B. F., and in six weeks with biweekly doses reached 0.001 c.c. The susceptibility to tuberculin varies greatly both in different patients as well as in the same individual at different times, and cannot be estimated accurately beforehand either irom the physical signs, the symptoms, or, indeed, from any data at our command. Such facts DOSAGE AND INTERVAL 525 emphasize the great necessity for careful individual treatment of each patient, and beginners especially should studiously avoid producing any evidence of reaction. The size of the first dose has been directly affected by the idea that the tuberculin treatment should extend over many months, and the final dose still influences many men in the selection of the first dose. This is especially true in sanatoriums, where oftentimes both patient and physician feel as if they must begin with as large a dose as possible and hurry on until a large final dose, often 1 c.c, is reached. (See Duration of Treatment.) This is based on wrong premises, as all patients need not be carried to the same dose to derive equal bene- fit, and the final dose should have no influence on the first. It is often well, as Sahli also holds, to repeat the first dose, especially if there be any doubt about its causing a reaction. The initial subcu- taneous dose for the tuberculins most frequently used are given on pages 540-541. Interval. — Wlien first used, tuberculin was given every day, a method soon found to be wrong. Many to-day, however, advise that at first it be given every day or every other day, and later every three or four days. As even slight reactions may not be manifested until as late as forty-eight or even sixty hours, the danger of giving tuberculin oftener than every three or four days (biweekly) is apparent. Many patients, especially those susceptible, often do better by taking but one dose in seven to ten days. This more nearly corresponds to the time required for the formation of antibodies, and fits in with the clinical work of Wright and others. When large doses (0.5 c.c. B. F. or 0. T., or 2 mgm. B. E.) are reached, an interval of seven to fourteen days is none too long. Furthermore, when tuberculin is given at too short intervals, hypersensibilit}' may occur. Increase of Dose. — The first dose, if sufficiently small, requires little consideration, but the key to successful tuberculin treatment lies in a proper gi'adation of the doses. It is here that experience is necessary and judgment at times difficult, for it is now well recognized that objective reactions are not necessary and should be avoided. The for- mation of antibodies requires time, and a quick increase is, therefore, of little avail, Avhile some hold that increase beyond a very small dose is of no value (Wright), but to get tuberculin immunity, a steady in- crease without reaction must be maintained. The most important rule to be remembered is that too little never injures, while too much tuber- culin may provoke a serious reaction and hypersensibility (see p. 538). Whenever, therefore, a question about a larger or smaller dose arises, it is well to choose the latter, for when hypersensibility is once pro- voked, it may be impossible to produce tuberculin immunity, and 526 SPECIFIC TREATMENT at least for some months the treatment may have to he discontin- ued (p. 549). In mild instances it may be sufficient to omit sev- eral doses, to reduce markedly the next dose and to lengthen the interval. The results of any single dose of tuberculin, well within the limits of reaction, have been most difficult to estimate. The administration of tuberculin has been, and, in the hands of most observers, still is undoubtedly empirical in the sense that they have at hand no practical means, either clinical or laboratory, of estimating exactly what the next dose should be from the effects produced by the last. Laboratoby Method. — The indications for increasing the dose may be based on clinical or laboratory observations or on both together. The only laboratory method of any value is that devised by A. E. Wright ('04) and based on the ojisonic index. The long apprenticeship necessary to acquire the teclmic, the time-consuming details, and the many chances for error inherent in the determination of the " opsonic in- dex," make AVright's method of little practical value where tul)erculin is given to a large number of patients, while in regard to pulmonary tuber- culosis he states that it is of no value, except in the very earliest stages. Eecent work at Cambridge (England) would seem to show that to avoid error it is necessary to count 1,000 cells, and inasmuch as it is necessary to compute the index every other day for four or five times following a dose of tuberculin to study its effect, the magnitude of the work is appalling. Wright has, however, emphasized the value of small repeated doses of tuberculin, especially in surgical tuberculosis. He strives to increase the tuberculo-opsonic content of the blood and totally dis- cards all idea of a tuberculin immunity, though some is probably acquired (p. 525). Wright's opsonic index method, while not prac- tical, is a great step in the right direction, inasmuch as it attempts to estimate the results of each dose of tuberculin. (For technic, see Appendix.) Clinical Method. — Careful clinical observations afford sufficient data for the proper administration of tuberculin when tuberculin im- munity is the object. Such methods are, however, gross, and all have to acknowledge that, in spite of the most careful observations, occasional reactions will occur. Many have attempted, b}^ studying the various fluids and excreta of the body, to determine the proper dosage. The urine has afforded no help and the sputum has been studied in regard to the number of tubercle bacilli, their virulence, morphology, and the number found intracellular (phagocytosis), but none of this is of avail in regard to the amount of the next dose. The blood has yielded no help either from a study of the erythrocytes, of the leucocytes (total or differential count, Arneth's ('05) neutrophilic picture, except after DOSAGE AND INTERVAL 527 a reaction ^), or from a study of the senim in regard to agglutinization. The opsonic index has been discussed, and in pulmonary tuberculosis, where tuberculin immunity is the object, it can, as Kinghorn and Twitchell have shown, be ignored. The index fluctuates, and whether tuberculin be given at any stage of a negative or positive phase, is as likely to go up as down. The blood-pressure aids little (Bauer, Miller). In fact, after careful consideration of the whole question, we are forced to rely chiefly, if not entirely, on the symptoms, general and localizing, the temperature, pulse, weight, and strength, and the phenomena that occur at the site of injection. Time of Injection. — In order to observe best these s3^mptoms, it is wise to give the injections in the evening or afternoon, and not in the morning as some advise (Sahli, '06; Bandelier and Eoepke, '08). An- other advantage of giving the injections late in the day is the oppor- tunity afforded for observing on the day of injection the maximum temperature, which in a number of instances precludes the dose. Sahli's contention that the normal morning remission may obscure a slight rise when tuberculin is given in the afternoon or evening is probably based on the fact that he usually administers it during the morn- ing, but Beraneck's tuberculin may cause a quicker rise of tem- perature. Whether the minimal or maximal temperature is affected first would decide this point, as the reaction usually begins about ten or twelve hours after the dose. When given late in the day, the afternoon or evening temperature on the following day is much more frequently and more violently affected than the morning tem- perature. Record of Treatment. — The observation of these symptoms has to be, in many cases, at least, relegated to the patient, and he should be made aware of what spnptoms to note, as, like most men, even when trained, he will observe only what he looks for. He should be supplied with a reliable thermometer, taught how to take his oral temperature, and required to take it at least three times a day, on awaking, at 4 and at 8 p.m., and at any other times of the day he may feel that he has some elevation of temperature, or at the time of the individual daily maximum, for one week previously as well as throughout the treatment. When restless at night after tuberculin he should also take his tem- perature. These should all be noted in a booklet, together with the presence or absence of the symptoms mentioned below, where are repro- duced specimen pages of a booklet used by the writer with considerable satisfaction for some, time. I Arneth holds that his blood picture is of some value in estimating the dose, but this lacks confirmation. 528 SPECIFIC TREATMENT This little record book is intended to aid your physician to give you tuberculin rnore carefully, moi*e intelligently, and more scientifically. He must depend upon your accuracy, which, accordingly, is closely connected with the benefits you will derive from this line of treatment. Put down no statement that is not, according to the best of your knowledge and belief, true in every particular and not in any way misleading. To render the temperature records accurate, it is never wise to leave the thermometer in your mouth less than five minutes, and in cold weather or out of doors the mouth should be kept closed for fifteen min- utes, the thermometer then inserted and left in place for ten to fifteen minutes. If you are taking the tubercidin treatment, the list of symptoms should be carefully scanned. The signs " + " and " " may be used to indicate " present " and " absent." If j-our back or arm, wherever you receive the injection, does not attract your attention, put down " " opposite " At Site of Injection." Othemuse indicate what symptoms you have at this spot. If you feel as usual and have none of the " General Symptoms," indicate this by an " " opposite " General Symptoms." Otherwise put " + " opposite each symptom that occurs and " " oppo- site the remainder. The same should be done with the " Localizing Symp- toms." When coug'h, expectoration, or strength are said to be increased or decreased, it means in comparison with the usual amount. The weight should be recorded once a week, and the pulse noted only when it varies from the usual rapidity. The temperature should be taken in the morn- ing in bed before rising and before the teeth have been cleaned. If by experience the hig'hest or lowest temperatures occur at other times than those indicated (7 a.m., 4 p.m., and 8 p.m.), these hours should be changed to the hours at which the minimum and maximum occur. " Low " and " high " are often simple repetitions of these temperatures, but they are useful to your physician. When your temperature reaches 100° F. and remains at this point two hours you should go to bed, unless otherwise directed by your physician. Always go to bed if you feel bad or have any pronounced symptoms. " In bed " means whether you spent the day, morning, or afternoon in bed. " Exercise " means how long each day you exercise, which is usually indicated by the amount taken morning and afternoon, e. g., " ^ hour " would mean one half hour's exercise morning and afternoon. Exercise shovdd be greatly restricted the day of the injection, and none taken the following day until late in the after- noon, when, if no symptoms have arisen, a less amount than usual may be taken. Be perfectly frank and honest with your physician. Tell him of any act of overexertion, and if any symptoms ever occur which are not men- tioned in this book, be sure to call his attention to them. It is only by mutual confidence that the best results can be obtained. You are both partners in the most serious business of your life, and partners should discuss every detail of their affairs, which, however, should not be divulged to the rest of the world. DOSAGE AND INTERVAL 529 Date Dose At Site of Injection: Paiu General Symptoms : Rash Localizing Symptoms : " 8 P.M " High. Pulse "Weight Strength : Increased . .•. . . Typical Beaction. — In a typical tuberculin reaction, nsnally ten to eighteen hours after the injection the patient begins to feel feverish (possibly chilly at tirst). heavy, and dull, e.xperiences lassitude and has slight elevation of temperature, often detected in the urine stream or rectum Ijefore in the mouth. These symptoms are rapidly aggravated, and in a short time the ])atient feels so ill that he is forced to go to 530 SPECIFIC TREATMENT bed with pains in the back, legs, and head, which are often severe. The tendency to cough may be increased, oppression may be felt in the chest, and the expectoration may be increased. The temperature may rise to 103° F. or higher, the pulse-rate reach 120 or over, the urine may be increased, with a slight trace of albumen or a diazo-reaction, and, on the whole, the patient is ill. These sj'mptoms persist for eight to twelve hours, and usually on the following day the patient feels a little weak, but otherwise all right. In a few instances the reaction is delayed for forty to forty-eight hours, and in others the rise of tem- perature is less (100° F.), but persists for several days, while the symptoms may he very severe. Skin Reaction. — The classical signs of inflammation occur at the point of injection, persist for one or two days, but, except with B. E., never go on to suppuration if asepsis has been preserved. Sites of former injections frequently present the same signs, though less pronounced, and the conjunctiva, if the ophthalmic tuberculin test has been given, as well as perceptible tuberculous foci, all show signs of more or less marked hj'peremia. The recent work of von Pirquet ('07), Wolff-Eis- ner ("08), Calmette ('07), and others on the reactions occurring in the skin and in the e3'e, following the application of tuberculin to these parts, suggests that this local reaction is definitely connected with the tuberculin and not due, especially when great dilutions are used, to any local irritation either of the tuberculin, of the glycerin, or of other constituents or diluents. In many instances when this local reaction is disregarded and the usual rate of increase followed, the skin reaction be- comes more pronounced and finally is accompanied by a general reaction. The relative irritability of the skin of different areas has not been definitely worked out, nor as yet is this reaction satisfactorily explained, though many attribute it to increased susceptibility (allergie, anaphy- laxis). It is inuch less pronounced when the injection is made in the back than when given in the limbs. If of great assistance in fore- stalling a general reaction, it would seem advisable to give the tuber- culin in the forearm, an area of skin of great sensitiveness, a procedure which Spengler has long followed. Injection of tuberculin in the skin causes very painful local redness and swelling, and at times minute quantities of tuberculin may accidentally be deposited in the skin on withdrawal of the needle. These " skin " reactions occur in different individuals with different intensity and vary at different times in the same individual. They occur more frequently at first in some patients, and in others are never present or only with large concentrated doses. They are directly con- nected with the form of tuberculin used, B. E. causing the reaction most frequently even in great dilution (0.00001 mgm.). In this eonnectioii DOSAGE AND INTERVAL 531 it is of interest to note that patients who have received the ophthalmo- tuberculin test and either reacted or failed to react (solution used 1 : 200), in some instances react again more severely or for the first time after the subcutaneous injection of tuberculin. This may occur after tuberculin is used in therapeutic doses and is one of the objections to the ophthalmo-tuberculin test. Tuberculin should always be administered in the same region of the body but on alternate sides. The concentration of the dose, on the whole, seems to have some influence on the " skin " reaction, and a few patients do react in this way to large doses of concentrated tuberculin, particularly B. E., but the majority take 1 c.c. undiluted of 0. T. or B. F. with very slight reaction. The injection of tuberculin into an area of induration produced by a former injection is much more likely to cause this reaction, and in the case of B. E. may produce sterile abscesses. Whenever this " skin " reaction occurs it is well to repeat the dose or to advance very cautiously, for in some cases it is undoubt- edly the forerunner of a general reaction. A very severe " skin " reac- tion would indicate omission of one or two doses and the use of smaller doses for a time. Organ Reactions. — The occurrence of local or " organ " reactions, manifested by hyperemia, are of great value when they so occur that they can be observed readily (e.g., in lupus, laryngitis, etc.), but it is fallacious to base any method of dosage on the " organ reaction " occur- ring in the lungs, for it cannot be detected by our methods of explo- ration in at least sixty per cent of all tuberculin reactions where severe general reactions occur, and, further, the occurrence of physical signs in the lungs is notoriously uncertain even when tuberculin is not ad- ministered. Petruschky holds these organ reactions of importance for cure, and Phillipi lays considerable stress on the increase and decrease of catarrhal signs. The writer has not used von Euck's watery extract where such reactions are said to occur so frequently as to be of value in dosing. Yon Eberts has noted a bleaching in an old lupus scar when the correct dose (laboratory method) was given. Localizing Symptoms. — The localizing or "organ" symptoms may be absent even when rather acute general sj'mptoms are present, and rarely occur with carefully adjusted doses. In pulmonary tuberculosis these consist of oppression in the chest, increased cough, increased ex- pectoration, pleurisy, and shortness of breath. In vesical tuberculosis increased frequency of micturition, in laryngeal tuberculosis, lupus and tuberculosis of the eye, increased congestion of the part are the main manifestations of this " organ " reaction, and are often of the greatest aid in determining the dosage, as in the eye and bladder, particularly, the " organ " reaction is very sensitive. 532 SPECIFIC TREATMENT The exact bearing of these symptoms on the dosage of tuberculin is not always easy to determine, for in many instances they do increase or occur from time to time when tuberculin is not administered. The safest course to pursue is to attribute any sudden marked increase to tuberculin, and to omit several doses, reducing also the following dose. If these symptoms are very slightly increased and the patient is doing as well as usual, the same dose should be repeated several times. If, however, these s3Tiiptoms become more pronounced, then it is wise to omit several doses and to reduce the next dose. Cough and expectora- tion are said to be increased at first during the treatment, but such is not the writer's experience. Hemoptysis rarely occurs during the tuber- culin treatment, and is best followed by the omission of several doses and a reduction of the next dose. In over 200 patients hemoptysis occurred 11 times in as many patients. In many instances both cough and expectoration are reduced following the injection. Pleurisy rarely occurs so severely as to necessitate omission of many doses and night sweats are rare. General Symptoms. — The general symptoms are by far the most important in estimating the dose, as they give the first signs of intol- erance. Pronounced symptoms should not be expected for they indicate overdosing, but the occurrence of any of the following symptoms, how- ever slight, is of great importance and indicates omission, reduction, or repetition of a dose. Slight headache is one of the most frequent of all symptoms, while severe headache rarely occurs. Even if no other symptom but slight headache is noticed, it is wise to repeat the dose, and severe headache should cause a cessation of the treatment. The same is true of malaise. Pain in the limbs, joints, and back, faintness, giddiness, insomnia, fatigue, rarely occur alone and often are com- bined, which is also true of indigestion, nausea, and vomiting. Somno- lence, restlessness, nervousness, and stimulation are of rarer occurrence, and so, in one way, of less importance. Chilliness may occur without a perceptible rise of temperature. A rash or fever blisters, as a rule, occur only with a pronounced general reaction. Enlarged glands are very infrequent. The decision whether or not these symptoms may be due to the tuberculin is a matter of moment, and at times of considerable dif- ficulty. Here, as elsewhere, it is always wise to give the benefit of the doubt to the tuberculin as the causative factor and to act accordingly. The occurrence of two of these symptoms should always indicate a repetition of the dose, and one, if severe, means an omission of one or more doses or a reduction of the dose. Temperature. — Any of these symptoms may occur without an appre- ciable rise of temperature, and so must be considered as a much more DOSAGE AND INTERVAL 533 delicate and earlier indication of intolerance than rise of temperature. It seems probable that some forms of tuberculin are less likely to produce rise of temperature, without "prodromal" symptoms, than others. This is especially true of B. E., where the patient may feel wretched without any elevation of temperature. B. E. more often produces a sudden rise of temperature when previously none of these symptoms had been noticed. Elevation of temperature has long been looked on as the chief characteristic of intolerance and considered only when the temperature reached 100° F. or more, but the al)sence of rise of temperature is no sign of the absence of reaction, which often occurs witliout rise of temperature. General febrile reactions coupled often with inflammatory organ reactions possess no curative action and are dangerous, especially when severe or repeated. A complete course of tuberculin can be given with- out febrile reaction, but the majority of patients react at some time. In a course of B. F., not more than three or four reactions should occur in afebrile patients, but in B. E. these reactions will be more numerous (eight to ten). The success of tul^ercvdin therapy depends mainly on the accurate observation of slight departures from the ordinary course, and a rise of a few tenths of a degree in temperature is always of moment. It is difficult to lay down any hard and fast rules, but a rise of one degree or less, even a few tenths, above the usual level, even if only temporary, always means a repetition of the dose, or if accompanied by other symptoms a reduction of the dose (to one fourth to one sixth of the last dose). A greater rise — e.g., from normal to 100° to 101° F. — would mean the omission of one or two doses, and then the indicated reduction. In no case should tuberculin be given until the temperature has been normal, or at least at the usual level for two entire days, and if the reaction is at all severe, for one week. If, on a repetition of the same dose after a slight reaction, a second reaction occur, it is always well to reduce the dose for fear of producing hypersensitiveness. A progressive rise, however slight, even one or two tenths a day, always indicates cessation of the tuberculin for a time; in other words, never give tuber- culin with a rising temperature. This holds also for febrile patients, and until the temperature remains at the same level for at least five or six days, no tuberculin should be given. It is at times difficult to determine whether or not the rise of tem- perature is due to tuberculin. As a rule, tuberculin usually produces its rise in aliout twelve to twent3'-four hours, occasionally in six or as late as forty-eight hours, but these limits are so rarely exceeded that a rise of temperature occurring either before four or after sixty hours can usually be attri1)utc(l to some other cause. 534 SPECIFIC TREATMENT The temperature caused by tuberculin is usually continuous, but may be intermittent and extend over four or tive days. The tempera- ture may not rise above the normal limits (99° F.) and yet the range increase. This, if explainable in no other way (e. g., external tem- perature), should arouse suspicion. The minimujn (usually the morning) temperature is of little value if tuberculin is given at night. Antipyretic Action. — When the elevated temperature is markedly reduced by tuberculin, it is unwise to increase the dose until this effect be lost, but if no effect is noticed the dose should be increased slowly, even until, as Bandelier and Eoepke also hold, a slight reaction occurs. Following this the temperature is often lower. Much experience is necessary to carry this out successfully, and longer intervals should be employed, while the usual increases may be maintained. Increased Susceptibility, — There is in many patients a period of increased susceptibility, when the patient reacts on the usual increase and reacts often two or three times to decreasing doses. This period varies for each tuberculin, being most frequent in the hundredths or tenths of a milligram (solid substance) of B. E., some tenths of a milligram of 0. T., some hundredths or tenths of a milligram of B. F. The smallest dose causing reaction was 0.00000005 gm. B. E., 0.0001 c.c. 0. T., and 0.00000003 c.c. B. F. In patients who have been sub- jected to the tuberculin test this increased susceptibility occurs earlier — i. e., to smaller doses — than in others. Once past this point without reaction, it is much less likely to occur. In patients with great sus- ceptibility the same dose should be repeated many times and occasional attempts made to increase it. This susceptibility is more frequent in the febrile, in those with extensive lesions, and in those in poor general condition. Pulse. — ]\Iuch importance has been attributed by some (Bandelier and Eoepke) to the pulse range, but in the writer's experience it is a less delicate guide than the other symptoms mentioned. An increase of pulse-rate alone, however, usually indicates caution and the repetition or reduction of the dose. Weight. — The weight is of much less importance in regard to the individual dose than in regard to the treatment in general. A con- tinuous loss of weight, which proceeds until the normal weight for height and age is not maintained, or until the individual's " normal " weight is no longer held, means cessation of treatment until the loss is repaired. The normal weight curve for patients with tuberculosis rises, as a rule, from August to December, fluctuates from December to March, and then falls to August (Brown, '03). This fact should be kept in mind in determining the influence of the tuberculin on the DOSAGE AND INTERVAL 535 weight. A loss of appetite means omission of several doses and reduc- tion of the following dose. From all this it ma}' be seen that whenever any of these SAmiptoms or signs, however slight, arise, one of ses'eral courses is open: (1) To repeat the dose, (2) to lengthen the interval, (3) to reduce the dose, and (4) to omit the dose. Tuberculin cannot be given on an " express- train " schedule, and the object is not to reach any definite station where great benefilt will be derived, but it is to travel slowly, stopping b}' each way station, as long as improvement is noticed and pushing on only by slow degrees. The benefit is derived during the journey, not at its end, and just as we cannot all climb to the same altitude, so we cannot all advance as far up the tuberculin scale, though we may derive from it the same benefit. If, at any time during the treatment, it becomes necessary to change the " brew " of tuberculin, even if the new be made from the same tubercle bacilli, the same broth, and in exactly the same way, it is wise to reduce the next dose to from forty to sixty per cent of the last. It is manifestly unwise to interrupt any treatment that is doing good, but occasionally it is necessary to do so, and beside requiring a reduction of the dose, the interruption has but little effect. Complications. — The occurrence of complications — e. g., a perineal abscess, a slight coryza, acute bronchitis, indigestion, etc. — often pro- duces increased susceptibility, and so demands for a time the cessation of treatment. The slightest departure from the ordinary course of events must be considered carefully, and it is often wise to omit one or two doses. Age. — The age naturally modifies somewhat the dosage, and in chil- dren it is wiser to begin with the lower limits of the doses scheduled. Bandelier and Eoej)ke ('08) believe the dose should be one half to one tenth of that for the adult. Estimation of Patient's Condition. — A patient may be said to be doing well when his temperature and pulse remain normal or become lower and slower (except for one or two days following injection), when the appetite is good, the weight increased, or the normal weight maintained, when the general condition is good and when the pulmonary symptoms are in any wise decreased. On the other hand, if the tem- perature and pulse become higher and faster for several days, the gen- eral condition fail, the appetite become poor, the weight decrease, and pulmonary symptoms steadily increase or recur (hemoptysis, pleurisy), the condition of the patient is unsatisfactory and the treatment should, for a time at least, be discontinued. Final Dose. — The final dose to be attained in any course of tuber- culin dq)ends on the individual, his susceptibility to tuberculin, and the 536 SPECIFIC TREATMENT variety used. No satisfactory proof has been adduced to show that large doses are of more avail than smaller doses, and some patients who can never attain the larger doses seem to do just as well as those with great insusceptibility to tuberculin. There is, however, some connection between tolerance and improvement, for when a patient relapses sen- sitiveness returns or intolerance may be accpiired, and Denys ("05) holds that large doses alone establish solid immunity. Cornet believes that larger doses do help more, but are inadmissible. Marked tuberculin immunity can be obtained in a majority of patients, but it is still an open question whether immunity to large doses should always be attempted. Sahli ('OG) believes that tuberculin immunity is tbe only thing tuljerculin can accomplisli. Trudeau, Ban- delier and Eoepke ('08), and others believe that tuberculin immunity is of great value and should be the ol)ject in the treatment. Tuberculin immunity is not immunity to tuberculosis, and animals immunized to tuberculosis show tuberculin susceptibility for some time. Petruschky has long held that large doses of tuberculin are not necessary, that tuberculin immunity is the main object to be attained, and that re- peated courses of tuberculin with smaller final doses than usually rec- ommended produce tlie best effect more quickly. Sahli speaks of the optimal dose for each individual and pays little or no attention to the absolute dosage, regarding only the relative dosage, and believing that tuberculin is the best treatment to avoid dangerous intoxication. These facts bring clearly before us the objects of tuberculin, and while the weight of opinion seems in favor of producing tuberculin immunity and so aiding the hody forces, b}^ removing the toxemia, to overcome the tubercle l)acillus, the results by this method have never been as striking as those attained (especially in surgical tuberculosis) by small repeated doses of tuberculin, which, however, does produce some tuberculin immunity. Bandelier and Eoepke hold that the best final dose is one that can be borne without reaction, and may not be over 1 mgm. Whether these results rest on increased susceptibility, anaphylaxis, aJlcrgie, or some hitherto undescribed immunity process, cannot yet be said, but such results have led the writer to believe that the increasing dosage (to large amounts) in the use of tuberculin will be pushed less and less, but that large doses may be necessary in some instances. Pardee's ("05) experience with T. R. in tuberculosis of the urinary tract is a striking example of this. He is guided by the s5'^mptoms, begins with 0.000002 gm., and increases until a reaction occurs, then reduces the dose considerably and gives the same dose over a long period. His results were excellent and seem to depend on the great irritability of the bladder (possibly to increased secretion of irritants. DOSAGE AND INTERVAL 537 followinfj the injection, T.iiieli, unfortunately, in the case of the luno^s is lacking). These facts suggest that the anatomy of the part — that is, its rich- ness in vascular supply — may have some hearing on the method of administration of tuberculin. The good results obtained by Wright's method are practically all in " surgical " tuberculosis — that is, in parts where the blood-vessels are usually less numerous and where the walls may be less permeable. Pronounced pulmonary tuberculosis, he states, is not suitable for this line of treatment on account of the frequent autoinoculations that occur. When the opsonic index is totally dis- regarded in this form of tuberculosis and tuberculin immunity is attempted, good results are, to say the least, not infrequent. Arbitrary limits have been set for many forms of tuberculin (1 c.c. for 0. T., B. F., and Beraneck's, 5 mgm. solid substance for B. E., 20 mgm. for T. E., etc.), but why these doses in some instances should not be surpassed has been little discussed. Den}^? has given up to 10 c.c. of B. F. subcutaneously and 2.5 c.c. intravenously, and Koch recommended 10 mgm. B. E. subcutaneously or a larger dose (20 mgm. ) intravenously. It is, however, a much wiser procedure to limit the final dose by the time required for the tuberculin treatment. A dose that falls short of the usual final dose, that has required nine to twelve months to attain, should, merely on account of the time, be looked on as the final dose, no matter how small. On the other hand, it is rarely wise to exceed the following doses : 0. T., 1 c.c. ; B. F., 1 to 3 c.c. ; B. E., 5 mgm. ; T. E., 10 to 20 mgm.; Beraneck's, 1 c.c. The final dose of B. E. should always be diluted and given in two places. Thorner holds that 0.001 c.c. 0. T. should never be exceeded in febrile patients. One patient who had showed remarkably little susceptibility to B. F. acquired hypersusceptibility when the dose was increased from 1 c.c. to 1.2 c.c. and reacted to the ophthalmo-tuberculin test. In a number of patients the writer could never increase the dose beyond a few milligrams of old tul)erculin, some thousandths of a milli- gram of B. F., and some hundredths of a milligram of B. E. (solid substance). For the most part (nine out of eleven) they had extensive lesions, one had an enlarged thyroid with some exophthalmos and a second developed a perineal abscess. Many authorities advocate the repetition of the final dose a number of times, as long as it does good, with the view of increasing the immu- nity. Denys ('05) finds, however, that a stage of intolerance is at times acquired in this way, and the writer has seen several instances of it. In this case the dose must be reduced or the treatment discon- tinued. On the whole, when sufficient time has elapsed since the begin- 538 SPECIFIC TREATMENT ning of treatment, it is wise to discontinue the treatment for a time when the foregoing limits are reached. If, however, the patient feels a lack of the stimulation produced by the tuberculin, it may speedily be begun anew. Hypersusceptibility. — No schematic plan of dosage can be blindly followed, as individualization plays the most important part in treat- ment with tuberculin. The proper rate of increase varies for each individual, and also for the same patient at different times during the treatment. The smaller doses are often given with larger increases, and some have noted a period of increased susceptibility which varies for each tuberculin. During this period greater care should be exer- cised, for the condition of hypersusceptibility may be more readily produced at this time. This condition must be carefully guarded against, as it frequently occurs from overdosage or from giving tuber- culin during a period of a slight exacerbation, too soon after a reac- tion, or during decreased resistance (slight coryza, gastric or intestinal disturbance, etc. ) . It is manifested at times by a more or less sharp reaction which necessitates a marked reduction of the next dose. This, however, also produces a reaction, which may follow several doses, each much reduced in turn. The only plan if this occurs is to discontinue the tuberculin for several weeks, or even months, and then begin again very slowly. In one patient, a woman, this hypersusceptibility was produced by the injection of 0.0000001 c.c. B. F. as a first dose several days after a slight attack of pleurisy. In four months of treatment this dose was never again attained, and the treatment had to be stopped on account of the severe headaches it produced. The " quotient of immunization " of Loewenstein and Rappoport (i. e., relation of the maximum dose injected Avithout reaction and the number of doses necessary to arrive at this dose) is much greater for early than advanced stages. Value of Small Doses. — The interesting problem of increased sus- ceptibility to serums (von Pirquet and Schick ('05), Eosenau and An- derson ('08)) suggests that a tuberculin anaphylaxis is possible, though the small interval between doses seems to render it improbable. Fol- lowing the tuberculin test, hypersusceptibility is often present in a marked degree, and Loewenstein has found it to persist for many months. It is not impossible that the increase in dosage, especially at first, is so small for some little while that the mechanism of the body is not adjusted finely enough to appreciate the increase, and so, when very minute doses are used, a hypersusceptibility may be produced when the organism is at all susceptible. Loewenstein and Eappoport ('04) have shown this to be true for DOSAGE AND INTERVAL 539 larger doses of 0. T. (0.0002 c.c.) repeated several times, and Koch has pointed out that this phenomenon is very characteristic of tuber- culin. This may be the explanation of some reactions to very small doses, and may further explain the good results obtained with small repeated doses of T. R. (^Yright and others). It is of interest to note that, in a woman aged twenty-four, with closed infiltration of the right upper lobe, while 0.0001 mgm. T. E. repeated weekly never brought the opsonic index to normal, it apparently produced immunity to 0. T. (0.01 c.c. 0. T. subcutaneously) and to the ophthalrao-tuberculin test (1 to 200). Schemata. — Some advocate the continued use of small doses, which seems especially of value in surgical tuberculosis, depending, however, largely on the clinical symptoms for guidance. The majority advise tuberculin to be given in increasing doses, and many schemata have been suggested. The fundamental principles have not yet been fully settled, and whether it is wiser to increase irregularly or by a definite logarithmic scale cannot at present be definitely answered. The major- ity use an irregular scale, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 20, 30, etc., Avith increases that vary from a hundred per cent down to eleven per cent. The experience of the writer seems to indicate that reactions occur most frequently when passing from 1 to 2 or from 2 to 3 of this scale. Accordingly, for some time the following scale was used at the Adi- rondack Cottage Sanitarium: 1, 1.5, 2, 2.5, 3, 4, 5, 6, 8, 10, 15, etc., with increases varying frequently from fifty to twenty per cent. This seemed to prevent reactions at the points indicated. Bandelier and Eoepke ('08) use the following doses: 1, 1.5, 2, 3, 5, 7, 10, while Petruschky employs (in milligrams) 0.1, 0.25, 0.5, 1, 2, 3, 4, 6, 8, 10, 15, 25, 35, 45, 60, 80, 100, etc. Logarithmic Scale. — More recently still, Weber's law of sense- perception has been taken cognizance of, and a logarithmic scale has been constructed. Concentration and Dosage. — Inasmuch as the effect of the varia- tion in concentrations used has seemed to the writer to exert no influ- ence, Sahli's suggestion of having each higher dilution only twice instead of ten times the strength of the preceding, which is the usual method, seems entirely unnecessary, and requires much time (e. g., for B. F. at least fifteen months for one course). Reaction on going from 0.68 c.c. of one solution to 0.1 c.c. of one ten times as strong has caused no reaction in a large number of cases. The advantage of hav- ing each solution ten times the strength of the preceding one is mani- fest. Sahli gives from 0.1 to 0.5 c.c. of one solution, and then changing to one twice as strong repeats the same dose once, giving consequently 0.25 c.c, and so on. There is no evidence to show that this is neces- 540 SPECIFIC TREATMENT sary. Denys uses a solution ten times stronger than the preceding, and advances usually from 1, 2, 3, 4, 5, 6, 7, 8, 9, to 0.1 of the next solution. At times he advances by 0.1, 0.25, 0.5, 0.75, 1, and so on. It is intended merely as a suggestion in controlling the dosage, which for each patient varies greatly, according to individual suscep- tibility, and is of use in giving any tuberculin, for all tuberculins are either in solution or suspensions in fluids. This schema, computed by Pope,^ is based on a logarithmic scale, and is so arranged that in going from 0.1 to 1 c.c. of any solution two to twelve doses may be employed, while the rate of increase of dose in each case is always constant. The average patient, in the writer's experience, can take the sixth scale (six doses to each solution) without any danger of reaction, but some must go more slowly, and a few, especially during a second course, may go more rapidly. DOSES (LOGARITHMIC SCALE) 2 3 4 5 6 7 8 9 10 11 12 1 1 1 1 1 1 1 1 1 1 1 3.2 2.2 1.8 1.6 1.5 1.4 1.3 1.3 1.3 1.2 1.2 10 4.7 3.2 2.5 2.2 2.0 1.8 1.7 1.6 1.5 15 10 5.6 4.0 3.2 2.7 2.4 2.2 2.0 1.8 1.8 10 6.3 4.7 3.7 3.2 2.8 2.5 2.3 2.2 10 6.8 5.2 4.2 3.6 3.2 2.9 2.6 10 7.2 5.6 4.7 4.0 3.5 3.2 10 7.5 10 6.0 7.7 10 5.0 6.3 8.0 10 4.3 5.3 6.6 8.0 10 3.8 4.7 5.6 6.8 8.3 10 1. Bouillon filtrate. Interval: twice a week until 0.1 c.c, then once a week. Doses (in cubic centimeters) : beginning, afebrile, 0.0000001-5 ; febrile, 0.00000001-2 ; final, 1 c.c. 2. Original tuberculin (Koch's). Doses in cubic centimeters. Interval: twice a week, after 0.1 c.c. may be given once a week. Beginning dose same as B. F., final, 1 c.c. 3. Bacillen emulsion : a. Doses in solid substance (grams). Interval; twice a week until .001, then once a week. Beginning dose afebrile, 0.0000001 ; febrile, 0.00000001 ; final dose, .005. iThe writer takes this opportunity of acknowledging the great assistance he has received in many parts of this article from the late Mr. E. G. Pope, statistician of the Adirondack Cottage Sanitarium. SELECTION OF PATIENTS 541 6. Doses in liquid measure (cubic centimeters). Interval: twice a week until 0.2 c.c, then once a week. Beginning dose afebrile, 0.00001 c.c; febrile, 0.000001 c.c; final dose, 1 c.c. Tuberculin R. : a. Doses in solid substance (grams). Interval: twice a week until .005, then once a week or less frequently. Begin- ning dose afebrile, 0.0000001; febrile, 0.00000001; final dose, 0.01 to 0.02. Dosage after 0.01:0.012, 0.015, 0.01 r, 0.03. b. Doses in liquid measure (cul)ic centimeters). Interval: twice a week until 0.02 c.c, then once a week or less fre- quently. Beginning dose afebrile, 0.00001 c.c ; febrile, 0.000001 c.c. ; final dose, 1 to 2 c.c. Dosage after 1 c.c. : 1.2, 1.5, 1.7, 2 c.c Beraneck's. Doses in cubic centimeters. Interval : twice a week. Beginning dose afebrile, 0.05 c.c. of ^ solution; febrile, final rlriGP 1 i 128 ' tuberculin). 0.05 c.c. of A or r^ ; final dose, 1 c.c of T. Bk (pure SELECTION OF PATIENTS Theory of Action. — The theory of action of tuberculin has much bearing on the selection of patients. Formerly, when Koch held that tuberculin caused a sloughing off of the tuberculous areas, all patients except those in early stages were soon considered from this standpoint as unsuital)lo, many of whom now are subjected to the treatment. On the other hand, the acuteness of the process, formerly disregarded, now plays an important ])art. Tuberculin is not an antitoxin, but a toxin, and the process of "tuberculin immunization" is not passive but active. The majority of observers (Trudeau and Baldwin, etc.) have failed to find any antitoxin in the serum, either during tuberculosis or during tuberculin treatment. The struggle seems closely connected with the cells, probably those about the foci, and some observers (Wasserman and Bruck) have noted an antituberculin in the tissues. An incubation period of six to twelve hours intervenes after the injection of tuberculin before a rise of temperature occurs. What occurs during this period of absorption and " attuning " of the system is impossible to say, but it may be that tuberculin acts as an " enzy- mogen," which in time sets free from the cells about the tubercle suf- ficient toxin of digested tubercle bacilli to produce the reaction. By this theory it is easy to understand how tuberculin would prove only of injury to acute cases already overwhelmed by toxin. It is also easy 542 SPECIFIC TREATMENT to see how overdosage, by liberating too much toxin, may overwhelm the organism, interfere with nutrition, and so produce disastrous results. The gradual liberation of the toxins of the digested tubercle bacilli, brought about by small doses of tuberculin, may free many already overloaded cells about the focus, thus enabling and stimulating them to attack and digest any bacilli escaping from the lesion, and permitting and stimulating the connective-tissue cells to act more rapidly in form- ing a capsule about the focus. In the ordinary course of the disease, according to another theory, the tuberculin is formed so gradually that the whole organism is rarely stimulated to the formation of any antibodies; in the tuberculin treat- ment a large amount is thrown into the circulation at once, and so the whole system is immunized in some way against tuberculin. This may permit the bacteriolytic properties of the tissues to exert themselves, whereas before they were too weakened to do so; in other words, it permits an auto-immunization to take place. The explanation of the failure of many patients in far-advanced stages to react to tuberculin may be that a system, already saturated with toxin, reacts less readily, if at all, to an increase of the toxin, and in these cases the cells are so affected that they can no longer respond to stimulation. They can, as Mitulescu says, neither take in material necessary for reconstruction nor protect themselves against the action of poisonous substances. Tuberculin, Sahli believes, is not merely a specific, but, like digitalis in cardiac disease, a functional therapeutic means which acts only in a definite way on the toxin sus- ceptibility of the organism. The natural healing powers are permitted to act after tuberculin has combated tlie toxemia. It is of interest to recall, as Loewenstein has pointed out, that almost all diseases in which immunization takes place are acute diseases. The struggle is sharp and quickly decisive, ending before the cells lose their powers of resistance (antitoxin formation). Tuberculosis is a chronic disease whose pathogenicity depends ratlier on the ability of the tubercle bacillns to live and multiply in the tissues, than on the potency of the poisons they produce (Vaughan). The nutrition is profoundly affected by this poison or toxin, a fact which gives the pulmonary form its vulgar name — consumption. Tlie toxemia usually progresses so slowly that its advance can scarcely be noted from day to day. Small quantities of the toxin of the tubercle bacillus affect man profoundly, while he has usually fairly good resisting powers against the tubercle bacillus itself. Such facts would suggest that could immunity to tuber- culous toxin be produced, man in many instances could overcome the tubercle bacillus. However this may be, remarkable tuberculin immu- nity may be acquired and maintained for long periods by suitable SELECTION OF PATIENTS 543 repetitions of the treatment. (See Eepeated Courses.) Immunity to tuberculin, unfortunately, does not mean immunity to tuberculosis, as many experiments have shown, and, on the other hand, susceptibility to tuberciriin does not always mean lessened resistance to a previously acquired tuberculosis. The results obtained in patients with surgical tuberculosis immunized to tuberculin are rarely, if ever, so striking as many instances reported of patients treated by Wright's method, but many have been unable to substantiate these results. Symptoms and General Condition. — From this Ave may conclude that all patients with acute tuberculosis, all patients whose nutrition is so profoundly affected that little response is possible, are unsuited for tuberculin treatment. When the general condition is far below normal every effort should be made to improve it, and at the same time to reduce the temperature and to abate the sjTuptoms, before resorting to the use of tuberculin, but Bandelier and Roepke believe that if the time is short (e. g., on account of financial resources) tuberculin should be begun at once and nothing else omitted to improve the condition of the patient. The results in such patients are, of course, as Petruschky ('04) points out, much more uncertain than in those in incipient stages. Elevated Temperatures. — Most observers select only those patients whose symptoms indicate an arrest, possibly only temporary, of the disease. For this reason, elevated temperature is said to be a contra- indication to the use of tuberculin, but recent experience shows that this is not true for all patients with elevated temperature. Many patients who persistently have a slightly elevated temperature ranging from normal or below to 99.5 to 100° F., presenting at the same time no other very marked symptoms, do remarkably well with tuberculin, and often regain a normal temperature. If, on the other hand, the tem- perature be persistently high, rarely falling below 100° F. for a period of some weeks, tuberculin can accomplish little. On the whole, it is rarely a wise procedure to give tuberculin to any patient whose tem- perature reaches 101° F. or over unless all other symptoms are dis- tinctly favorable, and too much must not be expected in any case. Koch, Goetsch, Holdheim, etc., oppose the use of tuberculin in patients with fever. A persistently rapid pulse after prolonged rest is a contraindication in most cases to tuberculin. Such patients do badly, and while not harmed, frequently derive little benefit from tuberculin. Cough or expectoration in themselves, unless excessive, are of small importance in connection with the selection of patients, but, when excessive, great caution should be used if tuberculin be administered at all. Slight dyspnea is of little moment, urgent dyspnea is a contraindication. A tendency to hemoptysis is no contraindication, and dry pleurisy, existing 544 SPECIFIC TREATMENT for some time, is of no significance unless very painful, and if not increased by tuberculin, need be little considered. Pleurisy with effu- sion after the acute stages are over need not cause any interference with the treatment. A feeling of oppression in the chest, unless arising dur- ing the treatment, is no contraindication. Emaciation and anorexia are, as previously stated, contraindications. Complications. — Most complications have with many men little influence on the selection of patients, but the prognosis, which is always worse in such cases, should always be considered. Meningitis is an abso- lute contraindication, but Vernet ('07) has stated that he cured one case in a child, and Maurange ('9G) noted marked improvement in another. The occurrence of a true nephritis (not the presence of a few casts in centrifugalized urine or the slightest trace of allnnnin) is a contraindication in most cases. This does not hold for tuberculous nephritis, where many good results have been obtained (von Euck, Whipple, and Duriac). Diabetes and cirrhosis of the liver are absolute contraindications for many who state no reason but a bad prognosis. Marked nervous symptoms, hysteria, neurasthenia, exophthalmic goiter, considered by some as contraindications, necessitate care, but many of these patients seem to derive from tuberculin the mental leverage neces- sary to carry them over rough places, as it enables them to attribute to tuberculin many slight exacerbations which otherwise would cause great mental disturbance. This is a factor of no little importance. Epilepsy, if not a positive contraindication, would necessitate the greatest care. Syphilis is no contraindication (Heron, Thorner). Valv- ular disease of the heart, if any history of noncompensation be obtain- able, or if degeneration of the heart muscle or blood-vessels occur, is a contraindication. The occurrence of secondary infections, which markedly influence the general condition of the patient, is a contra- indication. Sahli believes that " mixed infection " is the scapegoat for poor results, while Koch opposes the use of tuberculin when there are " morbid processes " caused by streptococci, staphylococci, pneumococci, influenza bacilli, etc. The poisons of the tubercle bacillus would seem from von Korczynski's ('05) work to increase the virulence in vitro of some organisms (colon, streptococcus, staphylococcus). Pregnancy is no contraindication, and Petruschky, basing his opinion on 11 cases, 10 alive and well and one dead from pneumonia with healed tuber- culosis, holds that patients who have been treated with tuberculin can marry without risk. Roepke strongly advises the use of tuberculin in these cases. Physical Signs. — The physical signs, except when extensive soften- ing and ulceration have occurred, need little consideration. If such be the case, little can be hoped from tuberculin treatment, and a wiser SELECTION OF TUBERCULIN 545 course is to refrain from its use, though if such a patient insist it should be given. Patients whose extent of physical signs corresponds to stage III Turban, may go through the entire course withou't the slightest reaction. When the physical signs are extensive the general condition must be good and the symptoms slight, or tuberculin is contraindicated. The location of the physical signs is of little importance. Duration of Disease. — The duration of the disease is often an indi- cation for tuberculin. The patient has tried the hygienic-dietetic treat- ment, a change of climate, and what not, without permanent benefit or even marked improvement. The disease has remained stationary or possibly advanced slightly at infrequent intervals. Such patients are preeminently suited for tuberculin, which should always be exhibited to them. The argument that tuberculin should be reserved only for such patients as fail to improve under other forms of treatment is an acknowledgment of lack of faith in tuberculin, and if tuberculin be of value for these patients it is of much more value for patients in incip- ient stages. It is true, as Spengler states, that in the incipient stages it is impossible to determine what value tuberculin possesses, but he believes that in more advanced stages his results leave no doubt as to the great value of tuberculin. A few patients, even in the earliest stage, cannot take tuberculin except in the most minute doses, but these, as Sahli says, are not always the most unfavorable. Age. — The question of age in the selection of patients need be little considered in its lower limits, as children often do remarkably well (Petruschky), though Vaquier and Ganghofner obtained only "fair" results. In patients past fifty years especial attention should be paid to complications in the cardiac or renal systems. Prophylactic Use. — Members of phthisical families, even though they present no signs or symptoms of disease, are often benefited by tuberculin (Sahli). Patients who must continue work should not for this reason alone be refused tuberculin. Advice for Inquiring Patients. — The advice to be given a patient who inquires about tuberculin is of considerable moment. He should be told that tuberculin properly given will not harm him, may produce no immediate results, but may act very beneficially both in regard to the future (relapse) and on the symptoms. It should be clearly stated to him that treatment for two or three months is of little avail, and that it means six to nine months at first, and later a repetition of the treatment. SELECTION OF TUBERCULIN The selection of a tuberculin is most difficult. The only perfect immunity obtained in animals has been by use of the attenuated cul- 36 546 SPECIFIC TREATMENT tures of the living human tubercle bacillus, which would suggest that the tubercle bacilli under stimulation of the cells and juices of the body produce some toxin not otherwise generated (Welch). The results have been especially favorable in cattle, which has led several observers to the use of tuberculin from the bovine strain of tubercle bacilli, or, indeed, to the use of the bovine tubercle l)acillus itself (Spongier, '05). Klemperer ('05) injected himself and five patients without apparent harm with a virulent bovine tubercle bacillus, but obtained no striking results. Moeller, after immunizing himself witli tubercle bacilli, passed through a blindworm, inoculated himself without effect with an attenu- ated tubercle bacillus which apparently failed to kill guinea pigs. His experiment proved little. Friedman carried out the same experiment in animals, using a turtle tiibercle bacillus, which was later found to be virulent in some cases. In tuberculosis in man the tubercle bacillus is already in the body, and it may be questioned whether the inoculation of more tul)ercle bacilli would prove of as great value as some hold. The normal and tuberculous animals react very differently to the tuberculous toxin, and the use of living tubercle bacilli in tuberculous cattle has not shown striking results. In any case it is not justifiable to subject man to such procedures. The use of homologous tuberculin or vaccines in tuberculosis has met with little favor, and the best immunizing results have been obtained with heterologous bacteria (attenuated human strains against virulent bovine strains). Loewenstein and Allen believe that homologous tuber- culin or vaccines should be used^ and Haentjens-Putten and Krause ('07) have employed them, while von Eljerts believes they are imprac- ticable in skin lesions. C. Spengler has claimed astounding results by the use of allotoxins; when the infection is with human tubercle bacilli, as is usual, he uses l)ovine tuberculin and vice versa, and when a dose of 100 mgm. is reached, he alternates human and bovine tuberculins and reports agglutination in strength of 1 : 2,000. AVoll)ack and Ernst found no difference experimentally in the action of human and bovine tuberculins. Theoretically it would seem sufficient to immunize man against the toxin (tuberculin) of the tubercle bacillus, for as yet no perfect bac- terial immunity has been produced by any other agent than the living bacillus, and by doing this enable him to overcome the tubercle bacillus itself against which he has considerable resistance. The use of non- toxic split products of the tubercle bacillus of Vaughan and of the nastin of Deycke and Reschad Bey, possibly also of von Behring's tulaselaktin, are all attempts not yet proved successful at bacteriolytic action. SELECTION OF TUBERCULIN 547 Judging from the results ol)tained up to the present time there is apparently little difference hetween the action of the various tuber- culins when jiroperly given, as all probably contain the specific tuber- stance. The original tuberculin has in the hands of many observers given just as reliable and satisfactory results as any of the later modi- fications. No satisfactory proof has been adduced to show that the culture fluid contains any substance not in or a])Out the body of the tubercle bacillus. In fresh cultures tubercle bacilli rarely lie imme- diately side by side, but are separated by some substance, which, dissolved in NH^C'l, is capable of producing the tuberculin reaction (Bald- win). Schmoeller ('05), quoting Denys, Koch, and Klebs as his authori- ties, states that the specifically acting substances are set free in the culture fluid, while the insoluble substances retained in the bacterial bodies have only inflammatory and pyogenic properties. Analogy with other bacterial vaccines would lead us to believe that heat may destroy, in part at least, the immunizing substance, and it certainly produces a precipitate. For these reasons it would seem best, theoretically, to employ an emulsion of "pulverized tubercle bacilli, killed at 59° F. by repeated heating, in the unhealed culture fluid, rendered sterile by fil- tration through porcelain. This would mean, expressed in other terms, B. E. in B. F. Next in theoretic value would stand B. E., an emulsion which pro- duces at times an unexplainable reaction, and so presents more difficulty in dosage, and T. R. an emulsion, acting similarly, of pulverized and water-extracted tubercle bacilli. It is of interest to note that Wright's results have been obtained Avith minute doses of T. R., while Goetsch ('01) was never able to obtain a complete disappearance of tubercle bacilli with T. R., and had to resort to 0. T., and Bandelier found that T. R. produced much weaker agglutination than B. E. Theobald Smith considers virulent uncrushed tubercle bacilli, killed by moderate heat, as the best vaccine. Jousset has obtained good results with a culture that was allowed to die in the culture fluid. B. F., which is unhealed, diluted 0. T., is a weak tuberculin less likel}^ to produce fever than general symptoms when carefully given, and an excellent form for anyone beginning the use of tuberculin. Spengler's TOA is really concentrated B. F. without the addition of thymol or phenol, which he believes in time gradually reduces tbe strength of the oi'dinary B. F. His TOA produces, he says, fewer cardiac syin])toms than the carbolized B. F. Sahli is as strong in his praise of Beraneck's tuber- culin as Denys is of B. F. Kleljs was the first to attempt to separate the beneficial from the liai'mful eom])onents of tuI)orcnlin, l)iit his tul)ercnlocidin, administered chiefly by mouth, either with <»r without sch'niii (a derivative of liis 548 SPECIFIC TREATMENT Diplococcus semilunaris), has been little used. Yon Ruck's watery ex- tract finds its greatest field among the general practitioners of the Southern States. Maragliano's work would suggest that B. F. might possess a hypo- thermic action, and in some instances this undoubtedly is true. Other observers attribute the same action to 0. T., T. R., B. E., Beraneck's product, etc. Bandelier and Roepke believe that B. E. is the best tuber- culin, and that T. R. is to be preferred to 0. T. when the antipyretic effect is desired. The separation of T. 0., which Koch thought to be the chief hyperthermic constituent of the tubercle bacillus, from T. R. does render the latter of value in some patients who are unable to take 0. T. (Goetsch, '01; Bandelier and Roepke, '08), and the same may prove to be true in the case of other forms of tuberculin than 0. T. Finally, it may be added that every form of tuberculin has its adherents, who often publish strong if not extravagant claims for the preference. This fact leads many to believe, as has been stated, that little real difference exists between many of the tuberculins (Sahli, "07). DURATION OF TREATMENT Tuberculosis is a very chronic disease, in many instances extending over four or five years before full recovery or death ensues. The hygienic-dietetic treatment, the so-called sanatorium treatment, has clearly proved that long periods of time (three or four years) are necessary to insure permanent recovery. Few patients, especially among the poorer classes, can afford to devote so much time to seeking health, and all recognize to-day that except for the very well-to-do, residence in a sanatorium until permanent recovery takes place is out of the question. Many sanatoria limit the term of residence to three to six months, and recognize fully that their chief purpose is to start well the recovery toward health and, what is more important, to inculcate ingrained habits of self-restraint and hygienic living. Tuberculin treat- ment cannot be completed at such institutions, and many question the advisability of beginning it at all. The same thing applies to the tuberculin treatment that applies to the hygienic-dietetic treatment at these institutions; neither can be completed, but the patients can be so trained that on their return home they can, when tuberculin has been found to be helpful, have their home physician continue the treatment, even while they are at work. They have learned how they should feel; they quickly recognize the essentials governing the increase of dose or the cessation for a time of the treatment. In this way they can aid immensely their family physician in conducting the tuberculin treatment at home or even, as DURATION OF TREATMENT 549 some physicians have permitted, although this is not advisable, continue to give tuberculin to themselves under the direction of the sanatorium physician. From what has been said, it is clear that the majority of physicians who give tuberculin hold that it should be given, even in incipient stages, over a period of at least six months, and after an interval of three to six months a second and shorter course should be begim. It is neither necessary nor advisable to discontinue tuberculin in patients, especially those in advanced stages, who at the end of six or nine months are doing well. It may be continued for twelve to fifteen months with benefit, but if given too long hypersusceptibility may occur. Petruschky believes that by stopping treatment when he reached a dose of 30 to 50 mgm., and awaiting the return of susceptibility to small doses, he shortened much the length of the treatment. Repeated Courses. — But little evidence is at hand on which to base judgment of the value of repeated courses of tuberculin, first suggested by Petruschky. It is well recognized that every tuberculous patient harbors in his body tuberculous foci of different ages, and for this reason any treatment, unless it be continued or repeated for months, has been, except in rare instances, of little avail. Theoretically, tuber- culin should be continued with intermissions of longer or shorter duration until the patient is cured or deriA'es no further benefit from the treatment. It is not always easy, after completing a course of treat- ment, to decide when a new course should be begun. If tubercle bacilli still occur in the sputum, a second course should be begun in three or four months. If, after a few months' interval, the patient begins to feel languid or to show any other signs of renewed activity, a second course should be begun. Tuberculin Test. — If, however, tubercle bacilli remain absent or no change in the physical signs or symptoms occur, the decision is more difficult. Petruschky has found that in patients with tubercle bacilli in the sputum, tuberculin susceptibility (to 0.010 c.c. or 0.001, 0.005, 0.010, 0.020 c.c. 0. T.) returns in about an average of three months, and he insists that when tuberculin susceptibility returns the patient is not cured and should take more tuberculin. If absent, the test should be repeated at the end of three more months, and if reaction takes place tuberculin is given. Koch upholds Petruschky, and C. Spengler uses up to 10 mgm. for this purpose. Goetsch followed a similar course, but subjects the patient to 50 mgm. 0. T. Denys, who prolongs his first course of B. F., found reaction to 0.005 to 0.010 c.c. of 0. T. in three patients after five, twelve, and nineteen months respectively. The recent ophthalmo-tuberculin test may prove to be of value in this connection, and in four patients who had taken 1 c.c. B. F. it 550 SPECIFIC TREATMENT remained absent for three or four months. It is interesting to recall in this connection the patient who after repeated doses of 0.001 mgm. T. R. failed to react. Sahli depends, in a decision about a second course, partly on the slowness and length of the first course, and at times gives it propliylactically. The second course of tuberculin can be begun with higher doses and given more rapidly than the first (Denys, '05). TREATMENT DURING THE ADMINISTRATION OF TUBERCULIN Sanatorium. — A patient with tuberculosis sliould be under the l)est bygienic-dietctic conditions possible, and these can for most patients be obtained more readily in sanatoria. Many, however, cannot remain long enough at a sanatorium to complete the tuberculin treatment, and such patients must be treated at home. Rest and Exercise. — It has been advised l)y some (Goetsch) that the patients remain in bed the day of the dose and the day following. Were this always necessary, it would debar many patients who have obtained apparently great benefit from tuberculin. It is advisable, when possible, to curtail the exercise on the day of the dose and the following day, but that this is not necessary many who give tuberculin to patients at work have proved (Denys, Krause, Holdheim, Heerman, Poppelheim, William Meyer, etc.). In one instance a patient who had been exercising for two hours a day began, when taking 0.1 c.c. B. F., to work six to eight hours daily. He continued at work and completed his course of tuberculin without reaction, but greater care should be exercised in dosage under these conditions. Tuberculin, therefore, may be administered without injury to the patient under somewhat adverse conditions, providing always that the patient get sufficient food. Rise of Temperature. — A rise of temperature to 100° F. for more than two hours always means absolute rest in bed for one or two days, or until the temperature is normal for at least one day, and a patient with a tendency to reaction should remain at absolute rest either in his reclining chair or in bed the day following the dose. The severe lieadache accompanying some reactions is best treated by an ice bag on the head, but codein sulphate (gr. ^ q. 2 h.) may be used. Anti- pyretics should be used sparingly if at all. Medicinal. — In conjunction with tuberculin many substances have been administered. Maragliano uses a serum and tuherculin in alter- nating doses. Eudolph gives calcium carbonate or phosphate in large doses, which he thinks is deposited in the tuberculous focus during the " organ " reaction. Poeppelmann rubs in iodin, Wolff used iodin, EFFECTS OF REPEATED DOSES 551 Marechal injects creosote jiliosphate, and Bernheim and Quentin and Pegurier confirmed Marechal's statements. Vaccines. — Vaccines made from organisms recovered from washed sputum have been employed^ and Klebs advocates the use of selenin, an extract of the Micrococcus catarrlialis in conjunction with tuber- culoidin. EFFECTS OF REPEATED DOSES Weight. — Tuberculin seems to exert little influence on the general condition and weight as long as reactions are avoided, or, indeed, an occasional slight reaction may occur with little if any harm, Mitulescu found, following the use of T. R., a retention of the nitrogenous and phosphorous substances and so increased nutrition, and Denys ('05) thinks B. F. increases the appetite. Patients who were gaining weight in the writer's experience seemed to continue to do so, and those losing weight were rarely affected. A few patients about held their own during treatment, but when it was completed showed a marked gain. Blood. — Erythrocytes. — An increase in the number of the erythro- cytes after small doses has been noted (Rebaudi and Alfonso), and following severe reactions a reduction in the erythrocytes may occur. Xo study of the blood platelets has been made in this connection. Leucocytes. — In rabbits Kinghorn ('02) observed first a leuco- penia, then a leucocytosis, while a study of this subject in patients at the Adirondack Cottage Sanitarium led Lupton and Bro'wn to conclude that while 10,000 per cubic centimeter was rarely reached, an essential increase was often present. In none of their cases was a marked leuco- cytosis present, and in only one or two cases was a leucopenia even suggested. The differential count showed that for rabbits the increase occurred in the amphophile cells while the lymphocytes were decreased (Kinghorn), while for man the increase, according to Botkin ('92), occurred in all varieties. He obtained this when no fever was present, but he examined only three patients. Tschistowitsch ('91) found a leucocytosis after tuberculin and Bischoff ('91) found a leucocytosis in pulmonary tuberculosis after tuberculin, but says it often occurs without tuberculin. yXrneth, believing that the neutrophilic leucocyte passes through definite stages from a cell with one nucleus (young) to a cell with five divisions (old), has worked out definite " blood pictures " for health and for pulmonary tuberculosis, which differ widely in that the younger neutropbilcs arc in excess in pulmonary tuberculosis over the older and better " trained " cells, and as the disease progresses be- come more numerous still. Tuberculin, he believes, restores the normal 552 SPECIFIC TREATMENT equilibrium. A few have confirmed his work in part. (Klebs, A. C. and H., '06.) Serum. — The blood serum plaj's the most important part in the changes produced by tuberculin. Arloing and Courmont noted the agglutination of a homogeneous culture of tubercle bacilli l)y the serum tuberculin and first advocated his bacillary emulsion because it produced more agglutination than any other tuberculin. The most important work, however, on the scrum has been that of Wright, whose tuberculo- opsonic index has been fully discussed elsewhere (Appendix). The op- sonic index to the tubercle bacillus is based on the number of tubercle bacilli " phagocyted " by the polymorphonuclear cells — cells probably little concerned in acquired immunity in animals. It has not yet been clearly proved that these cells give a true index of the action of tbe mononuclear cells, which apparently ^ilay the important role in the immunized animals. During the injection of small, well-spaced, well- measured doses of tuberculin (T. R.), the tuberculo-opsonic index, after a preliminary fall (negative phase), not always present, rises (positive phase) and remains high for some days (high tide of immunity). This opsonin is present in normal individuals, and is apparently complement, as it is thermolabile, while in tuberculous patients it is thermostable and is probably a specific amboceptor. Blood-pressure. — The blood-pressure is lowered after large experi- mental doses, but is unaffected by therapeutic doses (Bauer, A. F. Miller). Untoward Results. — The untoward results of tuberculin as clas- sified by Thorner ('94), at the close of the period of "tuberculin delirium,'' are collapse, impetuous reaction, dangerous swelling around tuberculous parts (e.g., lar^Tix and trachea), nephritis, severe hyper- emia of the skin and brain, hemorrhages (of the hmgs?), pneumonia, inflammation of the pleura, mobilization of the tubercle bacillus, and general tuberculosis, and, according to Virchow ('91), perforation of the intestine when tuberculous, and of the lung. Heron ('01) mentions several unfortunate and fatal accidents following tuberculin. A. Fraen- kel ('91) reported a case where the patient developed a tuberculous ulcer of the tongue that rapidly progressed in spite of tuberculin, which, however, was given while the patient had a temperature of 101.3° F. daily. Krause ('00) has carefully reviewed the cause of the early failure of tuberculin and decided that it was due mainly to the severe cases selected and the doses and intervals used. Some of the untoward results are unquestionably merely coinci- dences. The writer had decided to give two patients tuberculin, and in the meantime one had a severe attack of exudative pleurisy, the other an attack of hemiplegia. Trudeau, Latham, Marmorek, EFFECTS OF REPEATED DOSES 553 Denys, Campbell, Brieger, Moeller, and others have all had such ex- periences. Koehler ('05) had two cases of local gangrene after the use of tuberculin, but later found that he had employed a diluent which con- tained a little H2SO4. Sehrwald had also a case of circumscribed gan- grene following tuberculin. In the writer's experience a sterile abscess developed after a large dose of B. E., but no other untoward symptom occurred at the site of the injection in about 10,000 doses. Mobilization of Tubercle Bacilli. — The strongest objection urged against tuberculin has been that it mobilizes the tubercle bacillus, and many have attempted to verify Liebmann's ('91) work, which disclosed countless numbers of tubercle bacilli in the blood following tuberculin. In 141 patients tubercle bacilli were found 56 times. Barling and Wil- son found 2 tubercle bacilli in 1 and none in 3 preparations from one girl. Prior was able to find none in his patients, and Guttmann and Ehrlich none in 29 patients. Kossel ('91) in 800 preparations found 3 tubercle bacilli, 1 doubtful and 2 unverified. He also examined Liebmann's preparations, found no tubercle bacilli in cells, but in dirty areas, and accused him of using dirty slides formerly used for sputum examinations. Lustig (quoted by Kossel) found tubercle bacilli in the blood in miliary tuberculosis, and more recently several observers have found with improved technic (inoscopy, hemolysis, etc.) tubercle bacilli in the blood in patients not subjected to tuberculin. Such results show that tuberculin has no effect on mobilizing tubercle bacilli, for they occur as frequently in patients treated without tuberculin as in those with if we except Liebmann's work, which has never been confirmed and is probably valueless. Furthermore, experimental (Baldwin) and clinical (Petruschky, Trudeau, Wilkinson, Moeller, Beck) evidence has failed to show that tubercle bacilli may be disseminated by the use of tuberculin. Sputum. — The cough and sputmn are frequently increased after tuberculin, and a feeling of oppression is also often present, suggesting a congestion. A preliminary increase of sputum, which may be more pustular and " dirty," is thought by some to precede the following diminution in amount. C. Spengler believes this increase may be due to the fact that tuberculin produces about the tubercle a specific sero- plastic inflammation. The number of leucocytes in the sputum is thus consequently increased. Denys also has noted this. No effect can be detected on the tubercle bacillus other than what usually occurs as the sputum lessens (i. e., tubercle bacilli may be more numerous in the greatly reduced quantity, or, in other words, an appar- ent increase with a probable real decrease of the number). The viru- lence is unchanged and the morphologv unaffected, though Denys be- 37 554 .SPECIFIC TREATMENT lieves the tubercle bacilli are longer and more granular, and clumping is said to be more frequent. Closely similar results have been obtained by Pane working under De Eenzi, who has fully reviewed this subject up to 1894. Vierling could detect no definite changes in a case he carefully studied. Phagocytosis has been found, following the injection of tuberculin, to occur less frequently by Allen, more frequently by Denys and Buchanan. Urine. — The urine shows few changes except after severe reactions, when it is increased and may present slight traces of albumin and a diazo-reaction. The phosphates and chlorids are increased and urea decreased after the first injection. Salomon ('04) in experiments on animals found that it was very difficult to produce the sclerotic kidneys, long thought to be due to the action of tuberculin (difl'usible poisons of the tubercle bacillus), and attributed the kidney degeneration in man, in part at least, to the action of other toxic substances. Grancher and Martin found that their rabbits, partially or wholly immune to viru- lent tubercle bacilli, almost certainly died sooner or later of a nephritis, similar to the epithelial glomerulo-nephritis of scarlet fever. According to Eappin and Fortineau, and Eamord and Hulot (quoted by Lubarsch and Ostertag), the kidney epithelium often shows after the experimental use of tuberculin pronounced signs of degeneration, due probably to its toxic action. Denys has never observed albuminuria in any of his patients treated with B. F. Three patients out of over 200 during treat- ment with tuberculin by the writer developed nephritis; the tuberculin was stopped and one made a good recovery. The other two were in a far advanced stage. Another patient developed a fatal nephritis one year after leaving the sanatorium, during which period he worked hard and rapidly declined. L. Spengler believes T. E. is preferable, as he found no renal complications following its use, while after 0. T. eight per cent of his patients had albuminuria, C. Spengler states that albu- minuria is not uncommon after bovine tuberculin. De Eenzi ('94) reviews the work done on the urine after the use of tuberculin and found the diazo-reaction and albumin more frequently and urobilinuria almost constantly present. Elevated Temperature. — The effect on the symptoms, except ele- vated temperature, is very difficult to determine, and even if no results are apparent it is wise to continue the treatment if no bad results are noted. Tuberculin exerts on the whole no marked effect, and the improvement is no different from what occurs in patients improving and not taking tuberculin — i. e., it is by leaps and bounds, rarely stead- ily onward to cure. A very marked and immediate effect is seen on the temperature in some cases, especially when it does not rise above 100° F. Following each dose of tuberculin the temperature falls, and EFFECTS OF REPEATED DOSES 555 in some instances this is gradual until the temperature becomes and remains normal. In others the temperature is lowered only as long as tuberculin is administered. Zupnick, who is opposed to tuberculin, frankly acknowledges its antipyretic effect. Aufrecht, Koch, Denys, Elsaesser, and many others have noted a similar action. Rosenberg was nnable to detect any anti- pyretic effect. Hemoptysis. — Bandelier and Eoepke believe that practically all symptoms are improved by tuberculin and have never had a recurrence of hemoptysis, attributing this to a new distribution of the blood due to hyperemia, which relieves the weakened vessel. Goetsch has never seen hemoptysis occur for the first time during tuberculin treat- ment, while Grasset has in one case. It is a striking fact that tuberculin does not produce hemopt3'sis more frequently when we consider the finer structure of the lung and the congestion produced by tuberculin. In all, 11 instances of hemoptysis more or less connected with, or at least following, tuberculin (in one to three days), have come under the writer's notice. None was severe, and most slight or " streaky." In 8 a previous hemoptysis had occurred, and in only 2 was there any marked febrile movement, while in 4 the temperature remained normal. In 3 patients it rose to 99.4°, 99.6°, and 100° F. respectively. When it is considered that in over 200 patients, many well advanced, receiv- ing about 10,000 injections, many of whom had had previous hemoptysis, this symptom was present only 11 times, it seems as if the few hemop- tyses might be looked on, in part, at least, as coincidences. Physical Signs. — The physical signs present much fewer changes than many hold, and improvement when it takes place differs in no way from its usual course. Increase of physical signs after the use of tuberculin occurs in some cases, possibly more often after large doses or certain forms of tuberculin (watery extract). The local or " organ" reactions occurring in patients with secondary infection (really ad- vanced disease) are always serious. Complications. — The occurrence of complications in patients taking tuberculin has seemed to the writer to be less frequent than in those subjected only to the hygienic-dietetic treatment, and Bandelier and Eoepke have noted the same thing. When they do occur the course, unless benefited by tul)erculin, seems to run as usual. Laryngitis and all forms of surgical tuberculosis are apparently benefited by small, care- fully selected doses of tuberculin when the patient is in a suitable con- dition to take tu])orrulin. Pathologic Changes. — Other pathologic changes produced l)y tuber- culin are said to be cell proliferation if moderate doses be used, but 556 SPECIFIC TREATMENT when given in large closes fibrosis occurs about the foci, in the kidneys, and in the liver. Endarteritis and periarteritis have been found. An anatomic study, made by Pearson and Gilliland, showed in all of their treated animals (cattle) that the lesions had retrogressed, were qui- escent, encapsulated, but contained living tubercle bacilli, while in the untreated there was no encapsulation. Experimental Results. — The experimental basis for many tuber- culins is of considerable interest. Koch at first claimed excellent results in guinea pigs wutli 0. T. which later were not confirmed. T. R. and B. E. have given, like 0. T., only partial immunity in small animals, and some obtained none (Baumgarten, Arloing, Courmont, and Nico- las). These, as well as many other tuberculins not used clinically, have all been fully tested on animals. The experimental value of von Ruck's watery extract rests on the results obtained in six inoculated guinea pigs which outlived the controls, but were killed by a dog and not examined. Hirschfelder in his first paper based his claims on the experimental results obtained in one dog. Sahli states that the claims for Beraneck's tuberculin are supported by excellent (the best, he be- lieves) experimental evidence. Denys's tuberculin has no experimental backing, as the author believes animal experimentation of little value in proving the worth of tuberculin. A careful survey of the whole field of animal experimental research on the value of tuberculin gives definite proof that tuberculin affords no bacterial immunity, but often prolongs markedly the lives of the treated animals, even the most susceptible, retards the development of the disease in its earlier stages, and produces changes in the lesions which demonstrate an attempt at healing (Trudeau, '03, '06). RESULTS The results obtained in the treatment of pulmonary tuberculosis by tuberculin would indicate that this treatment is of value, and the view of the majority of those who administer it is decidedly in its favor, al- though some admit that their figures do not always bear out their opti:- mistic opinion. Tuberculin, Petruschky ('99) believes, can produce one of five things: (1) acute intoxication, (2) chronic intoxication, (3) fluc- tuation between immunization and intoxication, (4) regular immuni- zation, (5) lack of results due to a too timid method of procedure. Sahli ('07) holds, and with considerable reason, that the results are (1) cure (only in the earliest stages), (2) compensation (equilibrium, the disease neither advances nor retrogrades), (3) the disease slowly ad- vances, (4) no results. In many instances it is manifestly unfair to expect much from the use of tuberculin. The writer for several years RESULTS 557 Fig. 148. — Conditions on Discharge, Expressed Proportion.^lly, of Patients in the Incipi- ent Stage, Treated with Tuberculin, Dis- charged Each Year. A. C. apparently cured, D. A. disease arrested. Act., active. (Adiron- dack Cottage Sanatorium.) selected severe types of the disease, expecting a steadily downward progress, but on the whole such patients have done remarkably well, much better than he dared hope. Such results are difficult to record, can hardly be expressed in fig- ures, but suggest that there is reason for the belief in tuberculin that is gaining ground (see Figs. 148 to 151). While prognosis in any individual patient is most uncertain, the results in a large number of selected patients can be said to be practically always favor- able. Selection of patients may, therefore, have some, and in reality has had, a large part in the favorable results obtained with tuberculin. The scientific spirit seems sadly lacking in many observers who have reported on patients treated by this method. It appears that many be- lieve that a statement of the number of patients and of how many were " cured," " arrested," and " failed " was sufficient. A grave error may under- lie such figures. In one instance the patients may all be in such an early stage that an astonish- ingly large percentage must be apparently cured, while in another the pa- tients may be so severely affected that improvement of any sort is almost im- possible. When this error is avoided, the patients are often classified by some method peculiar to the observer. Notwithstanding this, many writers on the tuberculin Fig. 149. — Conditions on Discharge, Expressed Proportionally, of P.\tients in the Moder- ately Advanced Stage, Treated with Tu- berculin, Discharged Each Year. (Adiron- dack Cottage Sanatorium.) 558 SPECIFIC TREATMENT treatment have grouped all these patients together and hoped thus to get an idea of the results of tuberculin treatment. Such meth- ods easily lead to false conclusions. When patients are care- fully classified on admis- sion, the divisions of the classification may be so broad that such selection can be exercised as to in- terfere gravely with any comparison. Since 1890 Trudeau has continuously used various forms of tu- berculin at the Adiron- dack Cottage Sanatorium in spite of the fact that strong pressure was brought to bear on him to discontinue their use. The patients subjected to tliis treatment were carefully selected, and until 190'i only those in good general condition and without fever or Fig. 150. — Proportions of Dead and Living IN 1906 OF All Those Treated with Tu- berculin IN Each Year. (Adirondack Cot- tage Sanatorium.) lOOO, c— f ^ ^ t .5 6 y 8 9 to 11 IZ 13 14 15 1 o \ \, \ \ TnT) \ r ?00 TOO "" r- s Tw.A rc \ o ^ Act. \ Fig. 151. — Showing the Numbers per Thousand Surviving at the End of 1, 2, 3, ETC., Years After Leaving the Adirondack Cottage Sanatorium, OF Those Who were Discharged Apparently Cured, with Disease Ar- rested, AND Active. The solid lines represent the total, and the broken lines those treated with tuberculin. The dotted line shows the expected survivors according to general mortality table. (Farr, No. 3.) serious complication were given tuberculin treatment. It was given in 1890 and 1891 to a few patients in far advanced stages as a last resort. RESULTS 559 Since 1902 any patients who wished tuberculin received it, as it was hoped in this way to avoid selection, but such has not been the case. Inasmuch as patients who received tuberculin have been permitted to remain longer, those who for any reason — e. g., tubercle bacilli still present in the sputum, improvement not sufficiently rapid, the pres- ence of extensive lesions, etc. — desired to remain longer, elected to take tuberculin. Consequently, while from 1897 to 1900 a large number of incipient cases received tuberculin, from 1903 on the majority have been moderately advanced cases. This latter stage is the broadest in the classification used and admits of far wider variation than the incipient. Koch's original tuljcrculin, his bacillary emulsion, Tru- deau's modification B, Denys's bouillon filtrate and tuberculo-plasmin, have been chiefly used, but tuberculin 11 and tuberculol have been given to a few patients. While the number of patients treated with tuberculin at the Adi- rondack Cottage Sanatorium has not been large, the care with which the patients have been followed render the following results of in- terest. To allow of comparison, since the numbers in each group varied so much from year to year, it is necessary to reduce or to increase the numbers of the treated and untreated in each class in each year to 100. This gives the following tables, expressed in percentages, in which are included the results on discharge and the ultimate results of 185 patients treated with and 864 treated without tuberculin who remained in the institution over ninety days and had tubercle bacilli in their sputum : Results on Discharge With Tuberculin. Without Tuberculin. Incipient: Apparently cured Disease arrested 56 34 10 27 55 18 50 38 Active 11 Moderately advanced : Apparently cured 6 Disease arrested 51 Active 43 The ultimate results, expressed in percentages of those living one to fifteen years after discharge, proper allowance being made for the varying numbers in each year and class, are as follows: 560 SPECIFIC TREATMENT Ultimate Results With Tuberculin. Without Tuberculin. Incipient: Apparently cured 88 77 33 91 48 41 78 Disease arrested 78 Active 27 Moderately advanced: Apparently cured 86 Disease arrested. . 45 Active 22 These statistics indicate that on discharge the incipient cases have done somewhat better than those receiving no tuberculin, while the moderately advanced cases showed much better results. The ultimate results do not show such marked differences, but indicate that the treated, both incipient and moderately advanced, do better. Reports of Tuberculin Treatment. — A review of the literature shows that the lack of proper, or indeed of any, classification of patients ren- ders many results of small value for comparison — e. g., those of Amrein, Aufrecht, Beck, Elsaesser, A. Fraenkel, Heron, Holdheim, Kaatzer, Krause, Kreuser, Schroeder, and many others. Guttstadt ('91), who edited the first large collection of reports on the tuberculin test and treatment (1891), reported figures during the era of "tuberculin delir- ium " and overdosage. He found only twenty per cent of " cures," but all stages were treated, and his figures have little bearing on tuber- culin treatment as at present administered. Denison ('02) has reported 213 patients treated with various culture products and serums. His best results were obtained with von Ruck's watery extract. Of 33 patients so treated, of whom definite information was given, 28 were alive and 5 dead one and two third years after treatment. Denys ('05) reports 442 patients treated with bouillon filtrate (B. F.). He uses a personal classification both on admission and dis- charge and compares the results obtained with those secured in 39 non- injected patients (Stage I, Turban, afebrile), of whom 4 were healed, 24 died. 9 failed, and 2 remained stationary. Of the 442 patients treated, 193 (44 per cent) were healed, 56 (13 per cent) arrested, 65 (15 per cent) improved, 28 (6 per cent) stationary and failed, and 100 (23 per cent) died. The striking feature of these statistics is the fact that all the " controls " died. Febrile patients were not excluded from those treated (see Schnoeller). The results of Goetsch ('01) have been much quoted and received on RESULTS 561 their publication the indorsement of Koch. He treated with Koch's 0. T. 224 patients, chiefly in the incipient stage (88 only had tubercle bacilli in the sputum, 135 reacted to tuberculin, and 1 had tubercle bacilli in the glands). Of these, 12 were too short a time under treatment and in too advanced a stage to obtain any results of value, 37 patients had just started the treatment, and 50 were treated too short a time. These were excluded and the remainder (125), all in the incipient stage, were cured. Guttmann and Ehrlich ('91) the first to advocate small doses, gave old tuberculin to 18 men and 18 women, all afebrile, 13 in the incip- ient and 23 in the moderately advanced stage. They reported all " prac- tically improved." Inasmuch as only a small percentage of such patients fail to tin prove under suitable conditions without tuberculin, these figures are of small value. E. Klebs ("03-4) uses a personal classification and obtains results varying from 100 per cent of cures in his first stage through 90 per cent, 57 per cent down to 5.5 per cent of recoveries for his last stage (fourth). In his second stage all improved, in the third 97 per cent, in the fourth 33.5 per cent. The results of Langenbach and Wolff ("91) were based on a com- parison of 99 patients treated with original tuberculin and 99 untreated, all in as nearly as possible the same condition (many far advanced). After a careful study the authors conclude that those treated with tuberculin were on an average in slightly more advanced stages at the beginning of treatment. Of the treated patients 33 were healed and 21 died ; of the untreated 9 were healed and 45 died. Some of the patients treated with tuberculin were also given sodium picrate and sublimate (corrosive?), and these the authors think did best. These drugs alone were of no value. Ludke ('07) reported of 100 patients treated with old tuljerculin (Turban II, 64, III, 36) 62 improved and 11 died. Mitelescu classified 30 patients, 22 with closed and 8 with open pul- monaiy tuberculosis. Of the former, 20 were healed, 2 improved; of the latter, 5 were healed and 2 improved. The largest statistics so far published of value for comparison, are those of Moeller ('03-4) at Belzig. Only afebrile patients, with not too far advanced laryngeal and pulmonary disease, without heart or kidney disease, were given tuberculin. Eeduced to a percentage basis the tabular comparison is as follows: 562 SPECIFIC TREATMENT Stage Turban No. Healed (Per cent) Arrested (Per cent) Improved (Per cent) Unimproved OR Failed (Per cent) Tr. Untr. Tr. Untr. Tr. Untr. Tr. Untr. Tr. Untr. I 134 281 51 32 37 51 10 16 1 1 II 105 290 18 3 44 27 32 59 6 11 Ill 90 362 41 6 36 31 23 63 Total.. . . 329 933 27 10 40 26 24 35 9 28 Attention is here directed to the marked advantage in favor of the patients treated in Stage II. Stage I is much wider than Trudeau's incipient class and shows correspondingly a greater advantage in favor of the treated. In these stages careful selection may account in large part for the differences obtained. In a study of the tuberculin-treated patients at Belzig, Loewenstein and Eappoport state that they consider only those patients who received at least 10 mgm. of old tuberculin. By this selection all highly susceptible individuals are excluded. If this susceptibility is an indication of lack of resistance another proc- ess of selection is exercised. This docs not hold for the foregoing figures. Petruschky divides his patients treated with tuberculin into open (38) and closed (54) pulmonary tuberculosis. In the latter all were healed, in the former 15 were healed and 23 are dead. The results reported by Nagel ("06) from Cottbus are apparently in favor of the patients treated with tuberculin. Here the results ob- tained in Stage I (Turban) closely approximate the results in the incipient stage at the Adirondack Cottage Sanitarium — i. e., little dif- ference exists in the immediate result between the treated and untreated patients. In Stage II, however, the healed are three times as numerous among the treated as among the untreated, and those able to work fully two thirds as many more among the treated as among the untreated patients. Stage III shows similar results. Tuberculin has, however, been administered at Cottbus only for three years (1902-4). The improvement in sanatorium results during recent years, due no doubt to the earlier diagnoses, is very marked. The comparison given, there- fore, is between selected patients of later years and those not chosen for tuberculin. These latter are probably better than the tuberculin treated, and certainly no worse as a whole. Comparison of these (598) with the patients treated with tuberculin (184) (obtained by subtract- ing table of all patients treated with tuberculin from table of all pa- RESULTS 563 tients during years in whicli tuberculin was used) gives very interesting results, shown in the following table in percentages: No. OP Patients Stage Turban Healed and Able Partially Able TO Work ' to Work Unable to Work, Worse Tr. Untr. Tr. Untr. Tr. Untr. Tr. Untr. 32 116 36 521 65 12 I II III 87 70 14 92 71 13 23 56 s 20 58 7 30 0.2 9.0 42.0 These figures show very little difference between the treated and untreated patients, and would suggest that either tuberculin has exerted no effect upon the immediate results or that the patients subjected to the tuberculin treatment were worse, which Nagel states to be the case. Patients with more advanced disease were chosen for tuberculin treat- ment, and often only those not doing well under hygienic-dietetic treat- ment, especially in open pulmonary tuberculosis of the earlier stages. Eecently Bandelier and Roepke ('08) have published results ob- tained at Cottbus by the use of B, E. and Perlsucht 0. T. The follow- ing table gives these results as compared with the nontreated cases referred to above: Stage Results Nontreated Patients, 1902-4 Patients Treated with B. E. Patients Treated with Perlsucht O. T. I Healed 212—41% 265—51%, 43— 8% 1— 0% 10—37% 12—44% 5—19% 0— 0% 11—34% 19—59% 2- 6% 0- 0% Able to work Partly able to work Unable to work II Healed 5-8% 41—63% 13—20% 6— 9% 13—10% 77—62% 30—24% 4-3% 25—21% 66—56% 26—22% 0—0% Able to work Partly able to work Unable to work III Healed 0— 0% 0-0% 7—58% 5—42% 0— 0% 9—17% 35— 65%c, 10-19% 0-0% t>— 31% 16—55% 4—14% Able to work Partly able to work Unable to work For some years von Ruck has reported no patients who have not received treatment with his watery extract, and his figures therefore afford no basis for comparison of treated and untreated patients. His use of a personal classification also renders comparison of his results with those of others difficult or impossible. He has obtained, he states, excellent results. 564 SPECIFIC TREATMENT Schmoeller ('05) has reported 311 patients treated with Denys's tuberculin. Of these in Stage I (Turban) (25) 100 per cent improved, 68 per cent were healed; of Stage II (121), 94 per cent improved, 25 per cent were healed; of Stage III (65), 72 per cent improved, 3 per cent were healed. Carl Spengler, by the aid of bovine tuberculin, obtains 100 per cent of cures in Stages I and II (Turban) and 99.7 per cent of cures in the same stages with tuberculin from bovine and human strains. Such figures need no comment. Turban's ('06) results are based on the treatment of 327 patients, 241 without and 8.6 with tuberculin. All had tubercle bacilli in their sputum. " Lasting healing " was obtained in 53 per cent of the latter and in 39 per cent of the former. The idtimate results of tuberculin treatment are believed by some to be the real test of the value of this treatment. The ultimate results obtained by Trudeau have been mentioned. Heron treated 32 (un- classified) patients with tuberculin, and seven years later found 10 well, 1 relapsed, 8 dead, and 13 untraced. Holdheim in 15 unclassified ambulant patients similarly treated obtained after two years a negative tuberculin test and observed no recurrence of symptoms. During tlie winter of 1890-91 Eembold treated 82 patients with old tul)erculin. Six years later he traced 70 patients, 27 of whom had had mixed infec- tions and had died (23 in the first year, 2 in the second, and 2 in the third year after treatment). Of the remainder (43) 18 were dead, 12 improved, and 13 cured. Of the 13 cured 12 had early and 10 closed pulmonary tuberculosis. Three of the 12 patients improved had closed lesions. Loss of Tubercle Bacilli. — The loss of tubercle bacilli in the sputum by patients undergoing treatment is evidently of the greatest importance, and since it has been roughly estimated that only 42 per cent of patients lose their bacilli during residence in a sanatorium, it is clear that any treatment that will increase these figures is of great importance, even if it accomplished little else. Patients treated with tuberculin usually remain longer in sanatoriums, a fact that directly influences the dis- appearance of tubercle bacilli from the sputum. A study at the Adi- rondack Cottage Sanitarium of the cases previously mentioned showed that in the incipient class 64 per cent of those treated without and 67 per cent of those treated with tuberculin lost their bacilli, while for the moderately advanced the figures were 24 and 44. Bandelier and Roepke ('08) have recently published their results obtained with B. E. and bovine old tuberculin, which are as follows: ANTAGONISTIC BACTERIA 565 Percentages op Patient-s who Lost Tubercle Bacilli Stage B. E Bovine O. T. I 100 100 II 78 90 III 34 39 Kreuser selected 110 patients with tubercle bacilli in their sputum and treated 55 without and 55 with tuberculin. Of the latter, 23 lost their bacilli, of the former IG. Philippi ('06) compared 98 patients Avithout tuberculin treatment with 28 so treated (all afebrile), and found in the second stage (Turban) 19 per cent of the untreated and 58 per cent of the treated lost the tubercle bacilli from their sputum, while of the third stage 7 per cent of the untreated and 31 per cent of the treated lost their bacilli. Turban found at the end of from two to six years that 48 per cent of the treated and 27 per cent of the "untreated had sputum free from tubercle bacilli. The present status of tuberculin may be expressed in a few words. Tuberculin when properly given does no harm, may produce no appar- ent result, and may markedly benefit an individual patient, who can follow at the same time the hygienic-dietetic treatment while in a health resort, at home and at rest, or at work. Small doses and careful increase are most important, and by following them very closely some patients, even in advanced stages, reap great benefit. The immediate and ulti- mate results are improved, fewer relapses occur, and more patients lose the tubercle bacilli in their sputum. ANTAGONISTIC BACTERIA (Bacterio-tltcrapi/) Bacterium Termo. — Cantani ("85) advocated spraying into the lungs a culture of hacterium termo, which Ravenel states has been found to be a mixture of a number of putrefactive organisms. This treatment was based upon the theory that putrefactive organisms de- stroyed tubercle bacilli, a view that De Toma ('90) clearly disproved. It is useless to review the work on this subject, a task already performed by De Toma ('8S-'90) and Moeller ('04). Erysipelas. — Solles ('90) thought that erysipelas prolonged the life of tuberculous guinea pigs, a statement that has aroused little interest. Syphilis. — Portucalis is stated by Braunstein and Fraenkel ('01) to have inoculated patients with lues to cure tul)erculosis. There is 5G6 SPECIFIC TREATMENT no record to show that his temerity has l^een equaled, and proof exists to show that SA-philis is a predisposing factor to tuberculosis. Yeast. — Tournier ('00) stated that yeast had some healing influence on tuberculosis, and Huggard and Morland ("05) have since recom- mended it on account of its rich content of nucleic acid. (See Koumiss. ) Merrihy ("97) used Bacillus coll communis with good results, and Moeller (*04) sarcina and cocci without results and Bacillus tumesciis and Bacillus mesentericvs with slightly favorable results. Maher ('06) urged the use of a bacillus found in milk and elsewhere, which he called Bacillus X. His results have not been confirmed. There is at hand some evidence to show that patients contracting typhoid fever do remark- ably well, but no one to the writer's knowledge has as yet suggested the use of these organisms for the cure of tuberculosis. "Acid-fast" Bacteria. — Moeller ('04), the authority on this class of organisms, asserts that a close relationship exists between them and the tubercle bacillus, and that immunization against the one may pro- tect, in part, at least, against the other. The agglutination test does not differentiate them (Koch), and Klemperer and Moeller found that the timothy-hay bacilli offered some protection to experimental animals. Moeller found that the more virulent members of the group afforded the better protection against tubercle bacilli, but that avirulent indi- viduals of one species protected against the virulent members of the same species, and homologous bacteria were not necessary to produce marked immunity against these acid-fast bacteria. Attenuated Tubercle Bacilli. — The best immunity to tuberculosis has, as Trudoau ('0GB) has sho-WTi, been obtained by living tubercle bacilli, attenuated to a marked degree, but not completely avirulent for guinea pigs. These small animals have not yet been fully immunized against tuberculosis, and the results in rabbits on account of the pro- nounced natural immunity are often unsatisfying. The human strain of tubercle bacilli have been attenuated by many means (heat, sunlight, decomposition, long growth, unfavorable media, passage through refrac- tory animals, treatment with glycerin, phenol, and various antiseptics, soaking in serums and in emulsions of lymph glands), and the tubercle bacilli then used for immunizing purposes. Dixon ('89) first obtained a rather high degree of immunity to tuberculosis in experimental ani- mals by preliminary inoculation of attenuated tubercle bacilli (Pearson, 'Ofi). Trudeau ('93) was able to show marked improvement in rabbits' eyes by the use of living avian tubercle bacilli. De Schweinitz ('94) reported marked immunity in a cow inoculated with an organism attenuated by growth (Trudeau's R bacillus), but the work of McFadyean ('01), who used avian tubercle bacilli intra- ANTAGONISTIC BACTERIA 567 venoiisly, was the first to attract widespread attention. In December, 1901, von Behring announced that he was trjdng to immunize cattle by repeated intravenous inoculation of attenuated human tubercle bacilli, but Pearson and Gilliland were the first to bring forward proof sub- stantiating such a claim. Later von Behring ('05) has put ujjon the market his " bovo-vaccine," a powder of dried human tubercle bacilli which keeps but one month. "Tauruman" of Koch ('00) and Schiitz is a similar product, but retains its virulence longer. Both are used intravenously. Since then Neufeld, von Behring, Hutyra, and others have shown that cattle can be immunized against a dose of tubercle bacilli given experimentally and acquired naturally in infected stables, which is fatal for controls. Only young animals which are not to be milked or used for food for many months are suitalile for vaccination. Calmette and Guerin ('07) have obtained some immunity in calves by feeding them dead tubercle bacilli. Vaccination. — Marfan ('86) noted that patients, once fully cured of a local tulierculosis, rarely suffered again from tuberculosis. Koch ('90) had noted a difference in local reaction in tuberculous and healthy guinea pigs to the injection of tubercle bacilli. Maragliano ('01) more recently has attempted to produce a focus of tuberculous inflammation in the skin without the use of living tubercle bacilli. Accordingly, he has inoculated individuals in the arm in three places about one and a half inches apart with 1 mgm. of dried tubercle bacilli heated to 150° C. in glycerin for one and a half hours. A small pustule with a larger area of induration accompanied with some fever for two days occurs. This is repeated once and no reaction follows. The value of this has naturall}^ not been proved on man, but animals resist afterwards viru- lent tubercle bacilli. Other strains of tubercle bacilli have been used for immunity. Avian tubercle l)acilli were first used l)y Trudeau, Hericourt ('92), and Paterson, while Priedmann ('03) has urged the use of his turtle tubercle bacillus, wliich was later proved virulent for warm-blooded animals. Kiister ('06) employed a frog tubercle bacillus, Moeller ('04) on himself a tubercle bacillus passed through the blind- worm, while Klemperer ('05) inoculated himself and five j^atients with living bovine tubercle bacilli. Spengler ('04) has done the same thing, using 0.5 mgm. of living bovine tubercle bacilli and experienced only ulcera- tion at the site of inoculation. These attempts have not been followed up, as they proved lilllo. Products of the Tubercle Bacillus. — Since 1890 great attention has been given to the use of the various products of the tubercle bacillus, and more recently dead tubercle bacilli have been largely employed. Trudeau's ('06) experin^ents have conclusively shown that attenuated 568 SPECIFIC TREATMENT tubercle bacilli give the best protection ; then come in order dead tubercle bacilli and the various products of tubercle bacilli known as tuberculins, which have been discussed at length. ORGANOTHERAPY The treatment of pulmonary tuberculosis by extracts of various tis- sues, healthy and tuberculous, has been often attempted. The tissues most frequently employed have been the lymphatic glands, tlie muscles, tlie lungs, and the blood cells. Lungs. — As early as the seventeenth century (1638) Eobert Fludd, an English physician, advocated the injection of sputum for the cure of pulmonary tuberculosis. Cavagnis ('S6) obtained with tuberculous sputum, treated with phenol, favorable results in pulmonary tul)erculosis. Krause ('06) injected subcutaneously into one patient his own sterilized tu])erculous sputum with only slight rise of temperature and without local reaction, and obtained pronounced decrease of catarrh and marked improvement of the general health. Allen ('07) advocated the use of specially homogenized and sterilized (by repeated lieating to 60° C.) tuberculous sputum in pulmonary tuberculosis more on account, it is true, of the homologous uncul- tivated bacteria. Loewenstein ('06) found that leucocytes obtained from the urine of a patient with tuberculous cystitis phagocyted heterol- ogous but not homologous tubercle bacilli, until treated witli B. E. (heterologous). Wright ('07), who is strongly in favor of homologous bacterial vaccines, makes little or no mention of it in tuberculosis and, in all the vaccines employed, cultivation of the organisms seem.s in no way to decrease their effect. As late as 1897 and 1898, Lemery and Schroeder advocated the use of the lungs of the fox, one cooked, the other as a powder. Some years ago two homeopathic physicians, Jaeger and Burnett ('00), advocated the use of powdered tuberculous pulmonary tissue in the treatment of tuberculosis, and this substance in its various " potencies " is to be found to-day in the homeopathic pharmacopoeia. Allen ('07 B), Saranac Lake, was unable to discover any tubercle bacilli or their fragments in the sugar-coated pills. More recently Peter Paterson ('06) has used the caseous material from tuberculous foci. Basing his work upon a theory that because tubercle bacilli do not grow in pus in abscesses while they grow in the wall there is some antagonistic substance in the caseous matter, he has sterilized this by alternate freezing and thawing for six months. It is then thoroughly washed to remove all soluble toxins, and an emulsion (1 c.c. = 0.005 gm.) made in salt solution. Large doses only cause febrile reaction. The best dose is 0.1 c.c. to 0.5 c.c, which ORGANOTHERAPY 569 should cause a rise of 0.5° F. Five patients have done well under this treatment. A criticism of all such attempts with tuberculous tissue may readily be made, in that all these tissues contain tubercle bacilli and it is a fair induction that any benefit arising from such powders or emulsions may be due to the tubercle bacilli or its toxins which they contain. The juices or extracts of normal lungs have also been tried. Bru- net has found that guinea pigs inoculated with gh^cerin or aqueous extracts of pulmonary tissue lived a little longer than the controls, and that four patients, while experiencing some oppression and congestion (of the lung?), had less exjsectoration and were somewhat improved. Grande has used a pulmonary extract and also 4 to 5 gm. a day of powdered lung tissue in the form of pills, and one patient so treated improved. Lymphatic Glands. — (a) Tuberculous. — Eodet ('03) macerated in sterile water tuberculous glands from guinea pigs, added thymol and allowed the suspension to stand until the tubercle bacilli were dead. The results in guinea pigs were unfavorable in regard to treatment, but seemed to increase in a certain measure the resistance to infection. Large doses were employed. Bimbaud ('04) used practically the same method of preparation, but, on account of induration at the site of injection, he later filtered the emulsion through paper. Human tuberculous glands (excised at operation), as w^ell as tuberculous glands from guinea pigs, were em- ployed. His results were similar to those of Eodet. Baldwin and Price obtained negative results in guinea pigs from an emulsion of a tuberculous gland removed during the . height of a tuberculin reaction from a calf, previously inoculated with virulent human tubercle bacilli. McCullough, who has had good results in treating glandular tuberculosis with X-rays, attributes it to a setting free of vaccine, encapsulated in the gland, " in consequence of the re- sorbent action of the X-rays on the rudimentary neoplastic tissue that encapsulates the tuberculous gland." This auto-inoculation with homol- ogous bacteria raises the opsonic index. (&) Normal. — The lymphatic glands are said to contain nuich nucleic acid, which has been shown to stimulate the formation of leuco- cytes. Arguing from this and from the fact that thyroid extract is, when administered by mouth, just as efficacious as when injected sub- cutaneously, Hoffman had administered powdered bronchial glands dried in vacuo at a low temperature. His claims for this powder are absurdly extravagant. Several authorities have found that tubercle bacilli subjected to the influence of material obtained from lymphoid organs for twenty-two days were greatly attenuated (Brieger, Kitasato, 570 SPECIFIC TREATMENT and Wassermann, quoted by Bartel ('06) and Neumann), and Bartel believes that tubercle bacilli so treated will prove an effectual vaccine material. Baldwin has found that opsonized tubercle bacilli are more quickly fatal for guinea pigs. Muscle. — The muscle plasma, ordinarily termed fresh beef juice, has come into much prominence since the publications of Eichet ('00) and Hericourt ('00). They obtained striking results in the treat- ment . of inoculated dogs, many making good recoveries. Fraenkel and Sobcrnheim ('01), and again Brown ('03), were unable to substantiate these claims. In patients with pulmonary tuberculosis many have obtained good results, but tlie majority of observers attribute these favorable results to its action as a suraliment. Some (Balladere), however, still attribute to the muscle plasma an action, bactericidal and antitoxic for the tubercle bacilli, while others suggest the use of the meat of immunized cattle (Maragliano). Blood Cells. — Lumiere, and later Gelibert, have used by intramus- cular injection the plasmic contents of the blood cells " of a certain number of animals.," calling the extract hemoplase or plasmo-therapy. In 112 patients treated with this substance Gelibert found that only 9 failed to improve. Baldwin and Price obtained in guinea pigs nega- tive results from an extract of the leucocytes of an immunized cow. Daremberg, following Pasteur's work in rabies, injected without results an emulsion of the spinal cord of tuberculous guinea pigs and rabbits into guinea pigs and rabbits. An emulsion of marrow from a calf pro- duced no apparent results when injected into guinea pigs (Baldwin and Price). • Eimbaud ('04) has made some experiments on passive organotherapy, using the serum of a goat inoculated with the tuberculous glands of a guinea pig or man. The results were negative. Haentjens ('06) has used two dogs and tuberculous sputum in the same way, and obtained, he claims, good results in patients with the serum. Matsutow be- lieves that tuljerculin is not the toxin of the tubercle bacillus pro- duced in the living organism. This real toxin, free from tubercle bacilli, he claims to have obtained in extracts of tuberculous organs of guinea pigs, and with it has so immunized guinea pigs that they re- sisted a fully virulent culture. The organs of the goat and dog have also been used, but with little effect. Fauvel uses suljcutaneously in animals extracts of the nasal and pharyngeal mucous meml^ranes in Hayem's artificial serum with benefit. This preparation, which he called paratoxin T., gave good results in sixty-two patients. Organotherapy, active or passive, in pulmonary tuberculosis, rests to- day upon little sound favorable evidence, and occupies in the specific SEROTHERAPY 571 therapy of pulmonary tuberculosis a position demanding on its prac- tical side little or no consideration. HEMOTHERAPY Hemotherapy, first employed by Fiedler ('70), using defibrinated blood of immune animals, and later by Hericourt and Richet ('88-'90), has chiefly an historical interest, since Bouchard, Buchner and others showed that the senim contains practically all the immuniz- ing elements of the entire blood. The first investigators, basing their experiments upon the fact that dogs are refractory to tuberculosis, in- jected dogs' blood into the peritoneal cavity of rabbits and rendered them more refractory to tuberculosis. Bernheim, having found the goat very refractory to tuberculosis, used intravenous injections of goats' blood in 13 patients. Of 11 in the " first and second" stages, 7 were cured, 4 greatly improved, while 2 in the " tliird " stage died, 1 from syncope during the transfusion. Bertin and Picq injected goats' blood in the subcutaneous and muscular tissue of the buttock in 150 patients with good results, save in a few who overexercised and devel- oped abscesses and urticaria. Figari has obtained increased antitoxic and antibacillary sub- stances in the serum of 18 patients (5 cured, 13 greatly improved), who were given pulverized l)lood clots to which had been added glycerin and aromatics. Similar results were obtained with guinea pigs. The immunizing substance is in the hemoglobin, Figari holds. Ricci ob- tained poor results in three cases, but upholds the views of Figari. Xiccolini, who similarly prepared and administered blood clots from immunized calves^ observed in patients increased weight and increased agglutinating power of the serum. He gave 7 patients Maragliano's hcmoantitoxin in doses of 15 c.c. or less^ according to age, and ob- tained healing in 4, improvement in 2, while 1 died. Hemoplase, the plasmatic content of hemoglobin, gave good results according to Lu- miere, quoted by Gelibert. Since the work of Boucliard, which showed that all the immunizing properties of the blood are contained in the serum, little interest has been taken in hemotherapy, and in the liglit of our present knowledge of agglutinins and precipitins the blood should not be used for immu- nizing purposes. SEROTHERAPY Passive immunization by means of serums of treated animals has been attempted by many, more especially since Behring's and IJoux's successful work in diphtheria. The first work was naturally with the 572 SPECIFIC TREATMENT serums of animals immune to tuberculosis, which Bouchard ('93) by experiments on guinea pigs sliowed of little value. This again turned attention to organotherapy, which in turn was supplanted by the use of serums of artificially immunized animals. The tirst work along these lines was that by Auclair ('96), who immunized fowls to human tubercle bacilli, but obtained no antitoxic serum. Following this, many attempts have been made to obtain such a serum, but to-day, while several men claim to have such a serum, they have so far been unal^le to establish their claim. The amount of work and literature upon this subject is overwhelm- ing, and can only be touched on summarily. Among the animals used for the production of an immune serum are fowls, the horse, mule, ass, goat, dog, sheep, and cattle (milk). These animals have been inoculated with many products mentioned un- der hemotherapy and organotherapy, with tubercle bacilli, virulent and attenuated by many means (long growth, passage through refractory animals, glycerin, heat, decomposition, sputum treated with phenol, etc.), of all strains, human, bovine, avian, and cold-blooded; with many varieties of tuberculin (0. T., T. K., B. E., Beraneck's, etc.) ; with acid- resisting bacilli (timothy hay). Varieties. — The immunizing serums in use at present have dwindled down to very few. Those most used are Marmorek's ('03, '04, '05) and Maragliano's, but de Schweinitz, Fisch, Paquin, Arloing, Baumgarten, von Behring, have also worked on serums. Monard, Blache, and others have prepared and used artificial serums; others have combined iodoform and guaiacol with serums. The scrum of the normal horse and the diphtheria-antitoxic serum have been advocated. The milk of immu- nized animals (cows chiefly) has also been emplo^-ed. Administration. — The method of administration was at first entirely subcutaneous, but more recently serums have been extensively used per rectum (Chantemesse, '96), and many given per os. Maragliano and several of his pupils claim to have given intrapulmonary injections with benefit. Large quantities of serum (one eiglith of tlie body weight of a rabbit) can be administered to some animals without any apparent in- jury (Heilner). The use of serums by mouth, especially in the case of milk of immunized cows, has led to much work. It may now be stated that only during the first two or three weeks of life can antitoxic serums be absorbed by intact mucous membranes, and Salge, quoted by Ham- burger ('05), has shown that diphtheria antitoxin is not absorbed from milk by infants, which leads Hamburger to doul)t if foreign ahmuiins in cows' milk are ever absorbed. It is possible, but not probable, tliat antituberculosis serums may act differently from others. Jemma has found that infants acquire no increased agglutination after using im- SEROTHERAPY 573 mime milk unless the parents be tuberculous. Maragliano and Figari deny these assertions. Results. — Tlie results of passive immunization are neither brilliant nor promising. The injection of a serum produces a ferment in the blood, not usually present, and dependent only upon the presence of the peculiar proteid injected (Heilner). Many of the serums advocated for use in man rest upon little or no experimental basis, and this, coupled with the facts that normal serum of one species of animal may stimu- late slightly the blood-forming organs of another and so increase re- sistance to infection (Weigert), and that suggestion cannot be elim- inated, throws much doubt upon the results of many observers. Trudeau and Baldwin, Arloing, Mafucci and Di Vestea, Sokolowski, Karwacki ('05), and others have either obtained no proof of antitoxic substances or no beneficial clinical results. Serum Disease. — ^The " serum disease " (v. Pirquet and Schick ('05)) manifested in man by urticaria, arthralgia, and fever, occurs usually ten to twelve days after the injection of a serum. The " Theo- bald Smith" phenomenon, anaphylaxis to serum, described by Eosenau and Anderson ('08) in America and Otto ('04) in Germany, occur- ring violently and fatally in guinea pigs if an interval of eight to thir- teen days be suffered to elapse between the first and second injections, rarely occurs severely in man, and needs little consideration in most patients. Calcium salts, as Wright ('96) suggested, lessen the S3anp- toms in man. The injection of any serum into the veins causes severe collapse and cyanosis, and every care should be taken to avoid this, for at least one fatal case has occurred. Marag-liano's Serum. — Maragliano in 1895 first began to publish his results with his antituberculosis serum, and from that time to 1900 he wrote twenty-three articles, and others brought up the list to one hun- dred and eighty-two papers on this senim. In immunizing animals (usually the horse, cow, or calf), Maragliano used sul)cutaneously increasing quantities of (1) his watery extract and tlie filtrate through porcelain of virulent, living cultures, together with the (2) bacillary pulp, a filtrate through porcelain of tubercle bacilli ground in sand and water. Equal quantities of these two sub- stances are injected simultaneously in different parts of the body. If borne without marked fever or local reaction, a second injection of double the amount is made after three days. The dose is steadily in- creased until the serum of the animal has a high agglutiiuition and ])ro- tective power — i. e., until the serum is of such a ])Ower that -nunr C-C. will protect 1 gm. guinea pig. The test poison is the watery tuberculin, which is so concentrated that doses of one per cent of body weiglit will kill a guinea pig not sooner than twenty-four hours nor later than five days. 574 SPECIFIC TREATMENT The administration of the serum has l)een chiefly siihciitaneons, 1 c.c. every second day for ten days, then 5 c.c. every second day for ten days, next 10 c.c. every second day for twenty days more. More recently Maragliano has advocated its use by mouth, Livierato has injected it into the lung, and Hegar has painted it upon exposed tuberculous areas — all, they claim, Avith good results. Any case, Maragliano says, is suitable for treatment, and many good results are obtained in patients who continue to work and follow few hygienic rules. The serum, according to Maragliano, is both antitoxic and bacteri- cidal; it reduces fever, lessens the "number of tubercle bacilli," in- creases the weight and abates symptoms. Hegar believes it acts only on the toxins. Karwacki ('05), who experimented with the serum, came to the following conclusions: Maragliano's serum is more poisonous to guinea pigs than normal horse serum. Tlie serum contains no antiprotein, and does not protect the guinea pig from a letlial dose of tuberculin, but ratlier it hastens death through acute intoxica- tion. The serum has no higher agglutinating properties than normal horse serum. The serum contains specific amboceptors, and in the ani- mal organism gives rise to bacteriolysis of the tubercle bacilli. The serum when injected together with tubercle bacilli protects from anatom- ical tuberculosis, but not from protein intoxication. The serum has an unfavorable action on tuberculosis in process of evolution. The results obtained by Maragliano ('05) and bis confreres, from 1895 to 1905, in 1,16-1 patients ma}^ ])e grouped as follows: Total. Healed. Per Cent. Destructive lesion with cavity 102 164 206 191 191 250 .3 17 19 26 68 45 2 Destructive lesion without cavitv 10 Diffuse lesion with fever ' 9 Diffuse lesion without fever Limited lesion with fever 14 56 Limited lesion without fever 58 These results are good, Imt are no better than many ol)tain witliout specific treatment. In tliis country, l^nvenel, Walsh, Landis, and Stan- ton, at tlie Pliipps Institute, obtained no definitely beneficial results. Eavenel, who has Avorked with Maragliano, is convinced that tliis serum will protect animals from fatal doses of tubercle Ijacilli, but is not so sure of its curative properties. Marmorek's Serum. — Marmorek in 1903 resigned from the Pasteur Institute to present to the French Academy of Medicine his discoveries in regard to the antitu])erculosis serum now bearing his name. He stated that tuberculin was not the true toxin of tuberculosis ; that young "FALSE SPECIFICS" 575 (primitif) tiil)crele l)acilli excreted no tiibercnlin, but a different toxin; that by the use of a medium consisting of a mixture of leucoc3'tic serum (from a calf injected with guinea-pig's leucocA'tes) and of glycer- inated li^er bouillon ho could obtain these young forms in sufficient quantities to immunize a horse whose serum was strongly antitoxic. The serum was first advised to be used subcutaneously, but later has been given per rectum, in doses of 5 or 10 c.c. every day for three weeks, omitted for two weeks and then repeated. A cleansing enema should be first given. The results are very difficult to determine. Monod ('07), who is in favor of it, has reviewed the literature up to 1907, and states that tliirty- eight out of forty-three papers were in favor of it. Closer analysis than this cannot be made of these results, and the fact that other workers (Roux, Borrel) at the Pasteur Institute were unable to confirm his fun- damental experiments has thrown grave doubt upon this serum. Accord- ing to some observers, normal horse or any foreign serum has a stimu- lating eifect upon patients (Weigert), and this with suggestion may in part at least account for the results. As is usual with all remedies, the s}anptoms and signs are said to decrease markedly under Marmorek's serum, but Levin has found that in guinea pigs it retards the growth of tlie tul)ercle bacilli and neutralizes the poison. Notwithstanding the numerous " testimonials " from many sources, this and all other serums for use in tuberculosis must still be considered in the experimental stage. TjTidale ('00) suggested the use of pure vaccine l3"mph, and a few used it, but without avail.- The serous exudate from blisters has been used by Margant, and the injection of a small quantity of pleural-serous effusions under the skin is said to hasten their absorption. Flick and others advocate the produc- tion of blisters in order to allow absorption of the contents, and thus to inoculate tlie patient witli an homologous serum. Antistreptococcic Serum. — The use of antistreptococcus serums (Mar- morek, Aronsohn, Menzer, etc.) have been much vaunted by some observ- ers as exerting a " specific " action upon phthisis, which, they say, is due to a secondary infection with streptococci and other organisms. The results are not promising, and the premises not always sound. " Mixed infection " has been made the scapegoat, as Sahli says, for many failures in tuberculin and other treatments of tuberculosis. "FALSE SPECIFICS" The history of the use and advocacy of "specifics" in the treatment of tuberculosis long antedates the discovery of tlie tubercle bacillus, and, in fact, takes us back to the time when the memory of man runneth 576 SPECIFIC TREATMENT not to the contrary. Indeed, in the history of no disease are there re- corded more " specifics," advocated in many instances by men of higli reputations, who were misled by tlieir own enthusiasm and by the un- consciously imparted suggestion to the patients. In less enthusiastic hands the period of infatuation following the announcement of some new drug of great potency is shortly followed by disenchantment, disuse, or even oblivion, justly merited in many instances. These substances have been well named " false specifics." Tlie " antiseptic treatment " of pulmonary tuberculosis, based on the idea that it is possible to destroy the tubercle bacillus in situ without harming the tissues, needs only to be mentioned to be dismissed. Fur- thermore, many of the tubercle bacilli, embedded in thick fibrous tissue or even caseous matter, have little or no direct communication with the air (inhalation), or with the blood or lymph current. The view that healthy contiguous parts may be protected in this way has never been proved by clinical experience, either in pulmonary or localized surgical forms of tuberculosis. No medicinal substance has been found to neutralize the tuberculous toxin. Many drugs have been given empirically (iodin, mercury, arsenic, antimon}^, etc.), but, since the discovery of the tubercle bacillus, experi- mental research has been frequently employed in studying their effects. Neither guinea pigs nor rabbits are altogether suitable for such work; the former are too greatly, the latter too slightly, susceptible to tuber- culosis. The older work, based entirely upon the effect of substances upon the tubercle bacillus in vitro, has been largely abandoned, and inhalations and injections of many antiseptic substances are now recog- nized, as far as they exert any action upon the pulmonary tuberculosis, as of no specific value. Creosote and its Derivatives. — Among the most used of all the false specifics in pulmonary tuberculosis stand these drugs. They have never been proved to exert any action whatsoever upon the tuberculous process, but in some patients have almost a specific action upon the accompanying secondary infections of the lungs, such as simple bronchitis. They also exert a very stimulating effect upon the bronchial mucous membranes during their excretion tlirough it. For this effect small doses only are necessary in most patients (for example, 3 or 5 TTL of beechwood cre- osote, or creosotal, tliree times a day for some weeks, etc.) and Sommerbrodt's dictum that the larger tlie daily dose the better the results can now be refuted. One gram (15 gr.) of creosote (1 to 4,000 in the circulating blood) at least is necessarj'-, judging from experiments in vitro, to exert any influence upon the tubercle bacil- lus, and to maintain it at this level would require many times the dose that injures most patients. When the tissue fluid and lymph "FALSE SPECIFICS" 577 are taken into consideration, the absurdity of such attempts becomes apparent. It lias long been known that the coml)ination of small doses of creosote with cod-liver oil often render the oil more easily digested, which is due, no doubt, to the stimulating effect of the small quantity of creosote (drop doses) on a poorly secreting stomach. The substances have been said, but not proved, to increase the agglutinating power of the blood serum, to favor phagoc3'tosis, and to act upon the tubercle toxins. Guaiacol, more toxic than creosote, has been used for the reduction of fever (painting the skin with 1 gm. or less of pure guaiacol, or of 1 c.c. of a twenty- five-per-cent solution in alcohol), or for analgesia in complicating neuritis or intercostal neuralgia. In larger doses, repeated daily, it may produce collapse, and cannot be recommended. Like creosote it has been administered by inunction, by injection (subcutane- ous, intratracheal, intrapulmonary, and per rectum), or, preferably, per OS in capsules. Gluten-coated pills, insoluble in the stomach, or gelatin globules or capsules, are the best way in wliich to administer creosote. Flick advised rather large doses in water one hour before meals. The contraindications include, among others, fever, persistent tachycardia, and hemoptysis, but a persistent taste of creosote, gastric irritation, and nephritis are of more importance. The patient should always be warned to stop it or any medicine if the slightest digestive disturbances occur. Only pure beechwood creosote should be used, but several instances of poisoning from the usual doses have been recorded. The derivatives of creosote are increasing daily, and the following list includes only some of the more important: Creosotal (creosote car- bonate, 93 per cent creosote), less irritating than creosote, 5 or more drops in capsules, etc., p. c. ; duotal (guaiacol carbonate, 90 per cent guaiacol), 5 to 15 gr. (0.3 to 1.0 gm.) in capsules p. c. ; thiocol (potas- sium guaiacol sulphonate, 60 per cent guaiacol), a nonirritating, nontoxic, odorless, tasteless powder, soluble in water; sirolin, 10 per cent thiocol in orange sirup, 5 to 10 gr. or more (0.3 to 0.6 gm.) p. c. Gomenol (Dubousquet and Laborderie, '05), distilled from selected leaves of meJalcuca verdifiura, and consisting in large part of a terebene, eucalyptol, citrene, and terpincol, is nontoxic, can be used subcutane- ously or per os, and has much the same effect as creosote, but is less irritant. Arsenic and its Derivatives. — Arsenic has been held by some to act as a specific in pulmonary tuberculosis, and in this, as in some other chronic nervous and wasting diseases, it stimulates nutrition remark- ably. It has long been used in anemic patients successfully, but in fever the results are questionable. It may be given as sodium or strychnin 38 578 SPECIFIC TREATMENT arsenate (gr. ^V ^^^ i)> ^^ ^^ Fowler's solution (gtt. ij, or more p. c). The latter has been combined with a tincture of iron or iron arsenate (gr. yV to I, 0.004 to 0.008 gm.), and has been administered alone in anemic patients with good results. The cacodylates (sodium, strychnin, guaiacol, iron), first advocated by Gautier, and containing 54 per cent of arsenic, can be given in large doses hypodermically (up to 4 eg. (6 gr.) p. d.), but are very little absorbed (Fraser), and in some patients produce disagreeable symptoms, such as garlicky odor of the breath, ex- foliative dermatitis, etc. A useful formula for subcutaneous injection is : I^ Morphinae hydrochloratis gr. ss. ; .03 gm. Cocainae hydrochloratis " Jss. ; 0.1 " Sodii chloridi " iij ; 0.2 " Sodium cacodylatis " xxv; 1.5 " Phenol ^t- ij ; gtt. ij Aqua destil q.s.ad. jiijss. ; 104 gm. The beginning dose is usually 0.5 c.c. (7| TTt) twice a day for six days, then thrice a day for three to five days. After an omission of several days the treatment is again begun. The results are not highly satisfactory, though it may be tried if arsenic, when found to be bene- ficial, cannot be taken continuously by mouth. Disorders of the liver and continued gastric or intestinal disturbances are contraindications to arsenic in any form. It lias been advised to administer arsenic only in early or quiescent stages. Histogenol (sodium methylarsenate and nucleic acid), arrhenal (monomethyl arsenate, atoxyl, and vanadium) have been used. Alcohol. — Alcohol, formerly considered a specific in pulmonary tuber- culosis, has a slight food value (as a tissue sparer) ; it may, when properly given, stimulate the appetite and lessen the cough, but exerts no action upon the disease itself. Harris, who gave twenty-six patients 1^ oz. alcohol every four hours, night and day, for some time, saw no extension of the disease. Mircoli, confirmed by Gervino, asserted that in moderate quantities it neutralizes the tuberculous toxin, and so helps pulmonary tuberculosis. Meltzer holds alcohol to be of benefit in acute infections, producing by its vasoconstricting action upon the splanchnic area a redistribution of the blood. Many have thought that, as alcohol pro- duced cirrhosis of the liver and of the kidney, it would also produce it in the lung, but no good evidence of this has been adduced. The advocates of alcohol in pulmonary tuberculosis have, however, always based their claim for it on its symptomatic effect. Brehmer based his warm support of alcohol on its power, as he had observed it, to increase the appetite and to lower the fever. Other observers claim it increases the gastric secretion, enaljles more fatty food to be taken and "FALSE SPECIFICS" 579 assimilated, stimulates the heart and central nervous system, preventing hypochondria, relieves night sweats and insomnia, and in some cases les- sens coughing. The modern tendency is to reduce greatly the dose earlier advocated by Brehmer, Dettweiler, Flint, etc. The objections to its use are numerous, and more patients with pul- monary tuljerculosis have been harmed than helped by alcohol. It is nothing short of criminal to send a young man away from home with his trunk full of whisky bottles, and tell him to drink all he can. The enforced idleness, the honne camaraderie, prove too much for many who have been warned against it, and great care should be exercised about sending patients to a hotel for a long residence. Xot only the men have to be considered, but, unfortunatel}', some classes of women are not wholly exempt from this danger, and Oliver has noted alcoholic neuritis most frequent in pulmonary tuberculosis. When a patient once begins to drink at a healtli resort, his only salvation lies in turning his back upon his boon companions and seeking health elsewhere. Alcohol should not be used for some time after hemoptysis, and es- pecial care should be taken when it is used in cold climates and higli elevations, though in the Alps it is widely used without any apparent deleterious effect. Nervous, excitable patients should avoid it, and indi- viduals long accustomed to its use in large quantities should reduce this amount to a minimum. When this is not possible, it should be proscribed, as is also the case when it increases cough or irritates the larynx or stomach. In brief, alcohol may be said to be a dangerous food and a " symp- tomatic " drug of considerable potential danger, but of value in some cases of pulmonary tuberculosis. A cocktail, tablespoonful of whisky, a glass of stout, of bitter ale, or of a good wine, taken before, or, better, with the first part of the meal, may aid a flagging appetite or a weak digestion. It must be remembered, however, that these are to be looked upon as drugs, and taken only when necessary. When it is impossible for a patient to take milk without a small amount of brandy or whisky, or eggs without sherry, these should be allowed. Insomnia may be re- lieved by a glass of beer or ale or a little whisky at bedtime, but these are dangerous remedies. Brandy and champagne are of value in some cases late in the disease. The judicious though rather free use of spirits does unquestionably prolong the existence of a few patients with slowly progressing chronic disease. Alcohol, on the whole, is not necessary in the treatment of pulmonary tuberculosis, as in nearly every instance the same effect can be produced more surely, even if less pleasantly, by some other drug. Drugs that Produce Leucocytosis. — Recent work upon the importance of leucocvtosis in tul)erciilosis has Ijrought again to attention a number 580 SPECIFIC TREATMENT of substances wliicli cause leucocytosis. Tlie effects of tuberculin are discussed in another place. The most important of these substances are nuclein and cinnamic acids. Nucleic Acid. — Nucleic acid, which is contained in tuberculin, is probably the best example of this class of drugs. Its use in the form of yeast, which is rich in nuclein, has recently been advocated by Ullmann, Huggard, and Morland ('05). Long an old-fashioned household rem- edy for boils, it has recently been said to be of value in pulmonary tuberculosis, where it increases the leucocytes and the opsonic index when administered by mouth in doses of 3 to 10 grams (50 to 150 grains) of dried yeast in milk twice a day. Brewer's yeast may be used. It exerts apparently no effect upon the temperature, the kidneys, or in- tercurrent affections. Cinnamic Acid. — Cinnamic acid and its sodium salt, hetol, first ad- vocated by Landerer ('98-'01), has been used chiefly in Germany. When properly administered, hetol is said to produce leucocyto'sis and an increase of connective tissue about the tuberculous focus. Others have claimed that it prevents or replaces caseous matter by vascular con- nective tissue, forming true cicatrices, increases the lymph flow, the alex- ines, and thus produces healing of the tuberculous lesion. Balsam of Peru, first employed by Sayre, of New York, led Landerer to the use of hetol. It has been administered by ingestion, by inhalation, by subcutaneous injection, but preferably by intravenous or intramuscular (intragluteal) injection. At first a dose of 0.05 to 0.1 c.c. (HI 1^) of a 1-per-cent solution of hetol (j to 1 mgm.) in 0.75 per cent NaCl solu- tion is injected into the brachial vein twice or thrice a week, and slowly increased up to 8 to 15 mgm. (^ to ^ gr.) for men, and 5 to 10 mgm. (tV to I gr.) for women, which dose is usually reached in three to five weeks. The " normal " dose is that Avhich produces no untoward symp- toms, but improvement of general and local symptoms. The rules for increasing the doses demand the same careful clinical observation and caution detailed for tuberculin. The treatment is continued for three months in early, six months in advanced, stages. After an interval of four to eight weeks, a second course of one to two months is advised if tubercle bacilli are still present. The treatment should be continued four weeks after the disappearance of tubercle bacilli. The results of tliis treatment are, in the hands of most observers, favorable. C'antorowitz and R. Weissmann, in Schmidt's " Jahrbiicher " ('01 and '04), have collected 140 papers on the subject, a large ma- jority being favorable. Among 28 papers by different observers, 4 noted improvement in the tuberculous condition, 9 in the symptoms, 7 were doubtful as to the results, and 8 were unfavoral)le (Brown). The same division of opinion exists in regard to experimental tuberculosis (in rab- "FALSE SPECIFICS" 581 bits and guinea pigs). Repeated injection into the same vein is not harmful, and the kidneys are not affected, but clironic albuminuria and diabetes are contraindications. Evidently much in regard to results depends upon the selection of early stages for treatment, and patients with fever, hemoptysis, and night sweats are not deemed suitable. Am- bulatory patients and those discharged " prematurely " from sanatoriums give good results, and, according to Landerer, need no change of resi- dence. Landerer obtained, in patients with uncomplicated pulmonary tuberculosis, healing in 85 per cent and improvement in 5 per cent. In all classes of patients he obtained 70 per cent of " good results." For febrile patients he advises colloid silver, and for patients with cavitation thoracoplasty. Calcium chloride and sodium silicate, in hope of their deposition in the scar tissue, have been injudiciously advised. The so-called " Hoff's cure," consisting of cinnamic acid, arsenic, and alcohol, is administered per os, and is now little used, either by the laity or by the profession. Loew advocated theoretically sodium phenyl- propyl ic acid, as it contained less hydrogen, and was, therefore^, more " strongly bactericidal." Bulling has used it as a spray, and obtained good results. Ichthyol. — Ichthyol, first used in pulmonary tul)erculosis by M. Cohn ('96), is held to possess a nonirritating, nonpoisonous, alterative action (checking albuminous decomposition), as well as tonic and vasocon- stricting properties. It is said to increase the appetite, to loosen and reduce the expectoration, to bronze the skin in some patients (10 per cent), and to be valuable in all patients through its vasoconstricting, de- congesting action on the lungs. A few observers have ol)tained good results. The ammonium sulphoichthyolate, in doses of 2 to 50 drops in water, capsules or pills, and ichthoform (ichthyol and formalin), in doses of gr. 1| to 5 (0.05 to 0.3 gm.) five or six times a day; ichthalbin, 10 to 15 gr. (0.6 to 1 gm.) p. c, a tasteless powder, consisting of ichthyol and albumin, are usually given for some months. Ichtliyol contains much sulphur, and has such a disagreeable taste and odor that it is little used. "Resorption pills" (ichtiiyol and salicylic acid) have been tried ( Rohden ) . Sulphur has for many centuries been used as an inhalation. lodin. — The antiseptic action of iodin on the tubercle bacillus is slight (0.5-per-cent solution, after exposure of one hour, prevents growth, Xinneman). It is said to excite phagocytosis. Potassium iodid (gr. 5 to 10), hydriodic acid, and iodopin may aid the cough, but the chief value at present of iodin in jmlinonary tiflierculosis is as a rubefacient in pleurisy. Iodin may be painted on (tincture, colorless), or rubbed into tlie skin (iodin ])etrogen, 10 ])er cent, euro])hon in olive oil, etc.). Iodoform, without action in ])ulinonarv tul)er(uh)sis, has been used intravenously (Dewar). Many coniMuatiuus of iodin and iodo- 582 SPECIFIC TREATMENT form have been employed (eigon, iodolen, iodal, aristol, nosophen, antinosin, eudoxin, losophan, europhen, loretin, vioform) for one pur- pose or another in tubercailous patients. Cantacuzene ('05) has recently found that defatted tubercle bacilli treated with iodin (Lugol's solu- tion) are absorbed much more readily, and apparently give better immunity to the animals experimented on, than tubercle bacilli not treated with iodin. He has also found that the administration of potassium iodid favors the absorption of these bacilli and of tubercu- lous deposits. Silver. — The chief benefit now attributed to the use of silver is its effect upon the secondary organisms in the lungs. In the form of col- largol it has been given per os, per rectum, and intravenously. The re- sults have not been very satisfactory. Mays ('00), who asserts that pulmonary tuberculosis is fundamentally a nervous disease, injects nitrate of silver under the skin of the neck over the vagus. Protargol and lysargin have been used. Lecithin. — Tuberculous guinea pigs are said to live longer when given lecithin (Claude, '01), which in man is asserted to be harmless, to decrease phosphorus output, to increase nitrogen absorption, weight, strength, and acidity of the urine, and to be of marked value in nervous conditions. It can be obtained in i)il]s or powder (dose 0.25 to 0.50 gm., 3 to 7^ gr., per day), or be given subcutaneously in oil (dose 0.05 to 0.15 every two days, or smaller doses more often. In nervous complications (neurasthenia, etc.) it may be tried. Biosin, an albumin-iron-lecithin combination, and glidin have been used. Calcium. — Various salts of calcium, carbonate, bicarbonate, phos- phate, iodid, given by mouth or hypodermically, alone or in combina- tion with creosote, tuberculin, etc., are of value on account of the de- mineralization occurring in ])ulmonary tuberculosis, but exert no specific action. They are said to be deposited in the foci of inflammation, and so afford a mechanical stimulus which starts and aids the process of repair (Michelaozzi, '04). Cellotropin (Kopp, '04), a monobenzoylarbutin, a white, odorless, slightly bitter, cry.stalline powder, easily soluble in alcohol, with diffi- culty in water, has been suggested by Kopp, for he believes, after ab- sorption unchanged into the blood, it stimulates the glands to increased enzyme formation, and thus forms " under the influence of the bacillus alexines." The substance, in doses of 15 gr. (1 gm.) three to five times a day, produces no gastric disturbances, and is suitable in not too far advanced stages, where it exerts a specific action. Further confirmation of the few published results are needed before it can be recommended. Harper ('01), basing his theory upon the antagonism of gout and tuberculosis, advocated* the use of urea (synthetic) in doses of 15 gr. "FALSE SPECIFICS" 583 (1 gm.) pro die, increased in some cases to 60 gr. (-i gm.) as a maxi- mum. Many observers have used it without any beneficial effect. The Calcutta Zoological Garden receives three hundred dollars annually from the natives for the urine of the rhinocerus, which is taken for lung disease. Griserin (Kiister, '04), first presented to the profession under the name of " loretin " as a substitute for iodoform, is of no value and of some danger in pulmonary tuberculosis. Basing his views on the results of Bier's treatment in tuberculous joints, as well as upon the " immunity " in heart disease, pregnancy, and gibbus, H. Weber ('08) attempts to explain the value of the prone position and the sanatorium treatment in pulmonary tuberculosis by the increased amount of COo in the lungs and body, and claims to have had excellent results in this disease by the use of sodium bicarbonate (4 gm. a. c.) or levulose (50 to 100 gm. daily for a month) per os, or the subcutaneous injection of liquid paraffin (an- tiphthisin). Strychnin. — Strychnin (gr. gV, 0.002 gm.) is of value. It acts ad- vantageously upon the lowered blood tension, a weakened heart, a jaded appetite, and upon the neurasthenia, but is no " specific." Inhalations. — Xo substance has 3'et been found (nor will there be) that acts only on the diseased part of the lung even were it able to pene- trate to the often inijjermeable or closed focus of disease. Inhalations have been used in the treatment of pulmonary tuberculosis since remote antiquity. The substances used have differed as widely as the effluvia of cow stables and aromatic oils on one hand, and chloroform and hydro- fluoric acid on the other. These substances have been in the form of gas, spray, fluid, and powder, varying from the most innocuous to ir- ritant, irrespirable substances (bromin, iodin, and chlorin). The object aimed at in most cases has been a direct action upon the tubercle bacillus. The nose, tongue, pharynx (at right angles to the entering vapor or spray), the lar}Tix, and the innumerable branchings of the bronchi, all offer in some instances (powders, coarse sprays) insuperable obstacles. The secretions upon the surface of the air passages may be coagulated by, or may absorb, the inhalant. Notwithstanding all this, however, there finally remains the fact that the diseased areas are often impermeal)lc, and if permeable the lesion may still be closed. Further- more, the failure of sprays to affect diphtheria or lupus, both so situated that they are ready of access, is well knouTi. From these facts, it is readily seen that no " specific " introduced by inhalation, and acting directly upon the focus of disease, can be hoped for. The hemoglobin absorbs all the oxygen it can hold in combination from the air, and superoxygenated gases increase only the oxygen in 584 SPECIFIC TREATMENT the serum (j^ to j\) . Oxygen in itself lias no specific effect. Ozone is an indicator of pure fresh air, and many iiave transferred the effect of the latter to the former, which in reality is an irritant to the respir- atory membranes, and more injurioi;s if absorbed. Any gas poor in oxygen causes reflexly deeper respiration, and consequently an increased blood flow, which may result in loosening, and even in lessening, the sputum in some cases. This, no doul)t, is the explanation of the results wlien any are obtained from the use of nitrogen, carbon dioxide, and sulphuretted hydrogen as inhalations. Inhalations of liydrocyanic acid, chlorin, bromin, iodin, hydrofluoric acid,- sulphuric acid, osmic acid, nitrous oxide, benzene, anilin, belladonna, and hemlock leaves have yielded no help, and possibly in some cases done harm. Inhalations of formaldehyde and its derivatives (igazol, mentho- bromo-formol, etc.) alone or in combination with sulphurous ether, chloroform, mentbol, etc., may exert some influence upon secondary in- fection, but can also cause pulmonary edema if too strong. Creosote and the ethereal oils have been much vaunted. From the fact tliat workers in and dwellers about cellulose factories seldom contract jjulmonary tuberculosis, and do well when this occurs, Hartmann ('92) was led to suggest the inhalation of ligno-sulphite, pro- duced by the action of sulphuric acid upon the etiiereal oil of fir, juniper, or eucalyptus. It seems to attack the mucin, and so loosens the ex- pectoration. It is now little used. Similar arguments have been ad- vanced for sulphurous-acid inhalation. Sanosin (Danelius and Sommerbrod), a mixture of charcoal, sul- phur, and leaves of a variety of the eucalyptus, for inhalation after vaporization, is of no value. Sprays. — A number of substances previously mentioned have been used in this manner. The inhalation of spray containing yeast has been suggested. The same objections hold for sprays as for inhalations, but many "specifics" have been so administered. Injections. — Inasmuch as a large number of substances have been injected in one way or another into the body, usually in the vain hope of finding a specific similar to mercury for lues, or quinin for malaria and further, as most of these do not merit a separate notice, it has been deemed wise to collect many of them under this head. The number of substances, soluble and insoluble, that have been injected into the body is extraordinary; the fertility of imagination exercised in their selection and the lack of ingenuity in controlling the results is astounding. These substances have been injected per rectum, subcutaneously, intravenously, intratracheally, and into the pulmonary tissue. A partial list is appended (the substances in italics may be of some value, the remainder cannot be recommended) : ADDENDA 585 Per Eectiim : Cod-liver oil, creosote, arsenious acid, H.S and CO,, etc. Subcutaneously : Cod-liver oil (glycerin extract, olive oil, camphor- ated oil (in late stages), vaselin, creosote, guaiacol (simple, cacodylate, iodoformized), eucalyptol, arsenious acid, arseniate of strychnin, of soda, sodium cacodylate, phosphate of lime (to replace excess lost), green ammonio citrate of iron, kalodal (soluble albuminate of silver, for nour- ishment), AgXOg (over vagus), phenol, salol, aristol, ether and opium, iodin with potassium iodid, etc.; chloride of gold, antiphthisicum (liquid paraffin), gomenol, glolnilin, yeast. Intravenously : Hetol, formaldehyde, iodoform, creosote, etc. Intratracheal: Creosote, guaiacol, menthol, camphor, chlorotone, iodo- form, potassium permanganate, izal, eucalyptol, gomenol, gobional, silver nitrate in olive oil, glycerin or water, through larynx or through skin, etc.; orthoform. Intrapulmonary : Zinc chlorid, phenol, naphthol, iodoform, creosote, thymol, iodoformized glycerin. The intravenous injection of formaldehyde (50 c.c. of a 0.5-per-cent solution in physiologic saline solution), advocated by Maguire, has been little used, and cannot be recommended. Intratracheal injection, first used by Green of Xew York ('55), has not been very extensively employed. Jacob's method of pulmonary infusion of tuberculin and creosote in large quantities has met with severe and just criticism on account of its danger. Among the many substances suggested, the most widely used are menthol, camphor, creosote, and guaiacol, alone or in combina- tion in one-to-four-per-cent solution in olive oil. The chief, if not the only, value of intratracheal injections is to control the cough. ADDENDA Summary of Specific Treatment Presented at the International Con- gress, Held in Washington, D. C. Tuberculinum purum is a form of toxin prepared by Gabrilowitsch from cultures of tubercle bacilli (human strain), and so altered by chemical reagents that it no longer produces any general reaction. The initial dose is 0.01 mgm., the final dose from 100 to '^00 mgm. In 80 per cent of 25 patients (8 with severe type of the disease, and only 3 with a mild type) the number of injections was twenty, extending over forty to sixty days. The results clainunl l)y Gal)rilowitsch are excellent, but verification in the hands of others has not yet been made public, and the results are almost too favorable, though details about the class 39 586 SPECIFIC TREATMENT of patients have not 3'et been puljlished. All patients, the author thinks, may derive benefit from this tuberculin. Calmette described a new form of tuberculin, C. L., obtained by centrifuging in vacuo at a low temperature entire cultures of bovine bacilli. The product is then filtered, precipitated three times with alco- hol and ether, redissolved in water, and dialyzed until all the salts and precipitants have been completely eliminated. The colloid substances in the dialyzer are precipitated once more by alcohol and ether, and dried m vacuo. The active substance is not heated, and subjected to no treat- ment except precipitation by alcohol and ether. By von Lingelsheim's method it was found ten times as toxic for guinea pigs as 0. T., but could be introduced intravenously into tlie body of an animal in large doses without producing any elevation of temperature. The beginning dose is 0.001 mgm., which should be slowly increased at intervals of ten to twelve days in order to avoid a reaction of more than 0.5° C. This tuberculin, Calmette believes, does not cure tuberculosis any more than any other form of tuberculin, but delays the progress of the disease and endows the organism with resistance to infection, which he and Guerin have proved on cattle. They, however, do not acquire a true immunity, and, although they do not react to tuljerculin, they are nevertheless car- riers of tubercle bacilli, and capable of contracting a chronic form of tuberculosis. Such results lead them to oppose the use of living tubercle bacilli in man, especially as tuberculin is equally efficient and less dan- gerous. Calmette also stated that tuberculin possesses an affinity for lipoids (probably identical with lecithin), which are almost constantly present in the serum of tuberculous men and cattle. Arguing from the fact that cobravenin is rendered active by the free lecithin of serum, he be- lieves that tuberculin is indicated for determining the affinity of the patient's serum for the secretory products of the tubercle bacillus. Its systematic emplo}nnent enables the clinician to observe accurately the effects of tuberculin medication. Trudeau discussed the laboratory (antibacterial) and the clinical (antitoxic) method of the administration of tuberculin, and stated that the latter was the better method. He held that the dose should be slowly increased, and that he now thought the size of the final dose was a matter of less importance than formerly. The final dose may be only a fraction of a milligram. Denys reaffirmed his absolute confidence in his broth filtrate, B. F., or F. B., as he calls it in English. He advocates beginning with very small doses, e. g., in afrebile patients with 0.000,000,05 to 0.000,000,1 c.c, while in even slightly febrile patients he advocates 0.000,000,000,5 to 0.000,000,001 c.c. He knows no contraindications to its use, and at- ADDENDA 587 tributes its failure in acute pulmonar}- tuberculosis to lack of time before death ensues. His enthusiasm is unbounded. Hammer stated that, while tuberculin would not cure the most ad- vanced stages of pulmonary tuberculosis, it eliminated many disagree- able symptoms. In patients whose physical signs were in Stage I or II, or at times even in III (Turban), recovery is to be expected. Petruschky reaffirmed his belief in tuberculin, both for treatment and diagnosis, and held that patients with closed lesions should be treated to prevent ulceration into the bronchus and the recurrence of tubercle bacilli in the sputum. Meissen still holds that tuberculin has not been proved to have a specific curative action, and, if used, should be given only in hospitals or institutions. The work of Kinghorn, Twichell, Carter, and Werry, who followed the tuberculo-opsonic index of patients who were given 0. T. and B. E. by the clinical method with progressing doses, showed that after inocu- lation this index was raised, that positive and negative phases do occur; that, when tuberculin is given at intervals of three or four days, 25 per cent received the injections during a negative phase; that in 85 per cent of these, the negative phase was not accentuated, but that a positive phase at once set in. Notwithstanding the fact that they believe that this index is of doubtful value in controlling tuberculin injections on phthisical patients, and that the aim of tuberculin treatment should be to produce tuberculin immunization, rather than to keep the opsonic index at a high level — notwithstanding these facts, they think the inter- val between doses should be increased to seven days, to allow the dis- turbance in the blood to subside. If an abolition of the negative phase be desirable, then this work proves that intervals of three or four days are advisable for most patients. Hastings, who has done much work with the opsonic index, an- nounced that the variations " are so wide without inoculation, and so inconstant after inoculation, that one cannot safely use the index as a guide for tuberculin inoculations." The very ingenious work of Webb, \Yilliams, and Barber in at- tempting immunization by the injection of increasing numbers of living organisms, beginning with one, is striking and original. The technic of Barber employed, consists of selecting under the microscope from a hanging drop of emulsion the exact number of bacilli l)y means of a cap- illary pipette. Such work, however, has to do chiefly with the pro- duction of immunity in healtliy animals, for many experimenters (Trudeau, Calmette, Courmont, and Lesieur) have found that injection of living tubercle bacilli influenced a previous tuberculosis little, if at all. The work of these latter observers is certainly oj^en to the objection that 588 SPECIFIC TREATMENT they used too large doses, a point which Webb and his confreres are now endeavoring to prove. They have, from their reports, conferred upon mice immunity to anthrax, and certainly upon guinea pigs some im- munity to tuberculosis. The use of living tubercle bacilli in man is not justifiable in the light of our present knowledge. The work of J. Courmont and Lesieur throws some doubt upon the immunity conferred upon animals (cattle, etc.) by some vaccinations, for they find tliat a lesion in process of evolution prevents the evolution of a second inoculation, while the first runs its normal course. An attenuated tubercle bacillus, however, or a strain little virulent for a species of animal may in this way protect against a second virulent inoculation. Flick reported the work on Maragliano's serum at the Phipps Insti- tute. Twenty members of the staff used this serum, which was prepared by Eavenel according to Maragliano's methods. It was found to have no specific value, and both cows wliich furnished tlie serum were discov- ered to be tuberculous, one dying from generalized tuberculosis. The untoward effects of Maragliano's serum were studied in foriy- one patients by Landis, who found evidence of marked hypersuscepti- bility (suffused face, dysjmea, oppression about the heart, rapid pulse, lumbar pain, muscular tremors, sense of impending death, but no fatali- ties) in seventeen per cent, who were in a moderately or far advanced stage, and confined to bed. Tliere was no definite time for the occur- rence of these symptoms. Amljulant patients in good condition did not develop anaphylaxis. CHAPTER II SPECIFIC THERAPEUTICS OF MIXED AND COiSTCOMITANT INFECTIOXS By GERALD B. WEBB A NATURAL outcome of Wright's exploitation of Ijacterial vaccines is the application of their use to the concomitant or mixed infections of pulmonary and other forms of tuberculosis. To attempt the cure of cases complicated by secondary infections by means of tuberculin alone, trusting that the organism will rid itself of these secondary invaders, is hardly rational. While the suggestion that mixed infections must be expected in the common suppurative processes which occur in connection with surfaces which harbor microbes may well be universally acceptable as not break- ing in on any accepted ideas, the suggestion that mixed infection must perforce be considered in every case of phthisis, lupus, tubercular caries, tubercular cystitis, and tubercular ulceration, in the very nature of things, will be unacceptable to many clinicians. Such a suggestion will be felt to throw doubt not only on the clearness of vision of those who have sought for antituberculous remedies in these diseases, but also on the critical acumen of those who, without taking into account the falla- cies which are incidental to clinical methods, have confidently undertaken to pass final judgment on antituberculous remedies by the observation of their clinical effects in cases in which, in addition to the tubercle bacillus, other pathogenetic microbes may have been at work. Be it acceptable or unacceptable, there is no escape from the fact that practically every case of suppurating lupus is complicated by staphylo- coccvis infection, and every aggravated case of lupus Avith a streptococcus infection. What holds true of lupus, mutatis mutandis, is true of every tuberculous affection to which microbes can find access (A. E. Wright, '07). At present tliere is the greatest divergence of opinion as to tlie in- fluence of secondary organisms on the course of pulmonary tuberculosis. It is, perhaps, a fact that nuiny of these secondary organisms are of low vitality and nonvinilent, but it is just as impossible for such patients to rid themselves of these as of local infections, such as acne, furuncu- 589 590 SPECIFIC THERAPEUTICS OF MIXED INFECTIONS losis, both such frequent afflictions of the tuberculous. Surgeons famil- iar with bone tuberculosis know how well patients with pure tuberculous disease improve, and yet how intractable are those cases with mixed infection. The results of Prudden's ('9i) well-known experiments on rabbits show conclusively that the concurrent action of two distinct pathogenic germs may result in a considerable modification of the lesions which either could produce alone. It has been well said l)y a Frenclunan that " the worst thing that can happen to a tuberculous person is to come in contact with a con- sumptive," a renuirk which I would extend to the greater danger the tuberculous invalid runs when exposed to an influenza epidemic. The suggestion has been made that the influenza organism is prob- ably the means of introducing the pneumococcus into the system of the victim of pulmonary tuberculosis, and it is perhaps true, yet my own observations would seem to show that the influenza bacillus alone is capable of much mischief in the tuberculous invalid. At the time of writing, forty-five patients, undergoing inoculations with tuberculin and mixed vaccines, have been exposed to a very wide- spread epidemic of a catarrhal condition due chiefly to the influenza bacillus, in part to the Micrococcus caiarrhalis. Of these forty-five pa- tients, five have the influenza bacillus persistently in the sputa, and they have been inoculated periodically with their influenza vaccines. These have escaped " colds." The results are only suggestive. They may be tabulated as follows — forty-five patients, exposed to a widespread influenza epidemic, receiving inoculations of tuberculin and mixed vaccines every seven to ten days: Inoculated against in- fluenza with their own vaccines Inoculated against in- fluenza with stock vaccines Preventive inoculation not given; patients denying that they ever had influenza 32 fAll gave accurate his- tories of repeated former attacks. J Escaped epidemic. Escaped epidemic. Fifteen succumbed to influenza epidemic. Fifteen of these patients, who at the outbreak of the epidemic claimed never to have had the grip — neither had the influenza bacillus hith- erto been found — succumbed, and the influenza bacillus was then found in their sputa. Two of these patients, for the first time, developed very serious hemorrhages within a few days of the infection. SPECIFIC THERAPEUTICS OF MIXED INFECTIONS 591 Eight 23atients who claimed to have had influenza frequently (one every year for eight years) were given from 125,000,000 to 500,000,000 of influenza vaccine at each weekly inoculation. These patients were well exposed to the epidemic, and without exception everyone escaped infection. The writer has ohserved a patient's opsonic index to tubercle low- ered to O.G during an influenza attack. It is a common observation that patients with pulmonary tuberculosis may go rapidly down hill following an attack of influenza, and the writer would suggest that the prevention of such concomitant infection should be sought by the means indicated above. The vaccine used in these cases was prepared according to Wright's methods from a case of acute infection of a maxillar}' sinus occurring in a patient who had suffered a similar attack for four or more successive years. Heretofore a period of chronicity had followed annually, necessitating a specialist's attention for a period of months. This year, however, rapid healing followed the iise of the vaccine. The frequency of occurrence of the secondary invaders is listed variously by different investigators. From an unpublished report from Dr. T. W. Hastings, of the Cornell University Medical College, it is learned that in 375 cases of nontuberculous pulmonary conditions (tu- berculosis suspected, but tubercle bacilli not found), the frequency of occurrence of secondary organisms was as follows: Micrococcus catarrhalis. Pneumococcus ( Fraenkel ) . Streptococcus pyogenes. Staphylococcus pyogenes (aureus, albus, or citreus). Friedlander's bacillus (Bacillus mucosus capsulatus). Micrococcus tetragenus. Bacillus influenza. Bacillus subtilis. Bacillus pyocyaneus. Cultures were taken in only 105 of these cases, and the same order of frequency held, except that staphylococci were first instead of fourth. Of 156 cases of pulmonary tuberculosis (tubercle bacilli detected in sputum), cultures were taken in only 20 cases. The order of occurrence of secondary organisms was as follows: Streptococcus pyogenes. Micrococcus catarrhalis. Pneumococcus ( Fraenkel ) . Staphylococcus (aureus, albus, or citreus). Bacillus pyocyaneus. Friedlander's bacillus (Bacillus mucosus capsulatus). Micrococcus tetragenus. 592 SPECIFIC THERAPEUTICS OF MIXED INFECTIONS Reference to tlie work of Eavenel and Irwin ('07) shows results of examination of all the organs in 56 cases that came to the postmortem tahle : Bacillus coli communis in 40 cases. 39 " 30 " 26 " 9 " 11 " Streptococcus Staphylococcus pyogenes albus . Staphylococcus pyogenes aureus Pneumococcus Bacillus diphtherige (pseudo) . . Pyocyaneus, sarcinae, etc. Examination of the tables shows that our results agree in the main with those of other observers. The streptococcus, often in chains or pairs, was most frequently found, not only in cavities, but also in the organs. The notable exceptions to this were the kidneys, in which the bacillus coli communis was found nineteen times and the streptococcus ten times and the liver, in which the bacillus coli communis was found twelve times, and the streptococcus only twice. The frequency with which the kidney was infected is worthy of comment — twenty-nine times in the fifty-six autopsies — leading the liver in this respect. It is, of course, impossible to say in what proportion of cases the bacillary inva- sion was agonal, or postmortem, but, in any event, the liver \vould seem to be more open to such invasion than the kidneys. LUNG CAVITIES Streptococcus. 37 cases. Staphylococcus pyogenes albus. 25 " Staphylococcus pyogenes aureus 24 " Pneumococcus. 8 " Bacillus pyocyaneus. 2 " Number of cases examined, 50; i Bacillus coli communis. 37 " microorganisms being found in ( Bacillus lactis aerogenes. 3 " all. Bacillus diphtheria; (pseudo). 9 " Sarcinae. in " Yeasts. 12 " Spirillum. 1 case. Small diplococcus (unidentified). 2 cases. Bacillus (unidentified). 6 " AREAS OF BRONCHOPNEUMONIA Streptococcus. 1 case. Staphylococcus pyogenes albus. 1 " Number of cases examined, 5; / microorganisms found in 3. \ Staphylococcus pyogenes aureus 2 cases. Pneumococcus. Bacillus diphtherise. 1 case. 1 " Bacillus coli communis. 1 " Unidentified diplococcus. 1 " PLATE II 1. — Shows ix the Same Field Pus Cells Containing Tubercle Bacilli and Strepto- cocci (Carbol FrcHsix and Methylene-blve). 2. — Organisms Similar to (1), but Contained in the Same Pus Cell. 3. — A Large Pus Cell Containing a Tubercle Bacillus and Many Staphylococci (Carbol Thionin). 4. — Pus Cells Containing Staphylococci, Pneumococci, and One Cell Containing a Tukercle Bacillus and Pneumococci (Carbol Fuchsin and Methy'lene-blue). r. MV66. .5. — The Micrococcus catarrhalis (not Taking Gram's Stain) and the Pneumococci AND Txtbercle Bacilli (Taking Gram's Stain>. 6. — The Influenza Bacillus (Carbol Thionin). SPECIFIC THERAPEUTICS OF MIXED INFECTIONS 593 In lung cavities, an organism resembling the Klebs-Liiffler bacillus is frequently found, and it has been called the " pseudo-diphtheria bacillus pulmonalis.'' It is often indistinguishable morphologically and culturally from the true diphtheria bacillus, but we have never foimd it virulent for guinea pigs. Some of the cultures we have been forced to regard as true diphtheria which had lost its pathogenic power. Our studies have not enabled us to draw any positive conclusions, though we are convinced that in pulmonary tuberculosis, mixed infections play an important part in the production of symptoms and in the course of the disease. Taking the staphylococcup as being one of the most frequently jires- ent of the mixed invaders, 1 have grown numerous colonies from every sputum, from fift}' different patients. Microscopic preparations have revealed it in almost every case (Plate II), and it has frequently been observed within the pus cells in the sputum. In infections (Ricketts, '06) the staph3dococcus attracts large num- bers of leucocytes, and the pus does not coagulate. The substance which attracts leucocytes is heat resistant, since killed cultures will cause ab- scesses. In all l)ut the most superficial lesions a characteristic result of infection is that of cell necrosis and the liquefaction of tissues. Xeisser and Lipstein state tliat the necrotizing substance is a soluble toxin, since culture filtrates cause marked necrosis of the internal organs (liver, lieart, kidney) when injected. "Hence, in staphylomycosis we can dis- tinguish two active substances (v. Lingelsheim, '08), the leucotactic sub- stance in the bodies of the cocci, and the more important soluble staphylotoxin, which exercises not only a local but also a general toxic action on the body (Neisser and Lipstein). The extensive necrosis of carbuncles is an every-day observation pro- duced in an afebrile manner by the Stnphylococrnx pi/ogcnrs. Tiie sputum from many cavity cases has developed, on culture, an overwhelm- ing number of Staphylococcus pyogenes alhns or aureus colonics, and microscopic examination has shown staphylococci as well as di|)hK()cci to 1)6 contained within the pus cells. With such knowledge of its necrotic poAvers, it would certainly seem just to attach to this organism some of the blame for cavity formation. The treatment of the mixed infections of pulmonary and other forms of tuberculosis must naturally be founded on the results of investigation of each individual case. This study may be ap])roached l)y three methods: 1. A carefully selected j)ortion of sputum may be examined micro- scopically, and the various organisms may be differentiated by methods of staining. 2. A ))ortion taken from the interior of the s|)utuiii mass may be planted out, and the growing colonies investigated. 594 SPECIFIC THERAPEUTICS OF MIXED INFECTIONS 3. The opsonic index of the patient may be studied in connection with the different bacteria thrown from the sputum. The writer's plan, in one hundred cases, has been to depend chiefly on the first two methods of investigation. In the first method especial care has been exercised in the examina- tion of the pus cells as to their bacterial contents, for it is only logical to conclude, since Wright's completion of Metchnikoff's theory, that the bacteria found in the dead leucocytes have been actively campaigning. 1. Carefully selected portions taken from the interior of sputum mass are teased on three separate slides. 2. These slides are fixed by placing them in a supersaturated solu- tion of mercuric chlorid for three minutes; then they are washed with water and. dried. 3. One slide is stained by the regular carbol-fuchsin, methylene-blue method. The second slide is stained according to Gram's method. The third slide is stained with carbol-thienin. Eeference to the plates will convey some of the results of each method. It must not be concluded that absence of bacteria from the pus cells disproves the activity of organisms found on the slides, for as the phagocytosis of the tubercle bacillus is most variable, as evidenced by sputum examination, so is the phagocytosis of these secondary organ- isms; neither in such investigations is phagocytosis of any prognostic value. The method of growing will confirm these examinations, and will frequently produce organisms not observed by the microscope. The technic of the Avriter has been to tease out a very carefully selected, small portion of sputum on blood agar in Petri dishes or tubes. On this medium the chief organisms will grow very rapidly. The Staphylococcus pyogenes alhus (or aureus) has always been found, and is readily identified. As a general rule the pneumococcus will form a green-looking colony, and the Streptococcus pyogenes a hemolyzing colony, so that these organisms can readily be picked out for transplanta- tion for vaccine-making. The differentiation of the pneumococcus from the streptococcus is by no means a simple task, and herein, probably, lies the reason that in- vestigators differ in their results of frequency. For practical treatment this differentiation is not necessary, and the writer has recently adopted the term of pneumostreptococcus as an escape from the difficulty, a term which will include both organisms. A pneumostreptococcus has been grown from every case. The third m^ethod of ascertaining the activity of these secondary bacteria, testing the patient's resistance to them, as measured by their SPECIFIC THERAPEUTICS OF MIXED INFECTIONS 595 opsonic indices, is a laborious and unnecessary procedure. In repeated instances patients have been found with a low index to their own staphylococcus and pneumococcus, and in febrile cases they have sho^^^l fluctuating indices to these as well as to the tubercle bacillus. Approaching now, more directly, the remedial agents for these in- fections, it has been repeatedly observed by Wright that, in the cure of lupus and subcutaneous tuberculosis, no progress was made with inocu- lations or tuberculin unless the secondary bacteria were removed. Hence the remarks contained in the paragraph quoted at the beginning of this chapter. The writer tried for weeks to improve a sycosis by inoculations of staphylococcus vaccine; an opsonic index to the tubercle bacillus of 0.5, heated serum 0.3, later gave a clue to a more exact diagnosis of tuberculous sycosis, and the addition of tuberculin to the staphylococcus vaccine soon produced a complete cure. To those who haA'e watched the almost miraculous disappearance of boils following the inoculation of an homologous staphylococcus vaccine, and who have also seen a pneumococcus pus pouring from an ear dis- appear entirely in a few days through the exploitation of the appropriate vaccine, it will cause no surprise to learn that comparatively similar results have been obtained in the reduction of sputum of consumptives by the application of similar methods. It has been the writer's lot to have chiefly had to apply these methods to patients with long-standing disease, old campaigners who have for years tried every form of treatment. These patients, through auto- inoculations and through the swallowing of their sputa ("Wright, '04),^ have largely worn out their mechanisms of defense, leaving little ma- chinery to place in motion. Vaccines have been made from pure cultures derived from patients' sputa, according to the technic of Wright, and inoculations have been made at intervals of from five to ten days. The doses, in all cases, have been small to begin with, usually about 20 millions of any vaccine, and the amount has been increased to rarely more than 150 millions. The time of da}' preferred has been within an hour or two after meals, when the receptor cells have presumably been occupied in the absorption of nourishment, and constitutional svTnptoms are at such times less likely to follow. It has been observed that a very small dose of tuberculin inoculated into a fasting patient has caused a reaction, whereas the same dose given ' Wright has shown considerable variation in the bactericidal power of serum following on the drinking of typhoid vaccine. His experiments are suggestive, and there is a wide field for investigation of the consequences of the tuberculous swallow- ing their sputa. 596 SPECIFIC THERAPEUTICS OF MIXED INFECTIONS several times before, but following a meal, bad never done so. Tbis may be the reason wliy different degi'ees of negative phase are found by dif- ferent workers. Perhaps a homely instance of toxic effect is the feeling resulting to the unaccustomed from smoking tobacco before breakfast. The reader who is familiar with Ehrlich's theory of immunity and with von Dungern's ('03) experiments in connection with the immuniza- tion of rabbits against the blood of a particular variety of crab will recognize that the occupation with food of the receptors which subserve the nutrition of the cell may delay the incorporation of the toxic ele- ments of the vaccine with the cell protoplasm. To ascertain if leucocytes had a preferential appetite for one organ- ism more than for another, an experiment was undertaken with the blood of a patient suffering from a mixed infection of tubercle and staphylococcus, and who received inoculations for both. The opsonic index to each organism was found to be 1.2. The tubercle and staphy- lococcus emulsions were then mixed, and the opsonic indices again taken. The mixed organisms found in the leucocytes were counted, and the index to tubercle was found to be 1.1, and to staphylococcus 1.2. These results, practically identical, were confirmed by a second experiment with another patient. It would, therefore, seem that, given sufficient opsonin, the white- blood corpuscle is impartial in his selection of foes. All patients affected with chronic pulmonary tuberculosis in an ar- rested condition have been found to have low opsonic indices to the tubercle bacillus as well as to their secondary organisms. The condition of such a patient is best described by comparing him to a coimtry mas- tered by the armed occu})ation of mixed hosts. It may be profitable to cite a few illustrative cases of different types of mixed infection: Case I. — Mrs. B., age twenty-six, sent to Colorado Springs, Novem- ber, 1906, for catarrhal phthisis. Infiltration and sticky rales at apices of both lungs; scarcely any cough; no expectoration; gradual gain in general health till February, 1907, when she had an attack of influenza, followed by a cough and purulent expectoration, with coarse rales at both apices. Sputum. — No tubercle bacilli ; pneumocoeci and staphylococci, the former found frequently within the pus cells. The sputum was planted out, and pneumococcus and staphylococcus colonies grew, the former out- numbering the latter. Vaccines were made, as the patient showed after several weeks no ability to conquer her cough. March 10th. — Inoculation of 20 millions of pneumococcus vaccine. Sputum increased in amount for several days, followed by a decrease. March 16th. — Inoculation of 30 millions of pneumococcus vaccine; SPECIFIC THERAPEUTICS OF MIXED INFECTIONS 597 bronchial wheezing which had been annoying patient all disappeared; no expectoration for several days. April 1st. — Rales at both apices now again of the sticky character; three more inoculations were given with the addition of some staphy- lococcus vaccine, and small doses of Koch's new tuberculin. October, 1907. — Patient still without cough or expectoration. Sticky rales persist at each apex. Opsonic index to tubercle persistently low; inocuhition of Koch's new tuberculin started, as climatic help has not i)ro- duced a complete cure. This case would seem to illustrate the theory held by some that the influenza bacillus is necessary for the introduction of the pneumoeoccus. Case II. — May, 1907. — Mr. G., age forty, had pulmonary tuberculosis for six years; cavity in each lung. For some months past was suffering from persistent fever, following an attack of influenza, accompanied by excessive expectoration; sputum measured six ounces. Extensive sycosis (staphylococcus) of mustache and hair in nostrils, of several years' duration. Sputum. — Tubercle bacilli, pneumostreptococci and staphylococci present; some phagocytosis of all. Cultures were made, and colonies of Staphylococcus aureus predominated. Inoculations of a staphylococcus vaccine temporarily increased the amount of sputum, soon followed hy a decrease to less than two ounces. The sycosis, which was assisted by epilation (former epilation had failed to cure), rapidly disappeared, as also did the patient's fever. A gain in weight of over thirty pounds was made, and a bedridden patient was restored to comparatively good health. Case III. — January, 1907. — Miss D., age forty, had pulmonary tuber- culosis eight years. Cavity in left apex. Profuse expectoration for six years; amount of sputum daily, four ounces. Sputum. — Tubercle bacilli, diplococci, staphylococci, some phagocyto- sis of all shown by examination of pus cells. Cultures showed a few colo- nies of a pneumostreptococcus, enormous numbers of Staphylococcus aureus colonies ; vaccine made of the latter. Following the first few inoculations, the sputum was reduced to barely half an ounce ; a clearing out of her cavity at night, caused by recumbent posture, was completely stopped, and for the first time in eight years the patient was able to lie down and sleep through the whole night undis- turbed by coughing. October, 1907. — With the exception of an exacerbation lasting a few days this summer, the same improvement continues. Results in Inoculated Cases The result in fifty cases inoculated by the author witli liomologous vaccines prepared from tlie mixed organisms are best summed up as follows : 598 SPECIFIC THERAPEUTICS OF MIXED INFECTIONS 1. In no case has a patient been harmed. 2. Many patients have had exacerbations more rarel5^ 3. Expectoration in nearly all cases has been lessened; nocturnal coughs have frequently been eliminated. 4. In some cases a chronic catarrhal hoarseness has entirely disap- peared. 5. Concomitant pus affections have cleared away, such as suppura- tion of ears, staphyloccic acne, and sycosis. 6. AVhen these vaccines have been combined with small doses of Koch's new tuberculin, spreading infiltrations have been averted and cleared up. 7. In a case which displayed tubercle bacillus, streptococcus, pneu- mococcus, staphylococcus, and Micrococcus catarrhalis, the latter was entirely eliminated by appropriate vaccine, and the amount of sputum was reduced from four ounces to less than one ounce daily. 8. Evacuations of four to six ounces of sputum daily from cavities have, in several cases, been reduced to less than one ounce. The impression h.as been gained that the " bronchorrhea " type of cases has, perhaps, received less benefit connected with the reduction of sjnitum than the " cavernous " ty])e, and a possil)le explanation may, perhaps, be found in the results of inoculations of staphylococcus vac- cines for acne and boils. Owing to the difference in the access of blood to the skin surface and to the subcutaneous tissues, the boils have been found much more amenable to increased opsonic lymph than the acne spots. The experience of the writer has been limited to vaccines made of the staphylococcus, streptococcus, pneumoeoccus, influenza jjacillus, and Micrococcus catarrhalis. At the present time a method is under trial which may very materially simplify the making of these vaccines, and also produce them more potent, as a result of lessened attenuation from transplantation. The sputum is teased on a slant of blood agar, which is prepared from each patient. Colonies develop in approximatel}'' the same proportion in which the organisms have been active. These are washed off in salt solution, the emulsion thorouglily shaken, a slide pre- pared for enumerating, and the production is immersed in a water bath at 60° C. for one and a quarter hours. The vaccine so made is tested in the usual manner, and, when counted, is decanted to the required dilution. This method has been tried with success in purulent ear and bladder infections, and so far has given excellent results in pulmonary tuber- culosis. It is not so scientific nor so exact as that of isolating each or- ganism. The count of each organism in such a mixed vaccine is difficult, it often being impossible to say what is a pneumoeoccus and what is a SPECIFIC THERAPEUTICS OF MIXED INFECTIONS 599 staphj'lococcus, yet an error witliin a few millions is practically imma- terial in vaccine therapy. A lasting immunity nmst not be expected from inoculations of these vaccines, just as a lasting immunity to the tubercle bacillus is unattain- able by any tuberculin administration. After the apparent maximum results have been obtained, most patients have been kept in touch by inoculations at intervals of a few weeks. In conclusion, the author would put forth the earnest plea that these potent remedies be used early, while the machinery of immuniza- tion is yet unworn, and that they be added to the tuberculin treatment so well advocated by Trudeau and Wright. Then the ranks of the ad- vanced tuberculous will be lessened. CHAPTER III HYGIENE, DIET, AND OPEN AIR IN THE TREATMENT OF TUBERCULOSIS HOME TREATMENT BY SANATORIUM METHODS By THOMAS D. COLEMAN Cases cared for in the liome are for the most part omitted in statis- tics because most doctors do not keep accurate case histories, and those who do, do not always report them ; on the other hand, most sanatoria do report their cases, and many of tliem do not accept patients who are in advanced stages of the disease. Flick, Pratt, and others have shown how, witli a little trouble, a small expenditure of money, and a directing hand, even the slum dweller may have his sanitary surroundings improved and the length of his life increased. They have recently been giving object lessons in this direction that are far reaching in their influences for good. They are showing not only to the laity but to the profession the bene- ficial results that may be obtained even in insanitary surroundings. The tuberculous patient is being taught that even in the slums and tenement- house districts their surroundings may be improved ; they are being taught the value of order and cleanliness, of wholesome food, and the necessity of fresh air. (See Appendix.) Instead of living in stuffy, ill-ventilated quarters which the sun never reaches, the patient is being taught to use the courtyard of the tene- ment, in which a tent may be erected, or a balcony over which a suitable awning may be placed to protect it from the inclemencies of the weather ; or even the roof of the house may be utilized for the erection of a tent. On sloping roofs a floor may be necessary with banisters around, but on a flat roof these may be dispensed with. These advantages may be ob- tained by almost anyone who will take the trouble or make the effort. These accessories to the home may often be obtained by the expenditure of a few dollars. In passing a palatial residence only recently, I had impressed on me how, in the essentials, the rich have little advantage of the poor. The stone mansion was imposing in its grandeur. It occu- pied a large plot of land, which was made more beautiful by the land- 600 FOOD 601 scape gardener's skill ; huge stone pillars supported the ornate iron fence that inclosed it. One could not but envy the possessor, but a glance a little farther back made the envy give place to pity — an unostentatious tent in the background, on the lawn, told tlie tale — the fight for life was going on not in the mansion, but in the tent. In presenting the detailed treatment of these cases, I have not con- sidered it desirable to separate the sanatorium from any other intelligent routine treatment, for the reason that in the homes of the well to do the sanatorium treatment may be equaled, if not surpassed ; in the homes of the less wtII to do, even in the houses of the poor, wdien the patient cannot or will not go to the sanatorium, an approximation to the ac- cepted standards should be made, as far as the intelligence and ability of the patient will permit. FOOD Tuberculosis formerly was generally called consumption, because of its destructive metamorphosis, and in the literature of medicine we still find the terms " galloping consumption,'' " quick consumption," etc. In both acute and chronic tuberculosis the subcutaneous fat disappears, the muscles decrease in size and power. To counteract this retrograde tend- ency, an intelligent direction of the food is necessary. This direction not only includes tiie quality and quantity, but its preparation as well. It has been determined by physiologists that a man of average size, doing ordinary work, requires about 120 gm. of albumin, 50 gm. of fat, 500 gm. of carbohydrates daily in order to replenish his bodily wastes, and he thrives best on a mixed diet. An adult of average size consumes about 3,000 calories of combustible material per dav, and since albumin yields 4.1, fat 9.3, and carbohydrate 4.1, it will be found that the afore- mentioned dietary contains approximately 3,000 calories. A tuberculous patient requires even more than this. While this serves as an index, it must not be followed too closely, since elements of error creep in that cannot be measured mathematically. For example, food constituents vary in composition in their raw state and in preparation. Again, the question of taste comes into considera- tion, and with it problems of digestion and assimilation, so that we must make a liberal allowance for these factors. Long before Pavloff chroni- cled his valuable observations, we were familiar with the expression, " his mouth watered for food " — the physiologic interpretation of which is that the smell or sight of food excited the salivary glands, and thus prepared for the digestion of food. We have known for many years that the opposite holds true: giving unappetizing food or giving food to an individual wbo is under great mental stress, the food is not only hard to swallow, but difficult of digestion as well. Again, T have found that 602 HOME TREATMENT BY SANATORIUM METHODS a large percentage of my tuberculous patients suffer from gastric catarrh, which not only blunts their appetites, but impairs their digestion. An experience of two decades has brought me to this attitude in prognosis : if, after two or three months, the patient can take the amount of food that he requires, and -gains weight on it, my prognosis is influ- enced favorably. In other words, an engine is no stronger than its boiler, and a man than his stomach. I have rarely found the tuberculous process to be advancing when the patient has been steadily gaining weight for any length of time. Proper nourishment, then, is of the first importance, for patients do well even under adverse climatic and other conditions, but they cannot improve without food, and an abundance of it. We must also introduce such aids to digestion as the individual case may require. Food values in calories of energy have their true place, and hold good for the healthy individual, but they often savor too much of the mechanical in those who are sick and have disordered digestions. The most reliable guide of the patient's improvement is liis gain in weight. He should be weighed each week, at the same time of day and under the same physical conditions, and his food consumption should be regulated by the result. Tlie following table, from calculations made by Boas and Cornet, gives the food values, in calories, in 100 gm. or 0.1 liter, of the articles of diet mentioned : Milk 67 Skimmed milk 40 Cream 215 Buttermilk. . .' 41 Butter 756-807 Pot cheese 179 Swiss cheese 340 Scrambled egg 188 One egg 70-80 Beef, raw 119 Beef, boiled 209 Beef, fried 214 Veal cutlet, raw 142 Veal cutlet, fried 230 Calves' brain, raw^ 140 Sweetbreads 90 Pork, fat 313 Bacon 617-761 Chicken (breast), raw 100 Tongue 393 Smoked meat 255 Smoked ham 438 Pomeranian goose's breast 381 Bologna sausage 445 Liver sausage 290 Carp, raw 93 Pike, raw 72 Turbot, raw 101 Trout, raw 106 Salmon, raw 133 Haddock, raw 61 Sole, raw 95 Perch, raw 76 Oysters, raw 20 Pickled herring 246 Smoked salmo.n 224 Kiel sprats 243 Caviar 278 Rice cooked in milk 177 Mashed potatoes with butter 127 Spinach, raw 39 Spinach, boiled 166 Puree of beans 193 Peas 75 Beans 41 Asparagus 18 Farina pudding 288 Omlette soufflee 237 Noodles (macaroni) 353 Raw sugar 406 Corn bread 203-232 Pumpernickel 229 Wheat bread 229-260 Zwieback 332-358 Cakes 374 Corn brandy 280 Carrots 41 FOOD 603 In no other chronic disease is abundant feeding so essential. It must be carried out, not only through the abundance of food furnished, but by its quality, by its variety, by its method of preparation, by digestive stimulants and aids, and, in special cases, by the employment of the stomach and rectal tube. While it is possible to overburden the digestive tract of the patient, this danger is insignificant compared with the like- lihood of not getting enough food to make good his wastes, and to fortify him against the ravages of the disease. That diet is best which taxes the alimentary powers least and furnishes the greatest amount of nour- ishment. The demand for an excess of fats is in no disease more pronounced, and was early recognized in the emplo}Tnent of cod-liver oil, under the impression that it was a cure for tuberculosis. Milk, fresh and pure, or in various modifications, is of greatest value in many cases. When there is hyperacidity, and the milk forms large curds in the stomach, a little limewater added to it will overcome the difficulty. In other cases, milk diluted with an equal part or a third of vichy or ordinary carbon- ated water will be tolerated Avhen plain milk will not. Similarly, but- termilk is not only more palatable to some, but is more easily digested, and koumiss, matzoon, and milk artificially fermented (" lactobacil- line ") are all varieties of milk to be considered and recommended as the case reqv;ires. The patient should take from one to two quarts of milk daily, plain or modified, in addition to other food. Eggs, in nutritive value and ease of assimilation, occupy a position second only to milk, and are sul)jeet to a like variety of preparation. The simplest form in which the egg may be administered is egg albumen, and I have found that not only invalid adults, but babies at the breast, can take this form of nourishment when they can take no other. The way in which I usually have it prepared is to take the white of the egg, clip it with scissors to keep it from cohering, add a little crushed ice, orange juice, and a ])inch of sugar. The most delicate stomach will not only tolerate this, but the patient will relish it. If for any reason, par- ticularly in the case of babies or patients suffering from intestinal tuber- culosis, the orange juice is contraindicated, arrowroot or oatmeal or bar- ley water may be substituted, and a flavoring extract or cognac brandy may be added. In the majority of cases the whole egg is taken. At the beginning a little sherry or port wine in the bottom of the glass, then the egg, and on top again the wine, making a sort of " egg sandwich," may be used, or whisky or brandy may be so employed, but soon these may be dis- pensed with and the egg swallowed without them. I have had patients take as many as twelve eggs daily. Again, patients may take the eggs in milk, or with the addition of whisky or brandy, making an eggnog, 604 HOME TREATMENT BY SANATORIUM METHODS or with sherry or port wine, making a sherry- or port-wine flip. In the matter of cooking, eggs may be taken soft boiled, shirred, poached, or scrambled, or they may even he hard boiled. Indeed, they occupy a place in our dietary that is insufficiently appreciated. They are used in all batter breads, meringue, and cakes. Meat comes third in the dietary of the tuberculous patient. Those who are robust take meat of many kinds and variously prepared. It may be stated generally that fried meat of any kind is harder to digest than when prepared in any other way. I think it is true of meat as of milk : that it is easiest digested raw, so that it will be found that the raw-beef sandwich can be digested when no other form of solid food can. The objections to taking meat raw come, first, from our natural aver- sion, which, strangely enough, does not pertain to oysters, clams, etc., and to the parasites (which are destroyed by cooking). Again, cooking makes the connective-tissue portion of the meat more digestible. ISText to this, and even beyond it in certain asthenic cases, is the squeezed-beef juice,^ and largely because it may be swallowed without mastication. In the matter of meat, the flesh of any edible animal is wholesome if properly seasoned and cooked. In this respect the taste of the patient should be consulted as far as possible, it being borne in mind that shell- fish are less nourishing than many lentils, and that pork and veal are difficult of digestion. Prepared Foods. — Of the prepared foods, some are of value. Among the first may be mentioned the milk preparations. Of all of these I may say that, so far as my experience goes, they are makeshifts; they may aid in nutrition, but are insufficient of themselves. The beef preparations depend largely for their nutritive value on the wine which they contain, and Graham Lusk has recently shown that one of the more popular of these contains no more nutrition than an equal quantity of milk. When administering them in tablespoonful doses they are totally inadequate. Alcohol. — It has been proved that alcohol, when used to excess, not only does not protect the individual from tuberculosis, as was formerly believed, but absolutely predisposes him to it. On the other hand, Professor Atwater and others have demonstrated beyond question that alcohol, in modera- tion, is a food and beneficial to the system. This he is able to maintain not only from his experiments, but from the fact that there is no hardier stock of people to be found on earth than the wine-drinking nations. 1 This is made by taking blocks of beef two inches square (round steak is best for this purpose), putting them into a red-hot skillet, and cooking them quickly, turn- ing the while. They are then gashed with a knife and squeezed with a meat press or lemon squeezer into a cup standing in hot water. This keeps the juice hot and makes it more palatable. FOOD 605 It luiR been shown tliat alcohol is a negative food; that, in its im- mediate oxidation, it saves tissues that would otherwise be expended in life processes. In moderate amounts it stimulates the appetite, improves digestion and reduces the temperature, and diminishes the night sweats. The excessive use of alcohol not only fails to stimulate, but depletes the system ; the continuous use of it also leads to the habit, so that the physi- cian and the patient must be constantly on guard. Alcohol taken un- wisely may not only destroy the appetite, but leads to poverty, degrada- tion, and crime. Wisely employed, it improves the appetite, makes the digestion better, and protects the tissues. WHienever the digestion will permit, an excess of fats should be fur- nished ; e. g., the fat of pork, mutton, fowl, beef, butter, cream, olive oil, fatty fish (e. g., Sjianish mackerel, poinpano, eels, salmon, shad, sardines, etc.). For a similar reason, beans and peas are to be recommended be- cause of their liigh nutritive value. Carbohydrates are fat producers, and these should be prescribed lib- erally. Among these may be mentioned corn, wheat, graham and batter breads, pies, puddings, and cakes ; cane sugar, maple sugar, and honey, all admitting of various combinations and an infinite variety in preparation. Among the proteids, milk, eggs, and meat form the triumvirate; all may be taken raw, or prepared in the more tempting ways known to the culinary art. Dietaries.— The following dietaries are applicable to the average in- cipient or moderately advanced case, it being remembered that the indi- vidual taste and the state of the digestive api^aratus of the patient cannot be disregarded. It should also be borne in mind that not only the time of feeding, but the quality and (minimum) quantity of food must be prescribed by the pliysician : Breakfast, 8 a.m. — Fruits; cereals; one raw egg; three glasses of milk ; coffee ; toast. Breakfast, 10 a.m. — Two raw eggs ; two glasses of milk ; crackers ; pret/els. Dinner: 13.30 p.m. Cream of Tomatoes. Broiled Sirloin Steak. Stewed Chicken. Boiled White Potatoes. Stewed Onions. String Beans. Steamed Rice. ,, , , Macaroni. Salad. Apple Tapioca. Rice I'udding. Crackers. Cheese. Nuts. Coffee. or 606 HOME TREATMENT BY SANATORIUM METHODS Puree of Peas. Breast Spring Lamb. Mint Sauce. Prime Ribs of Beef. Boiled White Potatoes. Baked Sweet Potatoes. Spinach. Stewed Tomatoes. Lettuce Salad. Baked Apples. Cup Custard. Crackers. Cheese. Nuts, Coffee ( demi-tasse ) . 4 P.M. — Two raw eggs; two glasses of milk; craekeri; pretzels. Supper, 6.30 p.m. — One raw egg; three glasses of milk; tea; toast; fruit. 8.30 P.M. — Two glasses of milk. Summary. — Six raw eggs, three quarts of milk, and full meal (Stockdale). Another dietary is as follows: 7.30 A.M.— Milk, I pint. 8.30 A.M. — Milk, ^ pint; bread or toast, 2 ounces; Imtter, ^ ounce; 2 ounces fish or bacon, etc., and an egg. 10.30 A.M.— Milk, I pint. 11 A.M. — Milk, I pint; bread, 2 ounces; butter, | ounce; fish, 2| ounces; meat, 3 ounces; milk pudding, 5 ounces. Dinner. — Similar to lunch, but meat, 2 ounces. Cornet, who adopts a somewhat lower fat standard for the diet in health than do these authors, is in the habit of prescribing for his pa- tients on the following lines : First Breal-fast, 7 a.m. — Milk (cocoa or coffee), | to 1 pint, with one or two eggs stirred in; or gruel, or meat, bacon, bread and butter. Second Breal-fast, 9 to 9.30 a.m. — Milk, | to 1 pint; or 3 ounces strong wine (sherry, port, marsala), bread and butter. Noon Meal, 1 p.m. — Soup; entree; fish; roast venison; fowl, with vegetables; preserves and salad; pudding; bread, butter, and cheese; 3 ounces red wine, or -| pint heer. Afternoon Meal; 4 p.m. — Milk (cocoa), -I to 1 pint, with one or two eggs stirred in; bread and butter (honey). Supper, 7 p.m. — Roast meat; vegetables; cold meat (ham) ; roasted potatoes; bread and butter; 3 ounces wine, or ^ to 1 pint beer or milk. 9 P.M. — Milk, i to 1 pint; 1 zwieback, cakes, or bread. FOOD GOT Lucas gives the amount of the various forms of food which are necessary as follows: Breakfast. — Porridge, \ pint, with 2 ounces of sugar; 2 rashers of bacon and 2 eggs (or chop, steak, or fish) ; bread, 4 ounces; butter, 2 ounces; | pint of tea or coffee; milk, 1 pint. Midday Meal. — Soup (optional) ; fish, 3 ounces (or poultry), with butter, 2 ounces ; 2 or 3 slices of meat, 4 ounces ; potatoes, 4 ounces ; cabbage and other vegetables, 4 ounces; pudding (various kinds), 6 ounces; cheese, 2 ounces; bread, 4 ounces; butter, 2 ounces; milk, 1 pint (or cocoa), with one or two eggs stirred in; bread and butter (honey). Supper preceded by one fourth to one half hour of rest. Supper, 7 p.m. — T?oast meat; vegetables; cold meat (ham) ; roasted potatoes; bread and butter; 100 c.c. of wine, or ^ to -J liter (quart) of beer or milk. 9 P.M. — Milk, I to f liter (quart) ; 1 zwieback, cakes, or bread. The rest before meals, which I prescribe even for fairly strong pa- tients, increases the consumption of food. Tuberculous patients with a temperature seem to be able to take and digest an amount of solid food which under other febrile conditions would not be tolerated. Any dietary suggested will have to be modified to suit the individual. If any other argument was necessary, this is sufficient to justify the claim for constant medical supervision in these cases, and infinite tact and perseverance are necessary. The simplest diet is that of milk and eggs ; if patients take enough of these, other food may be largely dispensed with, and yet, in the employment of these, tact and judgment will have to be displayed. A large percentage of patients can take raw milk — even many who think and say they cannot. Still, there remains a percentage of patients who cannot take milk at all, or for whom the milk must be modified in some way, or peptonized. Appetizing and Bitter Tonics "When the desire for food is poor, appetizers and bitter tonics may be indicated. Among these may be mentioned alcohol, which in moderate amount, and either plain or with vegetable bitters, not only stimulates the appetite, but improves tlie condition of the body as a whole. In this connection the following will be found of service : !^ Tr. nucis vomicae ."ij ; 5 gm. " gentianse composit., ) « ". 1 ., > aa .^i] ; 60 cmclionffi composit., I "^ ■* M. Sig. : Dose 3j, in a wineglassful of water before meals. 608 HOME TREATMENT BY SANATORIUM METHODS AIR AND ENVIRONMENT The life history of the tubercle l)acillus outside the body, and our knowledge of its existence in man and animals, all teach us that fresh air exercises an unfavorable effect on its growth. Tubercle bacilli dried and exposed to the sunlight lose their virulence in a few days; in dark, illy ventilated rooms they may retain it for many months. From the animal kingdom the same testimony is obtained; tuberculosis is not found in the monkey in his jungle life. In captivity it is tlie disease with which he is affected, and it probably accounts for more deaths tlian all other diseases combined. The same evidence is furnished by the human family. Tuberculosis is comparatively rare in the rural districts. In the negro, in his unciv- ilized state and even in his state of bondage, it was comparatively un- known. jSTow the deaths in that race from this disease are three or four times as great as among the whites. The congested districts of our cities — our slums, sweat shops, " lung blocks," etc. — furnish uncanny but instructive pictures to which we can- not shut our eyes. Fresh air in some of the abodes of the poor is more difficult to obtain than fresh food, and tliese " lung blocks " exact their tribute year after year. Fortunately for the human race, health boards and philanthropists are taking active hold of this problem, and are forcing conscienceless landlords to respect the commandment, "Thou shalt not kill." With these facts in our possession, it is easy to see the important role which pure air plays in checking the spread of tlie disease, and, therefore, the saving of human life. It is not in the least necessary or even desirable to draw the line in this respect between the patieiit in the sanatorium or out of it ; ]nire air and an abundance of it is a siiie qua non. How this is to be best ob- tained is a problem tliat will differ in almost every case, and it will often tax the ingenuity and sagacity of the physician to the utmost. Mani- festly, the problem is more beset with difficulties in the slums tlian in the abodes of the rich, and yet the prejudices of the latter, and their ignorance of hygienic laws as well, often present difficulties in tliis direc- tion that are greater than the obstacles that poverty enforces in the case of the poor. AVhatever the financial condition or social status of the patient, fresh air must be demanded. This can l)e obtained in most instances by the physician of average ingenuity and whose heart is in his work, for be it said to the credit of the human race, it is ever ready to alleviate dis- tress when the cause is just. I have never yet been refused aid for a sufferer for whose honesty I could vouch ; so that, when improved hygienic surroundings are necessary, they can usually be obtained. It AIR AND ENVIRONMENT 609 is simply necessary to have a directing liand. Again, the district nurse has demonstrated how order and cleanliness may be brought out of chaos and filth, and Pratt and others have shown the scientific world what truly marvelous results may be obtained with unfavorable environment and unfriendly climatic conditions. Education is the touchstone that brings about the wonderful trans- formation. Teach the sufferer that fresh air is not to be feared, but rather to be coveted, and a great stride in the fight will have been made. The temjjerature, when cold, or even if it is raining or snowing, does not prevent living a large portion of the time in the open air. It is essential to keep the body warm and dry l)y appropriate covering. At a minimum, eight to ten hours a day should be spent in the open air, and as much more as practicable, and a tent life away from the dust-laden and pol- luted air of cities is to be desired. If a tent life cannot be obtained — and it is not essential — as near an approximation as the means and en- vironment of the patient will admit must be secured. He must live out of doors while the sun is up, and at night he must sleep with his win- dows open, though not in a draught. It is to be deplored that civilized man tries to subvert the laws of nature. His life is spent in a race for wealth and preferment; and it too often happens that, when these are obtained, his capacity for enjoy- ment is gone, and all that is left to him is the privilege of bequeathing to posterity his life's blood coined into dollars. The business of life in the cities, whether it be to gain a bare subsistence or an effort to main- tain social position, is subversive of the laws of nature. "When the sun has sunk and the animal and vegetable world are at rest, the sweat- shop worker, wearied in body, is busy at his task; the society devotee, with less excuse, in like manner weary of bod}', but from a different cause, in a different way — is busy. The bodies and minds of both are worn with the struggle, differing, it is true, in its aims and necessities, but similar in its ravages on the constitution. Regularity and order are rules of our environment here; and the " early to bed and early to rise " is something more than a saw. It has been found that in this disease, especially, it is well to have patients follow, as nearly as possible, the course of the sun — to rise with it and to retire with it. Naturally, it is at best one of compromise and environ- ment. Tlie nearer we can approach the primitive state, the better. In a tent existence, if possible, it is best to have the abode arranged so that the necessary toilet arrangements may be carried on in comfort, protected from the inclemencies of the weather which are to be encoun- tered in any climate, but the sleeping and living of the patient should be in the open. This does not materially increase the expense of such an existence, for a tent, divided so that a closed portion is reserved for 40 610 HOME TREATMENT BY SANATORIUM METHODS these purposes, is not diflficult to devise and maintain. The tent sliould, in all cases, have a lloor elevated a))ove the ground; the location should be well drained, and protected as far as possible from winds. These points are essential. As to surroundings of pines or fir trees, a sandy, porous soil, and a particular climate for the individual case, these are to be desired, but not essential. When the patient is to be cared for in his home, the following details concerning his care are needful : Pure air, nourishing food, and the con- stant supervision of an able medical adviser. The patient's room should have an air capacity of approximately three thousand cubic feet; more does no harm, less makes an undesirable eneroaclmient, but in any room not only is its size to be considered, but its location and ventilation as well. In northern latitudes, except, perhaps, in the summer, the room should have a southern, southeastern, or southwestern exposure, so that the benefit of the sun can be had a large part of the day; in tropical climates and in summer it may be desirable to change this. The location, number, and size of the windows is also important. They should extend almost, if not quite, to the ceiling, and unnecessary brackets and abutments should be avoided, as they tend to catch dust. The angles of the room should be obliterated as far as possible ; e. g., those between the floor and wall, and wall and ceiling. These may be rounded by metal or cloth, that may be painted. It is preferable to paint the walls, because they may then be cleansed more frequently and properly. Unnecessary curtains and hangings of every sort are to be avoided, as are also Venetian blinds, since, while they shut off the light and some heat, they still collect quantities of dust. To keep out the light when it is not desired, I know of nothing better than tha modern opaque roller shade. The floors, if of wood^ should be painted or waxed, so that they may be cleaned readily. Whatever the floor surface, it should be made non- absorbing, so that it may be wiped up thoroughly. Carpets should have no place in the room, but a few rugs may be allowed. In this, as in many other ways, the rich have very little advantage of the poor. A Persian rug costing many hundreds of dollars, infected by tuberculous sputum, is not apt to be consigned to the trash barrel — it matters not what the wealth of the patient may be — whereas the morning newspaper, on which the cuspidor of the poor usually rests, is destroyed without hesitation when it becomes soiled. With reference to cuspidors, while they are frequently spoken of in derision as an American invention, the writer, as an American, is glad to acknowledge their paternity. I believe them to be the greatest prophylactic device employed in preventing the spread of tulierculosis. Whatever may be said on this score, pro and con, it is certain that the AIR AND ENVIRONMENT GU average poor patient is not al)le or willing to furnish himself with cloths or tissue-paper napkins into which to expectorate; and, while well-to-do patients are able, many are unwilling to take the trouble which the employment of cloths or napkins entails. I consider a cuspidor half filled with an efficient germicide, or simply water, less dangerous than any cloth on which the sputum is apt to dry, and from which bacilli must escape when they are used. The chairs should be constructed for comfort rather than beauty, and some covering which may be disinfected and washed may be i;sed. For the average patient some t3'pe of reclining chair (e. g., the average steamer chair, which is inexpensive) will be needed. The room should be on the first floor, so as to save the patient the necessity of climbing flights of stairs; it should be contiguous to the bathroom and toilet, so that the wants of nature, which are at times exacting, may be met with- out undue fatigue. It should be heated by hot water or steam prefer- abl}', and should be lighted by electricity. While no climate is univer- sally adapted to all patients, still, the average case will do best in a mild, equable climate. A sultry, depressing climate is to be avoided; a brac- ing climate with plenty of sunny days is to be desired. Climates in which sudden atmospheric changes and high winds prevail are undesir- able. The air should be free from dust and smoke, and the soil should be sandy or porous. A moderate altitude above the sea level is advan- tageous. ISTo hard-and-fast daily routine can be laid down for all patients. Any regulations that may be prescribed will have to be modified to suit the individual needs That employed at tlie Xordrach Sanatorium for convalescent patients able to take ordinary exercise will serve as a good working l)asis. The following is an outline of the daily routine observed at Xordrach : The patient is called at seven o'clock in the morning, and in the colder months the windows of his room are tlien closed, in order that the room may be comfortably warm while he dresses. This closing of the win- dows at this time serves another ])uri)ose, in that the air of the room immediately tends to become "stuffy" to those accustomed to open-air methods. Consequently, there is a direct incentive to patients to get up. The patient then takes his temperature (rectal), and rises not later than 7.30, and has a shower bath, at a temperature, in most cases, agree- able to himself. He must avoid overexertion in drying himself. On completion of his dressing, he should open the windows. Breakfast is at eight o'clock. Directly after breakfast, or at 8.30, the patient starts out for his morning walk, the length of which is grad- uated according to his condition. He walks deliberately, avoiding any strain, dyspnea, or perspiration, until he has arrived at his destination. 612 HOME TREATMENT BY SANATORIUM METHODS and waits there resting in the fresh air, but protected from the wind, until it is time for him to start home again. At 11.45 he must be in his own room, where the windows have shortly before been shut, and must take his temperature. In five or ten minutes he should open the windows. Between twelve and one o'clock he lies resting, and alone, at full length on a sofa chair near the window. At one o'clock he leaves his bedroom or shelter, and has luncheon, the principal meal of the day, with his family. Not later than 2.45 he must start on his slow afternoon walk, which is the shorter walk of the day. He rests, as before, when he arrives at his destination, and returns slowly, so that he reaches home at 5.30, or, if it is very cold, at about 4.45. He again takes his temperature, opens the windows, which have been closed shortly before his return, and rests alone until dinner time. At seven o'clock he joins his family at dinner. After dinner he may spend half an hour to an hour in the dining room, or preferaljly in some suitable recreation room, under open-air conditions. The patient retires to his own room at nine o'clock, opens the windows, and takes his tem- perature. He should be in bed at 9.30, or not later than ten o'clock. REST AND EXERCISE A fundamental principle in the repair of tuberculous tissue is rest. A tuberculous joint is rested by putting it up in a splint; in cases of Pott's disease the patient is placed in a plaster-of-Paris corset; in tuber- culous pleurisy, limit the excursions of the chest by means of adhesive strips; in pulmonary tuberculosis, if the process is active, general rest is prescribed. To those who have not made a special study of the disease, the good results obtai"ned by rest would seem almost chimerical, and yet they are demonstrable verities. Even witliout the administration of drugs the fever disappears, tlie night sweats diminish, the cough grows less, and the patient takes on flesh. I think this doctrine of rest is not now dis- puted by those having considerable experience in the treatment of this disease. It was on this theory that Forlanini, and later Murphy, Brauer, and others, suggested tlie ])lan of obtaining rest for the tuberculous lung by introducing nitrogen gas into the pleural cavity, thus causing the lung to collapse, and producing a state of rest which lasts until the gas is absorbed. Eest does not cure all cases of tuberculosis, but it is always indicated where there is hyperpyrexia, where the night sweats are exhausting, where the cough is incessant, where the prostration and dyspnea are great, and where there is a tendency to pulmonary hemorrhage. Wliere the morning temperature is 99° F., and the evening temperature REST AND EXERCISE 613 100° F. or more, rest tliroughout the entire day should be enjoined. On the other hand, when the active stage of the disease is checked, exercise, intelligently directed and faithfully carried out, is' to be pre- scribed. This must be undertaken gradually, and stopped at the return of fever or the production of too great fatigue. Some exercise may be obtained, even by patients who are confined to their rooms, by the employment of massage. This stimulates the cir- culation and, to an extent, improves the general nutrition, but, like other exercise, must be directed intelligently; and, if it produces too much fatigue or brings about a, rise of temperature, it must be curtailed or abated. The simplest form of exercise outside of this is walking. This should be taken at first on the level, and afterwards, as the strength in- creases, hill climbing may be prescribed ; it strengthens the leg muscles, improves the action of the heart, and thereby the general nutrition is improved. The hill climbing should be done gradually, and so that the ascent comes in the beginning rather than at the end of the walk. If fatigue ensues, a rest should be taken. The form of exercise should conform as nearly as possible to the tastes of the patient, and that which interests and attracts him should be indulged in as far as possible. This falls in line with the directions given for food. "Within certain limits that food is most effective which is toothsome to the patient, and that exercise accomplishes most good which is most attractive or most inter- esting to him. Dr. Paterson, of the Frimley Sanatorium, has prescribed a graded system of exercise which may be varied to suit the individual case, but Fig. 152.— Grade 1. B.\skets Holding About 12, 18 and 24 Pound.s of Mold or Other Material. Patients carry these a distance of 50 yards up a gradient of 1 in 10.7 (rising 14 feet), 80 loads per day. which may, nevertheless, be employed as a useful guide. He prescribed exercise and labor for two periods daily, each of two hours' duration. A patient is first placed on Grade 1, and then, as improvement shows itself, successively on Grades 2, 3, etc. If the work of the grade is 614 HOME TREATMENT BY SANATORIUM METHODS found to cause a rise of temperature, decrease of weight, or other bad symptom, the patient is at once placed on a lower grade. The grades are as follows: (1) Slow walking exercise, beginning at two miles a day and gradually increasing up to ten miles a day; (2) picking up fir cones and firewood in the grounds, and carrying a half basket (weight, 11 pounds) to the stack; (3) carrying a full basket of firewood and cones (weight, 16 pounds) ; (4) carrying a half basket of gravel or stones from the gravel pit to the place where paths are being made or repaired (weight, 21 pounds) ; (5) carrying a basket of gravel Fig. 153. — Shovels and Spades Used in Grade 2 and 3 for Digging Earth and Lifting it into Barrows. (Large shovels used also in concrete mixing as Grade 4.) or stones, the weiglit of which is gradually increased up to 38 pounds (see Fig. 152) ; (6) rolling the grass or gravel (sixteen men pull a roller weighing 15 hundredweight; (7) digging ground already broken; (8) mowing grass with a lawn mower; (9) digging unbroken ground; (10) the same as under (9), but for six hours daily in- stead of four hours — i. e., the hours usually spent at rest are spent in labor. No patient is classified on discharge as " arrested " unless for three weeks continuousl}' he can pass one or otlier of the following tests: REST AND EXERCISE 615 Test A. — For a patient who earns his living by manual labor: To be able, on an ordinary diet and without rest hours, to use a pick and shovel, of the full size and weight, for six hours daily, and to maintain his health. The shovels and sjaades are of three sizes, weighing 2, 4, and e e (ti Fig. 154. — Forks of Different Weight for Graduated Work in Grade 2. 6 pounds, respectively. The picks vary from 3 to 7 pounds in weight (see Figs. 153, 154, 155). Test B. — For a patient who does not earn his living by manual labor — clerks, shopmen, or salesmen : To be able, on an ordinary diet, to per- form the labor of Grade 6, or for six hours daily, for three weeks, and to maintain his health. These patients are, as a rule, gradually brought up to Grade 9, and, when it is found that they can do this work, they are put back to Grade 6 or 7. The theory is that a man doing the work described under Grades 9 and 10, who, on discharge, will engage in work involving but little bodily exercise, would suffer in health from such an abrupt transition. Further experience is, however, necessary on this point. In some cases it is found that patients are unfit for Grade 9, but that they can be raised to a standard of lal)or which is equal to their ordinary work. These patients arc tested before discharge on the grade to which they have attained, but they are not, as a rule, classified as " arrested." 616 HOME TREATMENT BY SANATORIUM METHODS On the supposition that the healthy portion of the lung undergoes hypertrophy, and that in this way loss of tissue is compensated, many authorities have advocated pulmonary gymnastics, but these have been opposed by Brehmer, Liebermeister, and others, for reasons already given, viz., that the nearer the diseased lung tissue approximates a con- dition of rest, the more readily it returns to the normal. Fig. 155. — Pickaxes of Various Weights Used in Grade 4 for Breaking Ground, Excavating, Etc. This being the hardest work possible. Within the last few months the untoward effects of exercise in the active stage of the disease have been impressed on me. An athletic young man, after a period of apparent quiescence in his lung trouble, suffered from a lively exacerbation in which he had serious and repeated hemorrhages, rise of temperature, etc. After the hemorrhages had ceased, and the temperature had been normal throughout the twenty-four hours for several days, and the patient was eating well, sleeping suffi- ciently, and taking some exercise in walking about the house and premises, I thought him strong enough to come to my office, instead of my visiting him, believing that the ride would not only be a diversion for him, but beneficial in other ways. Although the carriage ride, a distance of several miles, did not apparently fatigue him, his tempera- ture rose that night to 105° F. Confinement to bed for several days promptly brought it do^vai to normal, but the same result was produced by a -second trip. CLOTHING Clothing, both for patients confined to bed and those going about, should be light but Avarm. In each case the patient will find that he can keep comfortable with less clothing by a little practice and the exer- HYDROTHERAPY AND HARDENING 617 cise of a certain amount of will power. The end to be attained is to keep the body warm, but not to overheat it. Any clothing, whether bed or body clothing, which throws the individual into a sweat is bad. When confined to bed, it will often be found that an excess of covering is not needed if a hot-water bottle is applied to the feet. In the matter of body clothing, it is well to cover the body of the patient with woolen garments, summer and winter, the weight of the garments being gov- erned by the temperature and temperament of the patient. If wool irritates the skin, cotton, linen, or silk undergarments may be worn. For sudden or great drops in temperature, overgarments of varying weights may be employed, and the patient should not start out on a long drive or walk without providing against these contingencies. The overcoat or wrap is especially to be commended, because it may be thrown off easily or put on as occasion demands. HYDROTHERAPY AND HARDENING The value of the bath in cleansing the skin of dirt and grease has been recognized from the earliest times. It not only improves the physiologic activity of the skin, Imt accelerates the circulation of the blood. The cold bath stimulates the peripheral nerves, and produces an invigorating effect on the body as a whole. At first the cold bath cannot be taken by all patients, the shock being too great. Some patients cannot be hardened or educated into taking them. This is not a matter of mere volition on the part of these patients, but of temperament and constitution. These patients may greatly desire to avail themselves of this invigorating procedure, and may strive to coop- erate to their utmost, but, in spite of all efforts, they fail to react. In- stead, they feel depleted and benumbed ; the head aches, the circulation is depressed. Instead of the tingling and bodily glow which should follow the bath, they remain chilly throughout the day ; the extremities are cold and the nails and lips blue. These patients, many of whom are apparently strong, and others who are already depleted and deliilitated from the ravages of the disease, should confine themselves to hot and lukewann batlis. The process of hardening can be carried out in a larger percentage of cases than would at first sight seem possible, if the physician will exercise sufficient moral suasion, patience, and ingenuity ; but when the aforementioned train of symptoms follow the cold bath, it should be abandoned. Even in the case of patients who can take it and experience a marked tonic effect therefrom, it should be dispensed with if there is a tendency to hemorrhage. Eliminating, then, those patients who for one reason or another cannot take the cold bath, it will be 41 618 HOME TREATMENT BY SANATORIUM METHODS found tliat by far tlie larger percentage can take it, and witli distinct benefit. In the case of feeble and more bigbly sensitive patients, they will have to be initiated by sponging a ])ortion of the body with lukewarm water, and water to which alcohol, salt, or vinegar has been added; in the more difficult cases the bath should be preceded by dry friction; in fact, in all cases friction should be done during the process of the bath. Gradually the temperature of the bath may be reduced to 70° or 00° F. Patients who react w^ell, and who can practice friction on themselves, a cold plunge on rising, lasting from one to two minutes, followed by a brisk rubbing with a coarse bath towel, will be grateful and highly beneficial, producing a degree of exhilaration that can be obtained from no other procedure. Some patients prefer to take a cold sponge to the waist, others a shower bath or a needle bath, instead of the plunge. The cold plunges or shower baths which are taken for their tonic effect do not take the place of the hot baths, which are taken to cleanse the skin of its im- purities, and are demanded at least once a week. SYMPTOMATIC TREATMENT Debility and Loss of Appetite and Weight. — Second only to fever, in the earlier manifestations of tuberculosis, stand debility, loss of appetite and weight. These latter appear early in the course of the disease, frequently before the development of fever or sufficient physical signs to enable us in many cases to make a diagnosis, or in some cases even to suspect it. In other words, these symptoms are characteristic of so many conditions; they are due sometimes to overwork, improper food, distress and anxiety of mind, poor hygienic surroundings. In such cases tuberculosis is frequently little thought of by the doctor, and even less so by the patient and his friends, and yet the name consumption comes from these important symptoms which are present in varying degrees throughout the course of the disease. The main lesson which the physician should gain from this is to go more thoroughly into the history, symptoms, and physical signs of the case; in this way an error of diagnosis may be avoided and the patient's chances of recovery are greatly increased. It is better to go to great lengths of trouble to no purpose than to neglect needful details of technic and later reap a harvest of barren regrets. It is not meant to be implied in this that an early diagnosis can always be made; it is only to put the physician on his guard and remind him of what he already knows — that it is never wise, or safe, or just, either to himself or his patient, to outline a treatment based simply SYMPTOMATIC TREATMENT 619 on tlie feel of the pnlse, appearance of tlie tongue, and loss of flesh. Tonics and general directions do sometimes (for we have not yet, un- fortunately, a specific for tuberculosis) bring about a restoration to the normal; but a large percentage of these patients will come back sooner or later with more prominent s^miptoms, when the real cause of the trouble will be made manifest. With tlie diagnosis not in question, the symptoms of debility and loss of weight demand intelligent treatment, more tlian all others, taking the disease from its beginning to its end. As has been stated, patients do not gain in weight and strength when the tuberculous process is advancing and vice versa. Even under careful treatment, this, in the main, is true. The question of nourishment, then, is of the greatest importance, and what has been said of diet and hygiene will necessarily have to find some repetition and added emphasis here. It is doubtful whether any considerable loss of weight and bodily vigor, in the absence of apprecialde digestive disturbance, and frequently when it is present, often occurs without an impaired desire for food. Naturally, when the ingestion of food is not sufficient to make good the bodily wastes, whether from inability to obtain food either in sufficient quantity or proper quality, or from lack of desire in consequence of disease, the weight and bodily strength will wane. In tuberculosis these may be corrected by overcoming any digestive disturbance by forced feeding with wholesome food, and by tonics which stimulate the appe- tite, and thereby develop a craving for food. Tlie condition may also be alleviated by the administration of remedies which look to more active blood building and imjn-oving the nervous tone. If the patient has a coated tongue and a disturbed digestion, the first indication will be the relief of these. In the earlier stages of the disease this is not difficult. This having been accomplished, the quantity and quality of the food must receive consideration, and, as has been pointed out, these patients cannot only take, but often digest, a larger quantity of food than would be desired or could be cared for by an individual in health. Other points in this condition to be borne in mind are that these patients, even when fever is present, can take a greater quantity of solid food and demand a larger percentage of fats than in any other disease. For these reasons the feeding requires to be more intelligently and firmly directed. The variety and preparation of food accomplish much, and to tliis, no doubt, is due much of the success which follows the treatment of those patients wlio have been pinched by poverty, and to whom such food is not only a novelty, but a luxury. It holds good, too, even with patients in easy circumstances who have paid too little heed to these essentials. Aside from tliese, tlie moral influence of the 620 HOME TREATMENT BY SANATORIUM METHODS physician must be brought into play to teach these patients to take more food than they actually crave. In severe cases, liquid food, such as milk, broth, and eggs, will have to be employed, because they can be swallowed without mastication; but it has been found that a larger percentage of patients do best on solid food. When this cannot or will not be taken, in aggravated cases, resort to the stomach-tube may be necessary, but this is infrequent. Again, when much gastric disturbance is present, and no effort of will on the part of the patient will enable him either to take food or to retain it when introduced by the stomach-tube, or when the larynx is so affected that the swallowing of food or of a stomach-tube is distress- ing, and therefore impracticaljle, resort may be had to rectal feeding. Finally, some degree of nourislunent may be obtained by inunction of the body with olive oil or cocoa butter. Some or all of these procedures may be necessary in appropriate cases. Concerning tlie proteid foods, repetition will not be made here, but, in the matter of fats, the administration of butter and cream and oils is again emphasized. These are not only valuable as foods, but serve to keep the bowels open. Cod-liver oil has long been employed in the treatment of tuberculosis, formerly with the idea that it had a specific effect on the disease (and it may be that the small amount of iodin wbich it contains has some effect), but now it is regarded chiefly as a food. It was formerly given in too large doses, and was often nauseous from the impure quality of the oil. This is largely corrected now, so that a comparatively pure and relatively tasteless oil may readily be obtained. The oil is best admin- istered plain, as every emulsion and other combination is, in effect, a compromise with the patient. A little practice will make the patient not only take the oil plain, but like it. When this is not the case, a little whisky in the bottom of the glass, then the oil, and a little whisky on top, or sherry wine instead of the whisky, will readily disguise its taste. If these fail, an emulsion may be taken, or the oil may be combined with malt extract. It should be borne in mind, however, that the best of these preparations do not contain more than thirty to forty per cent of oil. When the oil is not borne well, the dose should be reduced to ten or fifteen drops at a time. Olive oil is being much used now. It is not so nauseous as cod-liver oil, is better borne by the stomach, and exercises a wholesome effect on the digestive tract. Much of the so-called olive oil of the trade is cotton- seed oil. Wliile not so palatable as olive oil, its nutritive value is high. Anemia. — The blood should be examined not only to determine the percentage of hemoglobin, actual as well as relative, but also the number of red blood-corpuscles. Additional information, the exact value of SYMPTOMATIC TREATMENT 621 which is as yet indeterminate, may be obtained from the opsonic index, which at the present time seems to promise much. Impoverishment of the blood is usually coincident in tuberculosis with asthenia, loss of appetite, and the other symptoms of debility already mentioned. In addition to proper nourishment and fresh air, it has been gener- ally found necessary to administer remedies to counteract these losses. To this end, ii-on in some form is indicated. While many of the newer preparations of iron have been employed during the past generation, the trend of unbiased clinical experience is gradually leading us back to the older officinal preparations, whose value has been established by time and experience — viz., the tincture of the chlorid of iron and car- bonate of iron, as contained in Blaud's pills, and the sirup of the iodid of iron. The main point to be boiae in mind in the administration of these and other salts of iron is not to give too much, as it then bur- dens the alimentary tract and causes headache and other disagreeable symptoms. Next to iron, the reconstructive agent which has for years been valued highly, and which still holds its place, is arsenic. This may be adminis- tered in the form of arsenious acid — dose for an adult, -^-q grain three times daily — or Fowler's solution, beginning with three drops and in- creasing up to eight drops. Other preparations of arsenic ma}^ be em- ployed which meet the approval of the clinician and the demands of the case. Arsenic is apt to produce gastric disturbances and puffing of the cellular tissues beneath the eyes. When these occur the dose must be reduced. To counteract the debility and improve the nervous tone, no drug takes the place of stryclmin. The preparation, usually employed for this purpose is the sulphate. It may be given in doses ranging from ■To to "sV grain three times daily, or it may be desirable to give it in the form of tincture of nux vomica, from which we get not only the tonic effect of the drug, but its action as a stomachic as well; of this 10 to 15 drops may be given three times daily. When excessive nervousness, muscular tremor, twitching, and high arterial tension are produced, the dose should be reduced or the drug withheld for a time. Any of the above-mentioned drugs may be given separately or in combination. In appropriate cases the hypophosphites will also prove of value. These are commonly administered in the form of compound sirup of hypophosphites (U. S. Phar.) or the more recent glycerophos- phates, which are prepared with and without sugar. The doses of these range from one to two teaspoonfuls three times daily. The clearer our insight into diseased processes becomes the more we find it desirable to confine ourselves to single drugs or simple com- binations which meet the particular indication rather than to adminis- 622 HOME TREATMENT BY SAxNATORIUM METHODS ter a combination of drugs, many of which add an additional ]f)ad to the already overburdened system of the patient. Fever. — Fever is an early, prominent, and frequently distressing symptom of tuberculosis. For a time it was thought that the pyrexia was produced by the presence of other organisms (e. g., streptococci, staphylococci, etc.), as these are commonly found associated with the tubercle bacillus; but judging from clinical experience and from the results of administration of tuberculin, we are justified in stating posi- tively that the toxins produced by the tubercle bacillus do produce fever without the presence of other organisms. For the prevention of fever, or to diminish it when present, our remedial agents may be classified under three subdivisions, viz.: (1) rest and food, (2) hydrotherapy. (3) medicines. It has been proved that exercise of body or mind elevates the tem- perature in tuberculosis. A walk beyond the endurance of the patient, a ride taxing his strength, or any undue physical exercise, has caused a rise of temperature of one or more degrees. On the other hand, dis- tressing news or too much excitement produce the same effect. An im- proper quality or quantity of food produce a like result, and Cornet lays special emphasis on the fact that, with other elements of error thrown out, the patient's temperature tends to decline the nearer you can bring him to a solid diet. When the patient's temperature is elevated, it is essential to give liini all the bodily and mental rest necessary. If this means keeping him constantly in bed, let it be so. This does not imply, however, that fresh air must be kept from him ; quite the contrary If, from the nature of his surroundings, the patient must keep to his bed, free ven- tilation of the apartment must be maintained. Change of environment seems to be beneficial and desired by all the animal kingdom, and counts even in matters of small detail. Hence, when possible in these cases, it is effective physically, if no other way, to change the patient from his sleeping bed to a couch or easy chair, from his room to a veranda or lawn, such change being accomplished without exertion or thought on the part of the patient. No one can be shielded from all trouble in this world, still such as may should be kept from the patient and he should not be allowed to receive visitors who tax his energies or who are injudicious in their conversation. It may be stated, generally, that patients whose temperature ranges over 99.5° F. should not only abstain from exercise, but should be confined to Ijed or to an easy chair until the temperature shall have remained normal for several days. The elTectiveness of rest is seen in the improvement which comes from the immobilizing of a tuberculous joint, the checking of the tuber- culous lung process by the development of a pleurisy, etc. SYMPTOMATIC TREATMENT 623 WJien the temperature is not controlled by these procedures, or even along with them, hydrotherapy may be employed. The temperature usually rises in the afternoon, except in advanced cases, when it may remain elevated more or less all day ; occasionally a reversal of the afternoon rise may occur. When the temperature rises it may be re- duced by a hot mustard jo(jt hath — two heaping tablespoonfuls of mus- tard in a foot tub two thirds full of water of a temperature as hot as can be borne comfortably. The feet should be allowed to remain in this until they tingle; the knees are covered with a blanket. Following this, the temperature will often drop, the pulse become quiet, headache (if present) will disappear, and the patient lapse into a tranquil, refresh- ing sleep. If the foot bath fails to reduce the temperature, resort to sponging may be had ; this may be general or include only portions of the body — e. g., the arms, legs, or head. Water of the ordinary temperature is commonly employed, though in cases of high fever ice may be added, or in the debilitated and where the temperature is low the water may be tepid. In the former the effect may be increased by the addition of alcohol or vinegar to the water, in the proportion of 1 part of alcohol or vinegar to 3 or 4 parts of water. Both increase the rapidity of evapo- ration, and not only remove the excess of heat, but are especially grate- ful to the patient. In some cases a general hath may be indicated, and in still others the application of an ice-cap. The employment of drugs to reduce the temperature is to be depre- cated, and is only to be resorted to when all other measures fail and the temporary condition of the patient seems to demand it; for it must be borne in mind that most drugs used for this purpose are muscle paralyzers and are effective by depressing the heart. The safest of all drugs is quinin, but it does not belong to the class mentioned. It will sometimes prove efficient, but its antipyretic effect is so slight that it will usually be found to avail little. Of all the coal- tar derivatives, I prefer phenacetin, as I believe it to be the safest. When given in the proportion of phenacetin, 5 grains, citrate of caffein, 1 grain, and camphor monobromate, ^ grain, and not repeated within three hours, I have never observed any unpleasant result. Some authori- ties give antipyrin, 5 to 10 grains, and Koch believes that pyramidon, not exceeding 30 grains in twenty-four hours, is more beneficial and less depressing than any of the class. Acetanilid I have found to be a dan- gerous drug, and I do not prescribe it. Aconite and veratrum viride act on the circulation and likewise depress the temperature. They may be employed in cases with high arterial tension. It is to be constantly borne in mind that in the employment of any 624 HOME TREATMENT BY SANATORIUM METHODS of these antipyretic drugs we are compromising both with the patient and the disease. They add to the immediate and temporary comfort of the patient, but no one claims that they exert any specific effect whatever on the disease. They should, therefore, be employed only at intervals and when all other measures fail. Cough. — It is essential to understand the physiologic nature of cough in order to treat it. In the absence of some abnormal stimulus, cough does not occur. In its last analysis, cough is nature's effort to free the bronchial tract from some offending stimulus. Just as stimu- lation of the olfactory ending in the nasal mucosa by means of a feather or by the edematous pressure produced by a " cold " will pro- duce a sneeze, so the stimulation of the laryngeal tract or bronchial mucosa, mechanically or by congestion, will produce a cough. In both instances the process is purposeful. It is an effort to free these pas- sages so that the normal respiratory movements may not be impeded. Again, while coughing has for its immediate object the clearing of the respiratory passages, it is ultimately for the benefit of the body as a whole. Coughing ma}'^ likewise occur from other reflex stimuli. A cough results from a mechanical stimulation of an area in the external audi- tory canal, and similarly the stimulation of the terminal filaments of the vagus nerve in the gastric mucosa may produce a cough, the so- called " stomach cough." Highly nervous patients, even in the absence of all objective causes, will have a dry, hacking cough, which, for the want of a better name, has been styled a nervous cough. Just what produces the peculiar cough characteristic of pertussis we cannot at the present time say; but all of these facts, physiologic and pathologic, teach us that we must, in all cases, endeavor to determine the cause of the cough before we attempt to abate it. In the course of chronic pulmonary tuberculosis, a certain amount and kind of coughing is not only not injurious, but positively beneficial. When the cough is productive, bringing up, as it often does, quantities of sputum, and when it is not too frequent, it is beneficial in freeing the bronchial tubes of the obstructing mucus and detritus. This is especially true when bronchiectasis is present. A mistake not infre- quently made in tuberculosis is to treat the cough rather than the dis- ease. An extreme, it seems, has been reached in the more or less gen- eral proscription of cough remedies which contain sugar. Opiates and expectorants are at times demanded, and I fail to see why we should not be allowed to make these palatable by the use of sugar. If sugar must be eliminated because it upsets the digestion, take the sirup from the griddle cakes when you take it from the cough mixture. The writer believes that in a majority of instances it is the expectorant drugs, rather SYMPTOMATIC TREATMENT 625 than the sugar, that derange the digestion; however, there are cases from which sugar should he withdrawn. In the control of the cough the essential thing is the determination of its cause. If produced by a disordered stomach, attention to the digestion is necessary. An inspection of the external auditory canal is never out of place, though cough produced by a trouble there is exceed- ingly rare. A very common cause of cough is found in catarrhal and other inflammations of the pharynx and larynx. Such a cough is little influenced by cough remedies unless they contain enough opiate to ob- tund the sensibilities of the patient. To relieve this cough, treatment of the local condition is essential. (Treatment of laryngeal tuberculosis is purposely omitted here.) In catarrhal inflammations of the pharynx and larynx, excellent re- sults have been obtained by jjainting the affected j^arts once daily with the following: ]^ Potassii iodidi gr. x; 0.66 gm. Tr. iodini, ") _ _ . , .^ . . M-aa .^ss; 16.00 " Glycerm:, J M. Sig. : Apply to throat as directed. This may be augmented by spraying the throat, p. r. n., with ^ Mentholi gr. xx ; 1.30 gm. Camphor* gr. v ; 0.33 " Eucalyptoli gtt. iv ; 0.26 " Ac. carbolic! gtt. vj ; 0.40 " Liquid albolene or (glymol) §ij ; 60.00 '' M. Sig. : Use in atomizer. When a more germicidal and a stringent effect is desired, some of the silver salts may be employed — e. g., one per cent silver nitrate or five to ten per cent argyrol, applied with a cotton applicator once daily. The additional employment of a spray of Dobell's solution, or some such alkaline antiseptic preparation, f. r. n., will often prove of service. Xaturally, tumors or ulcers on the larynx or epiglottis will require treatment, but these produce a cough that is more or less characteristic. Leaving out of consideration these extrabronchial factors, we come to the treatment of the cough which commonly forms a part of the history of pulmonary tuberculosis. In the first place, coughing gets to be more or less a matter of habit and is, more than would generally be believed, under control of the will. This is amply demonstrated in all well-conducted sanatoria where, considering the large number of pa- tients in varying stages of the disease, the amount of coughing is exceed- 626 HOME TREATMENT BY SANATORIUM METHODS ingly small. Patients may be educated to suppress the cough when it is not productive. As a routine measure, patients of all kinds, both in and outside of sanatoria, should be taught to favor the cough when material may be raised, to repress it as far as possible when the cough accomplishes nothing. It is surprising how much the cough may be repressed in this way. By avoiding excessive exercise in which respira- tion is carried on through the mouth, thereby causing undue dryness of the throat, the cough may be lessened. Some patients must be con- fined to bed so as to avoid all muscular activity. In like manner, by lessening or leaving off the use of tobacco (espe- cially cigarettes, which are almost universally inhaled) and avoiding alcoholic excesses, the cough resulting from local congestion produced by these habits will be relieved without the use of medicine. In certain coughs which are more or less irritative, and in which the patient's rest is much disturbed, in addition to the local applica- tions mentioned, I have obtained very gratifying results from the use of an inhaler which covers the mouth and nose. (For ordinary use the Beverly Robinson inhaler, a perforated zinc mask which covers the mouth and nose, in the end of which is a sponge, and which is held in place by elastic strings going round the ears, is commonly employed.) The following prescription has given much relief: ^ Mentholi gr. x ; 0.G6 gm. Alcoholi, \ Creosoti, I aa oijss ; 10.00 " Chloroformi, ) M. Sig. : Put a few drops on the inhaler and use for fifteen minutes, p. r. n. The writer has found this to act well in cases where there is a tend- ency to hemorrhage. The chloroform lessens the local sensibility, and in diminishing the expulsive efforts of the cough it lessens the tendency to hemorrhage. Tiie ])aticnt must be removed from dust-laden atmos- pheres, those containing irritating gases, and from regions where high winds prevail. In a large percentage of cases many patients will not require internal remedies for the cough, or if so, a glass of hot milk on retiring will suffice. On rising, or immediately after breakfast, coughing paroxysms are frequent. This cough should not be checked, as it serves to remove the secretions which accumulated in the bronchial tubes during sleep; after this the patient ordinarily coughs little, or at infrequent intervals throughout the day. Sometimes the morning cough is sufficient to produce emesis. The emesis is caused by me- chanical stimulation of the pharynx by the mucopurulent secretion SYMPTOMATIC TREATMENT 627 brouglit up, so that wlieri the cougli lias sul>sided food should again be taken. Remedies should be administered for the relief of the cough (1) when it is so incessant and rasping as to disturb the rest of the patient or exhaust his strength, (8) when the cough is tight and the frequent expulsive efforts cannot remove the secretion from the tubes, and (3) when the secretion is excessive and coughing is necessar}^ to free the tubes in order that the respiratory movements may go on properly. In tlie first variety the cough is due to a dryness of the throat, trachea, or large bronchi, especially the throat. In this variety the sprays and the inhalations mentioned are of service, or some form of lozenge, or swallowing a bit of vaselin may prove efficacious. Occa- sionally an anodyne has to be used. For this purpose, heroin, -^^ to yV grain, at bedtime, or repeated two or three times during the day, will prove quite as effective as many of the more complicated cough mixtures. When the cough is tight and frequent, from inability to raise the expectoration, two demands are to be met on prescribing a cough mix- ture: first, an opiate to diminish the frequency of the cough, and sec- ond an expectorant to loosen the secretion. The vehicle is more or less neutral, so far as its effect is concerned, and there is a tendency to eliminate sugar from it. If sugar or sirup makes the dose more pala- table, there is no reason why it should be prohibited, unless it is neces- sary to eliminate sugar from the dietary. The following prescriptions are of service in this variety of cough : ^ Ammonii muriatis oiv; 16.00 gm. Codeinae sulphatis gr. ij-iv; 0.13-0.26 " Mist, glycyrrhizae comp 3iv; 120.00 " M. Sig. : Take in water every three or four hours. I^ Spiritus amnion, aromatici. qSs; 16.00 gm. Spiritus clilorofprmi gtt. xlviij-xcvj ; 3.16-6.32 " Heroin gi"- j ; 0.06 " Aquae menth. pip 5iij ; 90.00 " M. Sig. : Take in water every three hours. 1^ Morphinae sulphatis gr. j-ij ; 0.06-0.13 gm. Chloroformi gtt. Ixiv; 7.60 " Aqua; camphorae or menth. pip.. 3^^'j 120.00 " M. Sig.: One teaspoonful in water every three or four hours. !^ Heroin gr. j-ij : 0.06-0.13 gm. Spiritus amnion, aromat ,">iv; 16.00 " Aqua" ^iij ; !MKOO " M. Sig. : One teaspoonful in water every three or four hours. 628 HOME TREATMENT BY SANATORIUM METHODS When the secretion is excessive, an opiate, combined with some agent to diminish the secretion, is indicated — e. g., terpin liydrate, creo- sote, etc. Heroin with terpin hydrate and codein and creosote, in ac- ceptable vehicles, or in pill form, will yield good results in coughs when the expectoration is profuse. Atropin diminishes all glandular secre- tion, and for that reason would seem to be applicable here, but in less- ening the bronchial secretion it also diminishes the secretion of the glands of the pharynx and larynx and trachea. It produces a dryness that may intensify the cough, so that it must be used guardedly. Night Sweats. — Night sweats occur with varying degrees of inten- sity throughout tlie course of tuberculosis in a large percentage of cases. In some cases they are absent throughout; in others they are slight, transitory, or limited to certain areas of the body; in still others they are excessive, being sufficient to drench the bedclothing and mattress, as well as the clothing of the patient. They occur most frequently at night, hence the name, but may appear at any hour during the day or night. In the milder cases only one severe sweating period occurs; this usually follows the evening rise of temperature and when the first deep sleep takes place. It may occur several times, so that it thoroughly exhausts the patient, becoming a veritable nightmare to him, and in the morning he arises weakened and dejected. In endeavoring to relieve the condition, the cause producing it must be understood. It should be borne in mind that it is a toxemia — a septic process depending on the absorption of toxins into the blood. These toxins result from the life processes of the tubercle bacillus (?), streptococcus, staphylococcus, and perhaps other organisms; in brief, it is a septicemia. Therefore, it is irrational to treat the sweat. What should be attempted is to try to eliminate the cause of the sweat. In this it is not intended that we should not regard the comfort of the patient and alleviate the condition as far as possible, any more than we would refuse to give an anodyne to relieve the excruciating pain of renal colic on the plea that it is not the pain but the stone that we are after. From abundant experience, both in private and sanatorium practice, it has been demonstrated that the night sweats will cease in a large percentage of cases by confining the patient absolutely to bed, properly feeding him and giving him the benefit of an abundance of fresh air. These measures, combined with such tonic remedial agents as the indi- vidual case requires, Avill, except in advanced cases, in a comparatively short time bring relief. Until this takes place, and in advanced cases from which nothing may be expected, the sweating must be treated, diminishing it as much as possible and contributing everything to the comfort of the patient. In general and whenever the means of SYMPTOMATIC TREATMENT 629 the patient permit, the clothing of the patient should be removed as soon as it becomes wet, and his body sponged with alcohol and water, or vinegar and water, keeping up a brisk rubbing all the while. Fresh clothing and bedclothes should be provided. Most of the remedies employed to prevent or diminish the sweat act by controlling the sjnnptom and exert no effect on the causative process. At the same time, these remedies are neither to be condemned nor despised if the}^ contribute to the patient's comfort until the defensive forces of the body are reenforced to the point of defeating the infecting agents. Atropin, in doses of from g-^ to y^^j grain, is the remedy com- monly employed for this purpose, and the one which, on the whole, yields the best results. This may be repeated two or three times in the twenty- four hours, if necessary. Aromatic sulphuric acid, gtt. 10, in Avater three times daily, and agaricin, -^ grain, are similarly used. They may be employed singly or in combination. All are symptomatic remedies, and their administration should be stopped as soon as the distressing S}Tnptom abates. Gastro-intestinal Disturbances. — Derangements of digestion are a common accompaniment of tuberculosis, and present one of the great- est difficulties in its treatment. Where the digestion is normal, forced feeding is a comparatively easy matter, and where superalimentation and fresh air are possible, the disease is not apt to progress. Unfor- tunately, the alimentary tract is not always equal to the additional demand and catarrh of the stomach and intestines is relatively com- mon, so that when patients cooperate with the physician and take an excess of food, they are unable to digest it, and it acts as a burden rather than a benefit. In a majority of cases, however, the patient suffers, not because he cannot digest the food, but because his appetite is impaired and he cannot be induced to take it. For this reason, foods which can be swallowed easily and digested readily are usually recommended, such as milk, variously modified, eggs, animal broths, altliough experience teaches that those patients do best who can take a solid mixed diet. The digestive disturbances that follow in the wake of tuberculosis do not differ essentially from those which characterize other diseased processes, so that the problems to be solved are similar, except in the case of tuberculous enteritis. When the appetite fails the digestive stimulants already considered are to be administered. Again, a test meal and examination of the stomach contents will reveal what digestive elements are lacking in this as in any other gastric disorders. When it has been shown that a particu- lar element of the gastric juice is lacking, a restriction of the food, with reference to this, and the supplying of the lacking ingredients should 630 HOME TREATMENT BY SANATORIUM METHODS be attempted. The j^oint to be empliasizecl is that there is no reason why our therapeutics should differ when gastric disturbances are present in tuberculosis. Creosote has for a long time been regarded as a remedy for tuber- culosis, but as our experience accumulates we are forced to the con- clusion that its beneficial effects come from improvement of the diges- tion rather than from any specific action on the disease. It has been proved, it is true, that the bacilli can be killed by a sufficient amount of creosote, but clinical experience has also shown that a sufficient amount of it cannot be gotten into the circulation to produce any specific effect without deranging the digestion. In proper dosage, how- ever, it produces valuable digestive effects; it causes the dry and glazed tongue to become moist ; the appetite improves ; the fermentation is lessened. The same holds true in intestinal indigestion. Pure beech- wood creosote (gtt. 1-5) is employed, administered either in wine, milk, or capsule, or, what is thought to be less irritating to the stomach, car- bonate of guaiacol (5 to 10 grains) or creosotal (5 to 10 grains) may be substituted. When constipation is present laxatives should be emplo3'ed, as the comfort of the patient is thereby increased and his nutrition improved. No remedy has been found to supplant sulphate of magnesia or an occa- sional dose of castor oil. At least one good movement daily should be the rule. When diarrhea is present, its cause should be ascertained if possible; frequently an improved action on the part of the liver will be demanded, and a purge with castor oil or salts will bring about a return to the normal. This, and a proper regulation of the diet, are in most cases all that is necessary. In others, however, the admin- istration of bismuth or tanalbin and opium will be demanded. Wlien fermentation is excessive and undigested food is passing in the stools, aside from the regulation of the food it will be found necessary to give pancreatin (5 grains) with some agent which prevents fermentation, such as salol (5 grains) or guaiacol (5 grains), asafetida (5 grains), which last acts not only in this direction, but also serves as a sedative to the nervous system. I^ Extr. pancreatis, ") _. Sodii benzoatis, j ' ' ^^ ' '=' Asafetida oss ; 2 " M. Ft. in caps. ad. Xo. XII. Sig. : One capsule three times daily. These and other agents which will appeal to the individual prac- titioner may be employed with or without the addition of opium. Charcoal, by its mechanical action in absorbing many times its volume of gas, is highly recommended by some. When tlie accumulation of SYMPTOMATIC TREATMENT 631 gas is great, it produces much l)0(lily discomfort and mental distress, not only by its mechanical pressure on the heart and lungs, but by its absorption. In this condition a brisk cathartic is indicated and im- mediate relief may be obtained by an asafetida enema of tincture of asafetida, and warm water. The eifect of this is enhanced by giv- ing it through a rectal tube, and after its use, if the gaseous disten- tion still is great, the rectal tube may be inserted and left in place for several hours. Of course this effect is only temporary, but it at times means mucli to the patient's bodily comfort and relieves his mind. Hemorrhage. — Of all tlie symptoms of tuberculosis, hemorrhage is, perhaps, the most alarming to the patient and his friends. The abject terror and demoralization on the part of the patient is due to the fact that it is not infrequently tlie first flat argument that he has tubercu- losis, and, again, the source of the hemorrhage makes it plain to the average patient that not only he, but his physician, are, in a sense, at its mercy. Fortunately, no incipient and few advanced cases of tuber- culosis die from the immediate effects of hemorrhage. Before cavity formation the hemorrhage is bronchial. After this it comes from the erosion of a blood-vessel or the bursting of an aneurysm ; the result will depend on the size of the vessel that ruptures. Considering the preva- lence of tuberculosis and its destructive process in the lungs, it is singu- lar that so few patients die from hemorrhage. In rare cases, with enor- mous cavities, patients have been known to bleed to death with little or no blood appearing in the expectoration. In cases of pulmonary hemorrhage my practice is uniform, and no information which our present methods of physical examination give is suflficient to make me change it, for the very good reason that we have no means of telling, aside from the amount of blood that comes up, the size of the vessel that has ruptured. I have seen a patient who had a cavity apparently no larger than a walnut practically ex- sanguinated by the excessive loss of blood. On the other hand, in cases with enormous cavities, the hemorrhage is oftentimes small. There is, then, no infallible index, and when the hemorrhage is taking place, even the sojirce is immaterial, for whatever its source, outside of strapping the chest to restrict its movements the indications for treatment are the same. These consist of the following: Absolute rest in bed, with the body elevated by pillows so as to let gravity act as little as possible. The patient should make no active exertion whatever. If tlie hemor- rhage is excessive the blood should be caught by an attendant, who holds a basin under the chin of the ])atient. After this, when the hemorrhage is less active, the blood should be caught in a cloth, but the patient should not have to do this for himself. His position in bed 632 HOME TREATMENT BY SANATORIUM METHODS should be changed as little as possible, and he, of course, should not be allowed to talk or rise from his bed, even to attend to the wants of nature. It is a safe plan to keep all patients in bed for at least three days after the hemorrhage, and even then exercise should be resumed very gradually. Aside from the imposition of absolute and immediate rest, the first indication on the appearance of a hemorrhage is a hypodermic injection of morphin. I usually give \ grain, as I believe that ordinarily less does not accomplish the purpose. In those cases in which this amount causes the blood accumulation to strangle the patient, as is claimed by some, I believe that, if left to flow freely, it will more quickly exsan- guinate him. In other words, I believe that our only hope in pulmo- nary hemorrhage is the clotting of the blood so as to heal up the broken vessel by pressure. Morphin effects this ])y quieting the respiratory movements, checking the cough and obtunding the sensibilities of the patient. It is perfectly legitimate to argue that the hemorrhage may be of such a degree as to drown the patient in his own blood if it is pent up in the lungs; on the other hand, it seems to me to be equally true, in the first place, that a hypodermic of morphin wliich does not put the patient into a stupor is not going to accomplish this, and in the second place, if the flow is not checked by a certain amount of reten- tion of blood, the patient will surely bleed to death. The morphin also steadies and acts as a tonic to the heart. It goes without saying that the dose of mor])liin must be regulated by the age, size, physical condi- tion and idiosyncrasies of the patient. It should he repeated sufficiently often to control his cough and nervous perturbation. After the immediate demands are met, the same effects may be obtained by the administration of appropriate doses of heroin, codein, or morphin by the mouth. However, it is preferable to abstain from any medication that is apt to upset the stomach, as emesis would tend to increase or renew the hemorrhage. It is well also not to attempt to give any solid food for twenty-four hours. If the hemorrhage has been severe, an enema of salt solution or a hypodermoclysis will produce a more immediate effect than food introduced, often through protest and with difficulty into the stomach. There can, of course, be no objection to giving egg albumen in the water that is often craved in large quantities. Milk may be given in place of water. It is common for patients having a hemorrhage, from such information as they may have, or on the advice of solicitous friends, to eat salt. It serves to occupy the attention of the patient, but its effect on the hemorrhage is infinitesimal, while by deranging the stomach it may cause vomiting, which, as has already been stated, is bad. From its effect in uterine hemorrhage ergot has been employed as SYMPTOMATIC TREATMENT * 633 a routine practice in pulmonary hemorrhage. Confidence in it, with added experience, is wavering. I have never seen it accomplish any good whatever in pulmonary hemorrhage, and, indeed, some observers claim that it does harm. What applies to ergot applies with equal force to its preparations, ergotin and ergotole. It is probably also true that tannic and gallic acid not only fail to do good, but serve to derange the stomach. From a scientific standpoint calcium chlorid, by increasing the coag- ulative power of the blood, would seem a rational remedy to use. It may be given in doses of 5 to 15 grains, three or four times a day. It should be used more generally and its effects more carefully noted. Gelatin has been employed in somewhat the same way in an effort to increase the coagulability of the blood. From a purely empyric standpoint, perhaps, some of the prepara- tions of the suprarenal body are being used as remedies in pulmonary hemorrhage. For the past four or five years I have employed them, along with opium, in all my cases of pulmonary hemorrhage. It may be difficult to explain from a physiologic standpoint just how it may be expected to control hemorrhage from the pulmonary vessels. In the absence of a satisfactory explanation, my experience still leads me to rel}' on it in this condition. I usually employ 5 drops of adrenalin chlorid, or 3 grains of the suprarenal extract, every three or four hours, while the hemorrhage persists or the sputum is bloody. So far as we know, adrenalin inhibits hemorrhage by vasoconstric- tion. It is proved that it increases vascular tension by its vasocon- striction effect. If w« had only this evidence we would not use it even in epistaxis, as by increasing the pressure in the blood-vessels it gives additional power to wash away any clots that might form to seal up the vessels. Clinically, however, we know that it is the most reliable medicinal agent we possess for checking hemorrhage, with the possible exception of the perchlorid of iron, and this is rarely, if ever, employed because of its disagreeal^le local eil'ect. If the extract of tiie suprarenal gland controls hemorrhage that is accessible, it may have tlie same effect also on tliat which is not. In any event, it is recommended in cases of hemorrliage in typhoid and in uterine hemorrhage, and I see no reason why, if it acts well in these cases, it should not also be efficient in pulmonary hemorrhage. From a physiologic standpoint, the nitrites have a diametrically opposite action, producing vasodilation. They diminish intra-arterial tension. This produces less pressure on the break in the vascular mechanism and allows the coagulum more quickly to close the opening. This has led to the use of nitrite of amyl, which, because of its dif- fusibility, is usually dispensed in glass globules, one of which may be 634 HOME TREATMENT BY SANATORIUM METHODS broken in a handkerchief and inhaled as occasion demands. More com- monly nitroglycerin is used^ either hypodermically when the hemor- rhage is taking place, or by mouth to prevent its recurrence. The dose ranges from y^ to -g\ grain, repeated as occasion demands. When un- due flushing of the face and headache result, it is the signal that the dose should be diminished or the drug withheld. N. A. Johnson and R. H. Babcock recommend hypodermics of atropin immediately on the appear- ance of the hemorrhage, in doses of -jV to -g^ grain. When the intravascular pressure is great, the pulse rapid and Ijound- ing, and a marked accentuation of the second heart sound exists, nitro- glycerin may be employed. Flick believes that it not only diminishes hemorrhage, but that it prevents the development of hemorrhage. In extreme conditions j^o grain every two hours may be given. Nitro- glycerin possesses two advantages that should be considered. It lowers arterial tension and increases the secretion of urine. Sodium nitrite (3 to 5 grains) three or four times a day may be substituted for nitro- glycerin, and is said to have a more permanent effect. The vascular system may be depleted by the exliibition of salts. Their employment, is indicated for the same reason as are the nitrites, but their action is not so immediate and the additional drawback to their use is found in the exertion which active purgation enforces on the patient. While salts may be rationally employed after the hemorrhage has abated, I rarely prescribe them inside of twenty-four hours of an active hemorrhage. I speak lastly of the application of the ice-bag, because, as already mentioned, the source of the hemorrhage is not always accurately known, and while the hemorrhage is taking place it is unwise to try to find it; and to be more than generous in our estimate, it is of questionable value. It quiets the tumultuous activity of the heart, and in so far may do good, but I do not believe that it has any effect on the bleeding vessels. If it is of such questionable benefit, and the same results may be ob- tained by other more promising measures, I see no good reason for its employment. When the hemorrhage is excessive the emergency may be tided over, and the patient's life sometimes saved by keeping the blood in the extremities by means of a constricting band of rubber tubing or other form of tourniquet; these should be released successively so as to let the blood into the general circulation and to avoid the formation of clot and subso(|uoiit gangrene of the extremities. In extreme cases the elevation of the foot of tlie bed and hypodermoclysis may be necessary. Cardiac Weakness and Dyspnea. — The destructive metamorphosis which is general tiiroughout tlie nnisculature of the body is also present in the heart; tlie heart muscle gets weak and flal)by and dyspnea be- COMPLICATIONS 635 comes a distressing s3'mptom. In addition to the general and cardiac muscular weakness in producing dyspnea, we must also consider the effect produced by the destruction of lung tissue and the toxic effect of the poisons absorbed. The last is well illustrated in the dyspnea that accompanies excessively high fever. In combating the condition which is at times most distressing, one should look to two ends, viz. : the general treatment of the underlying condition which is producing the trouble, and the immediate alleviation of the urgent symptoms. Gradu- ated massage and exercise, an abundance of food and fresh air will, by improving the general condition, alleviate some cases, but the ma- jority of cases require absolute rest in bed. In this condition strychnin is almost always indicated, and it may be given in larger doses than are ordinarily employed. Tincture of digitalis (gtt. 15) three times daily or every four hours is a remedy of the greatest value. Alcohol in generous quantities should be admin- istered. The rapidly diffusible stimulants, such as aromatic spirits of ammonia, Hoffman's anodyne, or a solution of camphor in oil, either by mouth or hypodermically, may be employed in appropriate cases. In some cases the inhalation of oxygen gas will give the greatest temporar}'^ relief. Finally, when the dyspnea is excessive and the dis- tress of the patient great, the effect of the hypodermic injection of ^ grain of morphin is almost magical. Considering the amount of lung tis- sue destroyed and the toxic processes at work, it is singular that we do not have this distressing symptom oftener. COMPLICATIONS The more common complications of tuberculosis are pneumonia, in- somnia, pain, pleurisy, both with and without effusion, empyema, pneu- mothorax, jiityriasis versicolor, ischiorectal abscess, and fistula in ano. The treatment of pneumonia complicating tuberculosis does not differ from that complicating other diseases. Insomnia. — In dealing with insomnia in tuberculous patients, the same rule should guide us as in treating tlie proper symptoms of the trouble, give as little medicine as possible. In some cases allaying the cough, or in others checking the night sweats, may do away with the insomnia. A glass of hot milk taken at bedtime, or milk to which whisky or cognac brandy has been added, will make the patient fall into a tranquil sleep. When drugs must be employed, those which disturb digestion least should l)e used. I have found veronal, trional, and sulphonal to fulfill this condition and to produce a sleej) more closely akin to nature's sleep than any otiiei- liy})notics. Veronal is usually given in .l-grain doses iiS o^s; 15 636 HOME TREATMENT BY SANATORIUM METHODS in capsule. Trional and sulphonal are best administered in a powder or cachet. Ten to 15 grains are usually given at a dose, and should immediately be followed by a cupful of milk or water, as hot as can comfortably be swallowed. This hastens and increases the effect of the drug. In cases with much nervous disturbance I have found the fol- lowing prescription especially efficacious, particularly when there is present, in addition, the so-called nervous cough : I^ Sodii bromidi 5j 5 30 gm. Spiritus ammonii aromatici, Spiritus lavandulae comp., Essence pepsini qIv ; 130 " M. Sig. : One drachm to two drachms in water at bedtime. Instead of the above, chloralamid (10 grains) may be administered on retiring. Naturally opium, in some of its preparations, or cannabis indica will produce the same result, but they should only be given when the other remedies mentioned have failed. Fain. — When pain in the chest occurs in tuberculosis, its cause should be sought for and ascertained. The treatment of muscular pains and neuralgias does not differ essentially from that employed in other diseases. When the pain is pleuritic, it may be alleviated by external applications — e. g., mustard plasters, tincture of iodin, dry cupping, etc., over the affected area, or hot-Avater stupes, poultices, hot-oil com- presses, etc. In a majority of cases, strapping the chest on the affected side with strips of adhesive plaster will, by limiting the respiratory excursions, bring relief. In some cases it will be found advisable to administer sodium salicylate (5 to 10 grains) three times daily, or phe- nacetin (5 grains) repeated in three or four hours, if necessary. Occa- sionally a h3'podermic of morphin (^ grain) or codein (^ grain) may be necessary. Pleurisy with Effusion. — When there is pleurisy with effusion, when the fluid accumulation is sufficient, the pleuritic pains subside spon- taneously. In order to get rid of the exudate, the amount of fluid ingested should be cut down to the minimum, and the activity of the kidneys increased. For this purpose nitroglycerin (yi^ to -^^ grain) and infusion of digitalis (jss) every four hours may be given; or it may be necessary to add to the above acetate of potassium or sodium (20 to 30 grains), the object being to make the amount of liquid excreted greater than that which is drunk. If this cannot be done, then resort must be had to the aspirating needle. If paracentesis of the thorax is undertaken it should be done under the strictest aseptic precautions, otherwise a serous pleurisy will be converted into a purulent pleurisy. COMPLICATIONS 637 In performing paracentesis the skin should be cleansed thoroughly with green soap, alcohol, and ether at the point where the needle is to be inserted, which should be between the eighth and ninth ribs, in a line with the angle of the scapula, or in the seventh interspace, in the midaxillary line. The needle should be thoroughly sterilized by boiling, and should be inserted close to the margin of the lower rib, as in this way one will avoid wounding the intercostal artery which runs in the groove beneath the rib above. Local anesthesia of the part may be obtained, if desired, by the hypodermic use of cocain, by freezing the area either with an ethyl chlorid spray or by the application of ice. The intercostal space may be widened by placing the hand of the affected side on the opposite shoul- der. The fluid may be withdrawn simj^ly with a needle, to which a long tube is attached, thus siphoning it off, or the tube may be attached to a bottle in which a partial vacuum is produced by a pump and the fluid thus sucked out. In large effusions too much fluid should not be withdrawn at one time, as the too sudden removal of pressure on the heart and vessels has led to serious consequences. Wlien the patient com- plains much of faintness, or violent coughing ensues, it is well to desist. After withdrawing the needle the aperture in the skin should imme- diately- be closed by a strip of adhesive plaster. Empyema. — In the case of empyema the pus should be removed as soon as the diagnosis is made. In the majority of cases this may be effected by making a free incision in the midaxillary line l)etween the sixth and seventh ribs and introducing a drainage-tu])e. In some cases the space between the ribs is too narrow to admit a drainage-tube of sufficient size. Then two or more ribs must be resected (Estlander's operation). Pneumothorax, — In pneumothorax, rest in bed and strapping the chest are to be recommended. Stimulants will be necessary when faint- ness and collapse are present. Wlien much coughing and dyspnea occur, a hypodermic of morphin (I grain) is indicated. Pityriasis versicolor. — Pityriasis versicolor is a harmless though troublesome symptom which occurs in tuberculosis. It may be dis- tributed, more or less, over the entire body, the spots and bleblike ele- vations varying in size from a small shot to a split pea. It may read- ily be relieved by washing the skin with castile soap and warm water, sponging in vinegar or dilute acetic acid, and afterwards with a drachm of sodium hyposulphite to the ounce of water. Tliree applications of this, according to Latham, are usually sufficient. Ischiorectal Abscess. — Ischiorectal abscess occurs not infrequently in advanced stages of tlie disease as does also its companion, fistula in ano. The treatment is entirely surgical. 638 HOME TREATMENT BY SANATORIUM METHODS Tuberculous Laryngitis. — Tuberculous involvement of the larynx and ejjiglottis is one of the most serious and at the same time distress- ing complications of tuberculosis. For its relief the same general regime of fresh air, feeding, rest, etc., is demanded. In addition, local treatment of the affected area must be carried out. Nowhere is the effectiveness of rest better proved than here. The patient should not be allowed to talk at all ; even loud whispering is to be avoided. In mak- ing his wants known the deaf and dumb sign language or a Vv^riting tal)let should be used. As a local application, a ten-per-cent solution of argyrol may be applied to the vocal chords once daily or they may be paintx^-d with a solution of equal parts of tincture of iodin and glycerin, to which ten grains of potassium iodid have been added. Much relief will also be afforded by the use of the following oil s])ray, the patient taking deep inhalations the while: ^ Mentholi gr. xx ; 1.3.3 gm. Camphor;!^ gr. v ; 0.31? " Acidi carbolic i gr. vj : 0.40 " Eucalyptoli gtt. iij ; 0.-?0 " Glymoli ^ij ; 60.00 " M. Sig. : Use in atomizer^ p. r. n. When ulceration of the chords exists, Heryng and Krause recom- mend painting or gentle rubbing of the ulcers witii lactic acid, 30 to 80 per cent, once or twice a day, if too great distress is not caused; or Lake's pigment (lactic acid, 50 per cent; formalin, 7 per cent; car- bolic acid, 10 per cent). Deeper ulcers require curettement and electrol- ysis. Insufflations of iodol, aristol, and orthoform are also employed. Prior to the application of these, it is frequently desirable to cleanse the parts with an antisei)tic sj)ray — e.g., Dobell's solution. If much edema of tlie glottis exists, scarification may give some relief. In this condition the writer has gotten satisfactory results from the application of suprarenal extract with chloretone or adrenalin chlo- rid. It acts in the same way here as it does in opening up a nose that is closed by a congested mucous membrane. It has not the anesthetic properties of cocain, but it possesses two advantages that cocain has not — its effects last longer by several hours, and in addition it does not derange the digestion. In severe cases it may even be combined with cocain. When the ulceration is marked and the edema great, the patient reaches a point where proper nourishment is a serious matter, not only on account of the difficulty in swallowing, but also because of the pain COMPLICATIONS 639 and l)ecause tlie swollen and enlarged epiglottis does not close down pro]>erly, thus allowing food to go into the trachea, causing violent coughing and sufi'ocation. By painting the area with suprarenal extract and following this, if necessary, by the application of a four-per-cent solution of eocain, much comfort will be given the patient and he will more readily take the necessary amount of food. Sometimes his food will have to be administered through a stomach- tube, and in some cases even the passage of the stomach-tube is intol- erable, and resort will have to be had to rectal feeding. In extreme cases, with marked dyspnea, tracheotomy will have to be performed. Diarrhea. — Diarrhea occurring in the course of tuberculosis may be the result of indiscretions in dietj of irritation by foodstuffs, which, though not of necessity indigestible, still from impaired digestive activ- ity are not assimilated, act as irritants to the digestive tract. On the other hand, the diarrhea may arise from tuberculous ulceration of the intestine. Tlie latter necessarily causes the greater ditficulties, and at times is utterly beyond our control. In either case it is best to rid the alimentary tract of any indigestible food residue that may be pres- ent. For this purpose it is well to give calomel in ^-grain doses every half hour until 2 or 3 grains are taken. This should be followed by a brisk saline laxative, or, in some cases, castor oil. Xaturall)', the diet must be regulated and only such food as is easily digested should be allowed. Bismuth should be given in some form, either the sub- nitrate (30 to GO grains), the subgallate (10 grains), or the salicylate (5 grains), every four or six hours, with opium, either the powdered extract (5 to 4 grain), codein (| grain), paregoric (1 to 2 drachms), or Dover's powder (3 to 5 grains), and repeated as occasion demands. In some cases tannalbin (10 to 15 grains) will be of service. When the discharges are excessive I have obtained good results from bismuth. I^ Tincture catechu comp., "j Tincture opii, v aa oijss ; 10 gm. Spiritus camj)hora\ j M. Sig. : 30 to 40 drops every four hours. Francine recommends tlie following, as modified from Osier: I^ Plumbi acetatis oj ; 4 gm. Acidi acetici dil 3Jss; 6 " Syrupi simplicis oiij ; 12 " Aqua cinnamoni ad ,^iij ; 90 " M. Sig.: A teaspoonful three or four times a day. 640 THE SANATORIUM, ITS CONSTRUCTION AND MANAGEMENT THE SANATORIUM, ITS CONSTRUCTION AND MANAGEMENT By ARNOLD C. KLEBS In the foregoing paragraphs the hygienic treatment of tuberculosis has been discussed without particular reference to special institutions, wherein its details have been elaborated. Although these details are per- haps not of distinct interest to the general practitioner, they cannot fail to be suggestive in many ways, and particularly to those who are con- templating, as seems most desirable, the erection of smaller sanatoria throughout the country. The term "sanatorium" (sanarc, to heal) presupposes the cura- bility of the patients whom it is destined to receive. It is not merely a "sanitarium'' (sanitas, health), a health resort, an institution for the reception of the sick, no matter what their chances for cure. This refinement of terminology is perhaps somewhat artificial, but the tend- ency of late years lias been to call sanatoria those institutions which admit for treatment only patients in the early stages of the disease, in contradistinction to the hospitals which are open to any class of cases. At one time, especially through the influence of German propa- ganda, the sanatorium occupied the center of the stage in antitubercu- losis efforts. For the individual as well as for the State all hope was concentrated in the erection of such institutions. A clearer con- ception of its true position, through a more precise application of experi- ence, has been gained of late. First of all it has been realized that in order to accomplish a complete and lasting cure a longer sojourn of patients in the sanatorium than customary (three to four months) is necessary, and on the other hand that this longer sojourn has disadvan- tages in itself, in so far as it very often mentally disables the discharged patient for his former pursuits. Considerations of this kind have called forth of late unnecessarily violent attacks against the sanatorium (Cornet, '07), disclaiming all its merits, at least for the treatment of persons of slender means. That such wholesale condemnation goes too far can be easily demonstrated, and, in explanation of it, it can only be said that it is directed more against a special system as practiced in Germany, than against the principle itself of treatment in closed institutions. But this fight, pro and con sanatoria, has brought forth object lessons which those who are planning the construction of sana- toria will do well to examine more closely. Brehmer, in Gorbersdorf, and later his pupil, Dettweiler, in Falken- stein, by demonstrating the curability of tuberculosis by means of statistics of cases treated by hygienic-dietetic methods in their institu- THE SAXATORIUM, ITS CONSTRUCTION AND MANAGEMENT 641 tions, started not only an era of greater hopefulness in phthisio-tliera- peuties, but elevated the method itself to the position it now maintains. There was nothing particularly new in the method; as early pioneers in it must be named Andrew Stewart, of Erskine, Scotland (17-i7), William Buchan (1783), our own Benjamin Eush (179-1), and especially George Bodington, of Sutton Coldiield, Warwickshire, England, who had practiced it successfully before Brehmer and Dettweiler, but the credit for systematic application on a large scale and demonstration of tlie results, followed by a more general adoption, cannot be denied them. Typical of the German system, as we may call it, is the minute and individual application of hygienic principles under close and per- sistent supervision of the physician in an especially constructed insti- tution. They were regarded more as schools of hygienic discipline, with little left to the patient's initiative except strict obedience. Differences in national traits have long hindered the introduction of the system into other countries or have brought about modifications. Its paramount value as exemplified by its good results, has spread the sanatorium gospel all over the world, and although it cannot be said to have everywhere the same meaning as to details,' its range of activity and its position among other curative agencies, as well as its limitations, are pretty well realized. It is, however, becoming more and more apparent that the sanatorium in its present stage of evolution does not fulfill all the desiderata of institutional treatment, that it needs to be supplemented by other institutions and amplified in its scope; also that the home treatment on sanatorium lines allows perfections not thought possible only a few years ago. If credit must be given to the great Germans, Brehmer and Dettweiler, for having successfully launched the sys- tematic, hygienic, and dietetic treatment in institutions, the elaboration of it has-been done in other countries, particularly in England and America. The greatest impetus to English sanatorium evolution, how- ever, came from another German, Walthcr, who in his Xordrach colony in the Black Forest practiced the method on lines more sympathetic to an English public than those of Goerbersdorf and Falkenstein. In our own country, Edward Trudeau is the undisputed pioneer and leader in sanatorium work. Since 1873, when he was sent to the Adirondack Mountains as a patient, lie evolved there, stage by stage, one of the most admirable centers for the treatment of tuberculosis on hygienic- dietetic lines, and one which has been for a long time the sole inspira- tion for similar enterprises on this side of the Atlantic. Requisites of the Sanatorium. — An absolute and definite standard of requisites for a sanatorium cannot be laid down. Sanatoria have been constructed in all kinds of climates, after plans differing in many details and at an expenditure varying from a few hundred dollars per 42 642 THE SANATORIUM, ITS CONSTRUCTION AND MANAGEMENT bed to several thousand dollars. In location and in construction the sanatorium has to adapt itself to individual requirements, the financial resources and the number of patients it is to receive. The vast majority of candidates for the sanatorium, however, belong to a class which has to consider carefully every item of expenditure, particularly so in a disease of so chronic a course, which is bound to make heavy demands on all available resources for a long time to come. It is an important duty of the family physician to impress this fact upon his patients and not allow them to stake their last penny upon this one card, the sana- torium, in the belief that the regained health after a few months' treatment will permit their resuming without restraint their former occupation. Future sacrifices will be absolutely necessary in most cases to maintain the improvement made. It is also evident that a multi- plication of sanatoria is most desirable. Especially in this country, sanatorium treatment for those classes most in need of it is wholly inadequate. In Germany, where, very largely through the provision of an invalidity insurance system, large funds are available for the build- ing and maintenance of sanatoria, such a multiplication has been dis- tinctly furthered. We have no such system and are chiefly dependent on individual resources, charitable aid, and to some extent on State and municipal initiative. The various State sanatoria now in operation in this country have given a distinct impetus to the movement and it is much to be hoped that municipalities will also awaken to the exigencies of the situation and provide sanatoria for the numerous sick, which cannot find admittance in the State institutions. If a general standard cannot be laid down for sanatoria and is not even desirable, as was well pointed out recently by Bulstrode ('08), because of its hampering individual experiments, certain definite guid- ing principles ought to.be before those interested in the construction of sanatoria. They ought to embrace selection of a site, constructive planning, and management of the sanatorium. Before entering more in detail upon these features it may be well to point out that the results obtained in a sanatorium are in no way in proportion to the expense of the institutions. Excellent results can be achieved in an institution providing only the barest comforts; often better ones than in a most luxuriously equipped sanatorium. Eesults do not depend on elaborate equipment, but on the way in which every- thing is utilized to improve mentally and physically the condition of the patient. From this point of view elaborateness of equipment, even if to some extent only fulfilling many of the so-called modern sanitary requirements, is often rather hampering than furthering the purposes of a sanatorium. The " infinite number of discontented beings " who, according to Cornet ('07), return from comfortable sanatoria to poor SELECTION OF SANATORIUM SITE 643 domestic surroundings, could be considerably lessened by adhering rigidly to the fundamental principle of extreme simplicity in sana- torium construction. Tliis answers the question often asked, whether one shall build cheaply and temporarily, or expensively and perma- nently. Selection of Sanatorium Site. — Eemoval of the patient from the usual indoor existence in a town home to the outdoor life in the countrj^ sanatorium constitutes in a sense a change of climate sufficient for the vast majority. The choice of a climate, in the common and wider sense, can be guided by considerations discussed in another chapter. For most patients it is preferable and advantageous that the site be not too far removed from their home and the field of their active ties. Com- parative statistics of results obtained in sanatoria in mountain and low- land regions, for instance, diifer not sufficiently to form a material basis for the contention, formerly very prevalent, that the sanatorium ought to be situated in the mountains or some other distant region, with alleged climatic advantages. The evident advantage of easier accessi- bility, better and cheaper food supply from city markets in sanatoria near home, is enhanced by the frequent observation that patients sent to a greater distance and to radically different climatic conditions, though doing exceedingly well while there, often relapse more quickly and hopelessly upon their return. There is hardly any town or city in the temperate zone in which we live in the neighborhood of which land cannot be procured with all the essential requirements of a sanatorium site. These are, briefly: (1) A dry soil, covered with grass; (2) a cheerful, pleasant landscape', (3) absence of smoke- and noise-producing enterprises; and (4) acces- sibility. Many other requirements are theoretically elaborated in text- books, but for practical purposes hardly merit mention. Important here, as in any institution for the reception of patients, is, of course, an abundant pure water supply and facilities for proper sewage disposal. Protection against winds, very strongly demanded by some authors for the site, sliould be noted. It is here purposely left out as one of the essential requirements of a sanatorium site because protection against wind can be provided artificially by the planting of trees and shrubs or shelters built of wood or other material. The absence of natural shelters alone should not discourage the selection of a site otherwise satisfactory. It must also not be forgotten that stagnant air is most objectionable, and often to be found in sanatoria the site of which was selected with too great regard for protection against wind. As said before, artificial shelters can be found against winds, especially in win- ter, when most objectionable ; and, on the other hand, refreshing breezes may be most welcome in a hot summer, it being a common experience 644 THE SANATORIUM, ITS CONSTRUCTION AND MANAGEMENT in sanatoria that even excessive cold is well borne by most patients, while excessive heat always affects them badly. Dryness of ihe soil is of considerable importance, and merits careful examination before deciding on a site. A determination of the average level of the soil water ought to be undertaken always if the grounds are on level land. This level is usually low on sloping grounds, and for that reason alone a slope will merit preference even if the quality of the soil itself is otherwise imperfect. Given a low level of the soil water, not only on the immediate site of the building but also on the sur- rounding land (avoidance of marshy and swampy regions), a more or less impervious clay soil, if no other can be found, may be chosen, because the water will run off and leave the surface dry. That the larger part of the grounds be covered with grass is most desirable, be- cause thereby the formation of dust will be prevented to a large extent. It also forms one factor in the next important requirement, the cheer- fulness of the landscape. This point ought always to merit attention, because there are but few patients who are not sooner or later affected by it. Beautiful scenery is but rarely to be found in the neighborhood of centers where sanatoria are needed, but the open country, wherever it may be, offers choices of sites which can be considered from this view- point, although with more modest pretensions. A sloping, undulating, or hilly ground, also, in this regard, will be more desirable than a level one. Meadows, shrubs, and trees add considerably to the cheerfulness of the landscape. Pine-tree regions have for a long time been consid- ered to offer especially desirable sites for sanatoria. A pine forest pro- vides, indeed, a very good shelter, and the soil on which the trees grow usually fulfills the requirement of dryness. Where natural beauty is scant, much can be done toward the artificial improvement of the grounds in this respect, and a selection of a site in a bare country can often be made with this in view. At any rate, this point must merit a great deal more attention that it has often received. Absence of smol-e is the next essential. It means pure, open air. A few miles away from the outskirts of any city such air can be found, and if a greater distance seems desirable, it should be more for reason of the inexpensiveness of land, greater natural beauty, than for the fear that occasionally a few clouds of city smoke will sweep the grounds. Coal smoke is certainly less harmful than fine, irritating street dust; but where it is found, there are usually also other contaminations of the atmosphere from the same sources where it originated. The imme- diate proximity of railroads, of highroads, and of factories also should be avoided on account of their smoke, dust, and noise. Accessibility of the site is another desideratum which merits atten- tion. Electric rural lines are being multiplied rapidly nowadays in PLANNING AND CONSTRUCTION 645 the vicinity of cities, and form a very satisfactory means of transporta- tion to and from the sanatorium. Accessibility is also to be considered because of the necessity of a prompt supply of fresh provisions to the institution. But the desideratum of accessibility must not outweigh that of rural surroundings and sufficient remoteness from town life and its temptations. The sanatorium and its grounds ought to form a small colony by itself, where the inmates are busy getting well, an occupation which ought to be rendered not only useful to them, but also interesting. This can be much enhanced by appropriate outdoor life, and espe- cially by provisions for useful occupation. The question of the size of sanatorium grounds has therefore to be considered. Existing sanatoria are mostly provided with amjsle grounds up to several hundred acres. The size of these institutions and the cost of land will, of course, set a limit. It can only be stated that a sanatorium without ample grounds under its control cannot properly fulfill its objects, as they are nowadays understood. Provision for systematic outdoor occupation is of essential importance to the future welfare of the patients, and it cannot be obtained on cramped grounds. The institution which through rest treat- ment in the open-air galleries and occasional walks and overfeeding alone accomplishes the famous ninety per cent of cures on dismissal is doing work for the " galleries," but not for the patients, and especially not for their future. This is well substantiated by the after-results in patients treated in German sanatoria by this method (Klebs, A. C, '07). It cannot be urged too much, not only that the grounds be ample, but also that they be chosen with the prospective of serving directly toward the occupation of the patients, particularly as regards gardening, path-making, etc., as well as for their diversion by certain games, walks, etc. Planning and Construction. — After the essential requirements with regard to the nature and size of the grounds have been fulfilled, the planning proper of the sanatorium buildings is comparatively simple, although technically more complex. Individual circumstances will have to govern the procedure in each case. An already existing ])uilding sometimes will have to be, and can suitably be, altered and utilized for a sanatorium, or administrative purposes, in the latter case the patients being accommodated in separate buildings or shacks. Thus evolved what is usually termed the cottage type of sanatorium characteristic of the sanatoria in this country, modeled after the Adirondack Cottage Sanatorium. This type does not show any purjjoscful ])lanning, as is sometimes thought. It adapted itself merely to existing conditions, gradually increasing its capacity by additions of new cottages. The type having once become established, and with satisfactory curative re- 646 THE SANATORIUM, ITS CONSTRUCTION AND MANAGEMENT suits, the advantages of it and the one-building plan have frequently been discussed with considerable feeling by the advocates of the two types. It is desirable to set aside prejudices in regard to this subject, because au fond the differences of the two types are of slight impor- tance. There have to be two distinct departments in every sanatorium : (1) Administrative, including dining room, kitchen, day rooms, etc.; the central heating, lighting, and water plant, as well as the laundry, will in very large institutions form a separate machinery department. (2) Sleeping accommodations for the patients. The difference between the cottage and the one-building type of sanatorium resolves itself into the two departments being structurally separate or connected. From the plan wliich provides one separate administration building with one or more independent patients' cottages to the building which under one roof contains all the departments, various transitional types can be seen in existing sanatoria. A connecting and covered gallery between the patients' quarters and the main building is gradually shortened, and narrow wings, with patients' rooms, radiate from a central building, more or less directly accessible from it. In a larger sanatorium a closer structural connection of the departments facilitates the medical supervision and discipline, reduces the difficulties of cleaning and serv- ice, but does not allow a very desirable segi'egation of patients into groups, according to their congeniality and the stage of the disease, especially in buildings of more than two stories. For this reason alone higher buildings, as so often erected in Germany for sanatorium pur- poses, do not recommend themselves, although it matters but little how many stories are provided for the administration building. From the foregoing is seen that it is of but little consequence what type of building plan is adopted, but in coristructivc detail certain prime requisites must be fulfilled. For their discussion we may suitably sepa- rate the two principal parts of the sanatorium. The Patients' Quarters. — Abundant ventilation is here, of course, of first importance. The requirements in this respect cannot be fixed, as is customarily done in hospital buildings, by a certain cubic space per bed. Ventilation does not necessarily improve with the size of an in- closed space, but is dependent on the amount of fresh air supplied, which obviously can be lacking in a large room, while amply provided for in a small one. Mechanical ventilation systems, intended to renew the air by propulsion or traction, are of no use in a sanatorium; they may have some usefulness in the administrative part of a very large insti- tution. In the patients' quarters, however, it is best to rely entirely on ventilation through windows, or, better still, by leaving one wall of the bedroom out entirely. This latter plan has been employed in PLANNING AND CONSTRUCTION 647 this country, and its practicability was first demonstrated by Dr. Millet, of Brockton, Mass., for small individual shacks, and by Dr. H. M. King at the Loomis Sanatorium, Liberty, N. Y., for small wards (ten and more patients). King's "lean-to" introduced one exceedingly impor- tant feature, and one which was bound to assure it great popularity — i. e., the addition to the " open-air ward " of a beatable dressing room, with bath and toilet appliances. The principle of the King lean-to has been copied and modified practically everywhere in this country, and fully merits a still wider application. In England of late a similar plan has been followed in some sanatoria (Frimley), and a report made by the writer at the International Tuberculosis Conference at The Hague (Klebs, A. C, '06) has served toward its introduction on the Continent. The ideal sleeping unit, as at present evolved, can therefore be said to consist of a shelter offering protection against heat and the weather; Fig. 156. — Dr. Millet's New Modified Shack for One Patient at Brockton, Mass. above and below, and on two, preferably opposite, sides a beatable dress- ing and toilet room should be easily accessible from it. The two opposite walls can be left out entirely, but in our climate it is necessary to pro- vide one or both of these spaces with some protecting fixtures for use in inclement weather. In order to allow the proper place of the unit in a coordinate whole it will usually be necessary to provide a "back- wall " (against the most exposed side) ; but in this a window or door leading into a corridor will have to be placed, providing the unit, when open, with a continuous current of air. The remaining fourth wall space can then be protected, when necessary, by an awning, or often 648 THE SANATORIUM, ITS COiNSTRUCTION AND MANAGEMENT the overhanging roof affords all the protection required. The impor- tance of free cross- ventilation cannot be sufficiently insisted on; often Fig. 157. — Open-air Gallery Joinixg Two Buildings. Gaylord Farm Sanatorium, Wallingford, Conn. in cubicles, with one wall left out, the air is found stagnant except when it happens that the wind blows into it. Not too much reliance, there- fore, must be placed on ventilation by diffusion only; even when the Fig. 158. — Dr. King's Original "Lean-to" for Eight Patients at Loomis Sanatorium, Liberty, Sullivan County, N. Y. opening to the outer air is quite large, it must be supplemented by cross-current ventilation. Fig. loy. — Two "Lean-tos" of the Loomis SANATORiUiM, Liberty, Sullivan County, N. Y. Fig. 160. — Dr. King's Modified and Enlarged "Lean-to" (Anne M. Loomis Memorial) for Sixteen Patients. Loomis Sanatorium, Liberty, Sullivan County, N. Y. 43 649 650 THE SANATORIUM, ITS CONSTRUCTION AND MANAGEMENT The development of the constructive evolution of the patients' quar- ters in America contains so many suggestive data that it may be well to discuss it here by means of suitable pictures. It can be safely stated that the type evolved in this country will be adopted more and more, and everywhere, with modifications demanded by local conditions. Figure 156 shows Dr. Millet's latest modification of his shack for one patient. Here we see all the basic principles which have guided the construction of sleeping pavilions: an open part, in- tended for the patient's accommodation at night, and one inclosed part for his toilet. This general scheme is applied for use by more than one patient in several sanatoria by a utilization of porches and balconies for the housing of patients. This may serve its purpose in many cases, Fig. 161. — Interior of Sitting-room, Showing Locker, Toilet, and Bath- rooms IN THE Rear of a Sixteen-Bed "Lean-to." Loomis Sanatorium, Lib- erty, Sullivan County, N. Y. but in general is not to be recommended because of its obstruction of air and light for the adjoining rooms in the main building. Sometimes two buildings are joined by a gallery open to the weather on one side, which gives a very well protected and perfectly sufficient accommodation for patients, who for their toilet can retire into one of PLANNING AND CONSTRUCTION 651 the houses. Such an arrangement has been proposed in the constructive planning of some sanatoria, but more often has it been used where old buildings have been utilized for the accommodation of patients, as, for instance, at the Gaylord Farm Sanatorium, in Wallingford, Conn. (Fig. 157). The first purposeful application of this principle, however, we see carried out, as has already been mentioned, in Dr. King's " lean-to," Fig. 162. — One of Two Sleeping Galleries of Dr. King's Sixteen-Bed "Lean-to." of which several photographs are here given. Figure 158 shows the elevation of King's original " lean-to." It is a very primitive structure, but has served its purpose exceedingly well throughout the year — sum- mer and winter — without discomfort to the patients.. It may be said here that, as a general rule, patients very readily become accustomed to sleeping in these structures, and that it often becomes difficult to induce them to return to other more solidly built apartments. » Dr. King and others have elaborated considerably this original " lean- to," so that greater comfort has been insured at no considerable increase in expenditure. 652 THE SANATORIUM, ITS CONSTRUCTION AND MANAGEMENT Figures 159 and 160 show such modifications as are at present in use at the Loomis Sanatorium. Tliey only differ from tlie original " lean-to " in giving more space throughout, in the sleeping gallery as Fig. 163. — Open-air Pavilion Connected with Main Building. Infirmary rooms upstairs. Maine State Sanatorium. Designed by Dr. Estes Nichols, Hebron, Me. well as in the locker and toilet rooms. The jihotographs give a better description of tlicse constructive details than can be done in words. A sitting room is provided in these more recent modifications, occupying the central part of tlie structure (Fig. ICl), and from which immediate Fig. 164. — Dr. Holden's Open-air Pavilion, Agnes Memorial Sanatorium, Denver, Colo. access can be had to the locker and toilet rooms. On the sleeping gal- lery (Fig. 162) sufficient space is to be found in front of the beds for the patients to circulate and to rest on their steamer chairs. It will PLANNING AND CONSTRUCTION 653 be noted that in these structures the protection from the weather is obtained only by an overhanging roof and by an awning. Otlier modifications of this " lean-to " scheme show attempts at a more solid protection against the weather. This we see particularly in I \|3Ttl the open-air pavilions at tlie jMaine State Sanatorium, at Hebron. Me. (Fig. 163), and at the Agnes Memorial Sanatorium, in Denver (Figs. l()-t and 165). In the latter the protection is obtained by large French windows, which are open to the outside, obstructing in no way the 654 THE SANATORIUM, ITS CONSTRUCTION AND MANAGEMENT passage of air. In the former large doors are provided, an arrangement similar to that at the Frimley Sanatoria. Figure 163 shows, also, how the open-air pavilion can be connected directly with the main building. The pavilion contains no corridor, and access to the main building is to be had directly through one door, the pavilion not being divided up. At the Agnes Memorial Sanatorium partitions are used to separate the patients, an arrangement which may offer considerable advantage in some institutions where more advanced cases have to be admitted. In Fig. 166. — Boston Consumptives' Hospital at ]\Iattapan. Front elevation of Cottage Ward. general, it does not seem to be an advisable practice, at least not for patients in the earlier stages, who ought to constitute the major portion of the inmates of the sanatorium. LH GLND A ASSEMBLY ROOM C LOCKER- ROOM P TOILtT E NUtSE'5 tOOM f IMECCtMCY E.OOM G PI A'ZZ A pddflfltldDdDt]] Fig. 167. — Boston Consumptives' Hospital at Mattapan. Floor plan of Cottage Ward. It is of interest to note that the " lean-to " scheme has of late been adopted also for hospitals admitting advanced cases. Figures 166 and PLANNING AND CONSTRUCTION 655 167 show the elevation and the floor plan of a cottage ward at the Boston Consumptives' Hospital at Mattapan. In this admirahle plan an emer- gency room and a nurses' room have been added very appropriately, but Fig. 168. — Boston Consumptives' Hospital at Mattapan. Day camp. on the whole the deviation from the plan of the original "' lean-to " of King is but very slight. We also find a similar principle carried out LEGE/ND j A J TOM tOOM ft t;.rrcME/N- C PtlVATI DfNINC iM D DININC R.OOM E MENS' E,OOM F WOMINi ROOM C TOILET R.OOM H IAVATOB.Y 1 THEOAT EMM.E.M J LABORATOE.Y K OfriCES L CotB-IDOl? M PAJJACE. H LINEN R.OOM O COAL BOX P PIAZZA Fig. 169. — Boston Consumptives' Hospital at Matt.vpan. Floor plan of day camp. in the day-camp building of the same hospital (Figs. 168 and 169), although the inclosed spaces here are used for different purposes than in the other arrangement, a large dining room occupying the greatest space. 656 THE SANATORIUM, ITS CONSTRUCTION AND MANAGEMENT Mr. Edwin T. Hall, the successful architect of the Frimley Sana- torium, considers the " two essential details in the design of a sanato- rium: First, that all windows or other openings shall be carried up to the ceilings, so that all parts of the rooms and corridors may be scoured with fresh air; second, the sanitary apparatus should be external to the building." It is seen from the above descriptions that the " lean-to " scheme amply fulfills these two requirements. In his plans, Hall favors single- bed wards, but considers two- and three-bed wards as useful, deviating there- by from the American practice, where as many as sixteen and more are comfortably acconnnodat- ed in one open-air pavil- ion. The question as to whether single or multi- ple wards shall be con- structed depends wholly on the class of patients to be accommodated in the sanatorium; but, on the whole, it has been found that tlie larger ward offers in itself fea- tures conducive to better discipline and a better comradeship among the patients, very lielpful in a regime which, of ne- cessity, requires a long period. The " lean-to " scheme also does away en- tirely with porches ad- FiG. 170.— Main Building (Floor Plan of First -joinino' other buildings, Story) for Sanatorium for 100 Patients. ,-, 7- ■ 7 77 1 ■ 1 „ , ,. ^ ., X- f J • • X X- £c or the Lieqelialle which lo show distribution 01 administrative othces, "^ laundry, etc. (J. Gamble Rogers, Architect, forms the characteristic N. Y., from suggestions of Dr. A. C. Klebs.) feature of the Continen- tal European sanatorium. The disappearance of the LiegeJialle can only be welcomed, since it has been more and more realized that the treatment by absolute rest during the day, for many hours at a time, is not favorable for permanent recov- Tik-5T 5TDie-r TLAri THE ADMINISTRATION BUILDING 657 er}^ and frequently creates dissatisfaction, unhappiness, and idle habits among the patients. The graduated exercises and labor so successfully carried out by Paterson at Frimley, which have been described in the foregoing chapter, invite a more general adoption in sanatorium practice, and will further and fur- ther remove the necessity of special structures for the open-air rest cure. The material to be used for the building of the patients' quarters will be discussed later, to- gether with the cost of sanatoria in general. The Administration. Building. — Provision for the administrative offices, for the dining room, kitchen, and laundr}^ and for laboratories, can be made in one central building for institutions of considerable size. It will sometimes be desira- ble to have separate small houses for physicians' quarters, for the power plant, and for the farm, but that will depend en- tirely on the amount of money at disposal, and on the purposes of the sana- torium. It may be said, in general, that an elaborateness of planning is unde^^irable in the major- ity of institutions. There will have to be institutions where special research is carried on and everything done on a larger scale — as, for instance, in the superb King's Sanatorium at Midhurst, England. The writer has proposed, several years ago, a sanatorium consisting of an administration building, together with accommodations for the patients in "lean-tos." The adjoining plans (Figs. 170 to 172) may prove suggestive to anyone contemplating the erection of a SeicoND FLooK Pl^N Fig. 171. — Main Building (Floor Plan of Sec- ond Story) for SanatoriuxM for 100 P.a.- tients. To show distribution of dining room, pantry, kitchen, etc. Above are rooms for physicians, nurses, and help. (J. Gamble Rogers, Architect, from suggestions of Dr. A. C. Klebs.) 658 THE SANATORIUM, ITS CONSTRUCTION AND MANAGEMENT larger sanatorium. It is not necessary plans; they are self-explanatory. It CBOUMD PLAM LEAMTO Acte ..A. .:.• Fig. 172.~-H. M. King's Type of 16-Bed " Lean-to " in Connection with Main Building. to describe in detail these may, however, be well to state that the space in the second floor assigned to the dining room in the front part of the struc- ture seemed to be more desirable than any other, because of its exposure to both light and air from all sides. Accom- modations for help arc to be found in the third story above the kitchen. A very similar scheme has been adopted most recently in the plan- ning of the Maryland Tuberculosis Sanatorium, at Sabillasville, Md. (Fig. 173), an institution intended for one hundred patients. It will be advisable in the planning of an administration building to have it 60 arranged that it can be easily added to, especially in the spaces as- signed to the dining room and the kitchen departments. When the patients are accommodated at night in " lean-tos," these can be added to more or less indefinitely, while the administration building, if not planned with a view to a possible growth of the institution, is more or less an unchangeable feature of the sanatorium. General Planning of the Sanatorium Building. — If the patients are accommodated in shacks or " lean-tos," these latter are to be placed as near as possible to the administration building without suffering thereby from too great an obstruction of light and air. In some of the existing sanatoria, some of the shacks or " lean-tos " are entirely too far removed from the central building, necessitating considerable walking for the patients to reach the dining room at meal times. It seems to the writer that the arrangement as provided at the Maryland sanatorium is one of the best. Figure 174 shows this clearly. Building Material and Cost. — On the selection of the building mate- rial, the cost of the sanatorium will very largely depend. This subject has been discussed very extensively at the various national and inter- national tuberculosis meetings without ever having brought forth a practical solution of the question. The difficulty of fixing an average cost per bed for a sanatorium meets with considerable difficulty, because the material for building, the land, and labor will vary in different districts. One thing, however, can be said with certainty : that the esti- mates of cost for popular sanatoria which have been, given by some BUILDING MATERIAL AND COST 659 authors are entirely too high. The minimum figures exceed, in some cases, $1,000 per bed considerably. x\t such a rate it would be impos- sible to multiply sanatoria to a desirable degree. It is very essential Fig. 173. — Floor Plan of First Floor of Administration and Infir.mary Buildings of Maryland Tuberculosis Sanatorium at Sabillasville, Md. (Wyatt & Nolting, Baltimore, architects.) 660 THE SANATORIUM, ITS CONSTRUCTIOxN AND MANAGEMENT that it should be understood that at smaller figures perfectly comfort- able and efficient buildings can be constructed which will fulfill all the requirements; and it must be said, in addition, that the efficiency of a sanatorium rather decreases in proportion with the increase of comfort and elaborateness, and that therefore any individual or any community contemplating the erection of a sanatorium should not be deterred from ■SHA C K ^HACK ^HACK I*— '^— ^HACK SHACK I"—"— SHACK rgfc^ ^HACK — " 1| 5HACK I I II ' 5HACK — " 'I .SHACK II j~~ Fig. 174. — Bird's-eye View of Maryland Tuberculosis Sanatorium, Sabillas- viLLE, Md. (Wyatt & Nolting, Baltimore, architects.) SO doing by such estimates based on minimum figures of $1,000 per bed. As said above, the whole question rests to a great extent on the selection of building material, wood being the cheapest and stone the most expensive. In this country, wood has been very largely used. The canvas tent, which is still cheaper, has practically been given up because of its flimsy nature and other disadvantages. When one sees the wooden MANAGEMENT AND SANATORIUM REGIME 661 chalets in the storm-swept valleys of Switzerland, which have stood the inroads of time and weather for very considerable periods, it does not seem correct to speak of wooden structures as " temporary " buildings. It is of importance to keep this in mind, because the use of wood for sanatorium construction has been very often discouraged, and even ridi- culed, because of not offering elements of permanency. Its inflammable nature, of course, is of disadvantage, but very little so for the smaller buildings called for in the " lean-to " type. For a large central admin- istration building, its use may not recommend itself throughout, but it 7nay be stated that there is no objection to its extensive use in the planning of a modern sanatorium. It is possible that cheaper substitutes than wood may soon be found. Some efforts in this direction have been made; for instajnce, in the Doecher BarracTcs, which are extensively used in Germany in a similar manner as tents are used in this country. Chemically treated cardboard is the chief material used in their con- struction. Mr. Edwin T. Hall has of late recommended in his scheme of a standardized expanding sanatorium dry slabs of standard size, which are universal in application for the building unit. It would be inter- esting and valuable to have further details on this building material. Hall says: " A sanatorium on these lines, complete, with all essential adminis- trative buildings, to suit any required number of beds, with drains fitted to kitchen and laundry, and water storage, can be erected on a suitable and reasonably accessible site at a cost of about £85 ($425) to £105 ($525) per bed, depending upon its size." This scheme, it would seem, merits distinct attention as one coming from so experienced an architect as the builder of the Frimley Sana- torium. The estimates for sanatoria in this country, with wood entering primarily into its construction, does not exceed these figures given by JMr. Hall. They would help to fulfill the desiderata recently expressed by Heron : " All jjoor consumptives should be sent into sanatoria for tlieir own sakes, and for the sake of the health of the community. This could not be done if sanatoria were built costing $1,000 to $4,000 per bed. A sanatorium well equipped for the service of the poor should not cost more than $400 per bed." Management and Sanatorium Regime. — It is not necessary to enter here in detail into the administrative features of the sanatorium, nor is it necessary to outline the hygienic and dietetic regime which is fol- lowed in several institutions. The former will have to vary according to circumstances, and the latter is carried out on the principles already discussed in the foregoing chapter. It is desirable, however, to point out again that in the future it will become more and more necessary 662 THE SANATORIUM, ITS CONSTRUCTION AND MANAGEMENT to utilize the available working capacity of the patients toward the maintenance of the institution; and it will be of great advantage if it becomes more and more understood that in such a plan not the interests of the institution itself are kept in mind as much as the benefit to the patients themselves. Many of those being in charge of sanatoria have complained about the great difficulty of inducing patients to do any- thing else during their sojourn in the sanatorium than to take care of themselves; but, on the other hand, we have many reports from sana- toria where a purposeful, energetic scheme of providing useful work for the patients has succeeded. To restore the patient's embonpoint and to destroy his working energy and capacity has been for too long the result of a sanatorium regime, and it is high time that a greater amount of common sense be applied to these highly important questions. The purpose of the sanatorium regime must be to maintain or to im- prove the patient's working capacity, and that cannot be accomplished by a long-continued idleness. If such idleness is the only means by which a patient can hold in check his symptoms of disease, then the place for such a patient is not in a sanatorium, but in a hospital, from whence, perhaps, at some future time, if his condition continues to improve, he may be returned to the sanatorium. Such considerations will fix more definitely the range of usefulness of the sanatorium, and will, perhaps, enhance the position of the hospital to receive all kinds of patients suffering from tuberculosis, and admitted particularly from the large centers of population. The plans of institutional provision for sufferers from tuberculosis have not yet reached the last stage of evolu- tion; but it is very likely that it will be found in a successful cooperation of a receiving hospital and multiple sanatoria. CHAPTER IV CLIMATIC TREATMENT THE PHYSIOLOGY OF CLIMATE By HExNfRY SEWALL RELATION OF CLIMATE TO PHYSICAL AND PSYCHICAL CONDITION Medical climatology is based on the theory that the physiologic activities of the human mechanism are specifically stimulated or de- pressed, made easier or more difficult, according to the nature of the climatic environment. It would seem to be self-evident that every vital function must react in a definite way to definite changes in the physical factors of climate. Unfortunately for the solution of the problem, the scientific observer cannot often test the effect of specific physical conditions or of isolated functions, but must deduce conclusions from the resultants of many interacting variables. In the living body the coordination of various activities is relegated to a special mechanism — the nervous system — through whose interfer- ence the response of any tissue to a stimulus is modified by the asso- ciated effects on other tissues. For example, when a living heart, iso- lated from the body, is perfused with a nutrient solution, its rate of beat will remain unchanged through a wide range of resistance to outflow from it. The heart wall simply contract more or less forcibly, according to the work imposed on it. But in the normal body an increase of resistance to outflow^ from the heart at once excites a regu- lator apparatus through which not only is its rhythm slowed, but a profound influence is impressed on the vasomotor mechanism, not to speak of more remote effects. Many similar illustrations might be furnished of the important fact that the intrinsic action of a stimulus on a certain organ is apt to be completely masked by the associated reactions of other mechanisms. Nevertheless, nothing is more certain than that such a hypothetical increase of resistance to outflow from the heart would ])roduce in it a 663 664 THE PHYSIOLOGY OF CLIMATE vital reaction of far-reacliing import, the simplest manifestation of which would he found in hyjiertrophy of the organ. The illustration will serve its purpose if it makes clear the position that the reaction of the animal organism to a stimulus, of wliich a climatic change may be regarded as a very complex example, is at least twofold in its nature. First, there is a response through the modi- fication in coordination of the vital activities. This is an attribute of the nervous system, and its effect is immediate. Second, there proceeds a change in every tissue, the nature and extent of which depends on the reaction of that tissue to the variation of physical and cheniical forces acting on it. We are here contemplating the physiology of organic nutrition whose elaboration is gradual and its effects I'emote. We have thus far considered only the relations of climatic influences to that part of the nervous system which is concerned with the vegetative functions. But, as it is conceded that there is a physiology of climate, still more is it apparent that the effects on the human organism of place and change of place depend primarily on reactions of the psycliical functions, and that therefore a consideration of psychology is indispen- sable to any broad conception of medical climatology. The difference in feeling, ranging from depressing lassitude to ex- hilarant energy, or from gloom to joy, which may be based on condi- tions of weather and climate, is familiar to everyone. Not so evident is the reaction of the psychic state on the vegetative processes of me- tabolism. That such relations exist, though the science which should classify them may have no name, cannot be gainsaid. Brackett, Stone, and Low ('04) give reason for believing that painfvd mental emotions, such as fright, can produce profound disturbances of metabolism de- noted by acetonuria, and marked by vomiting, collapse, or even death. The inevitable influence of the psychic state on physiologic function has become the most prominent doctrine of modern therapeutics, and so de- monstral)le are the interaction of mind and living matter, that a powerful sect, an unwilling liandmaid of science, has been founded on its facts. In a preceding paragraph there was suggested an antagonism be- tween the vital effects immediately attendant on a change of climate, and those, often totally different in character, which may develop dur- ing permanent residence. In short, a change of scene, irrespective of the character of the environment, has often, temporarily, a mysteri- ous influence for good on the living organism. As pointed out above, the first vital reactions to new climatic conditions involve especially the nervous system, the final effects are dependent on the modified me- tabolism of the individual organs, and this may or may not be con- ducive to the efficiency of the body as a whole. The necessity of a change in the intensity of physical stimuli to RELATION OF CLIMATE TO PHYSICAL CONDITION 665 properly develop physiologic functions seems to be an inherent demand of living matter. I)u Bois-Reymond was the first to demonstrate that it is the rate of change in intensity of an artificial stimulus which determines the excitement of nerve tissue. It is an elementary fact of physiology that fatigue progressively blunts the sensory impression aroused by a steady irritation. Erlanger and Hooker ('04) have gone far to show that the variation of arterial blood-pressure incident to the normal cardiac cycle, the pulse-pressure, provides a succession of shocks which is indispensable to the normal activity of the tissues. Huggard ('06) records as an apparent exception to the laws of medical climatology, that " the newcomer from a temperate climate for a time tolerates the extreme cold of the arctic regions and the extreme heat of the tropics better than do the inhabitants or natives themselves." After a time, however, the immigrant becomes abnormally susceptible to the chill of cold or a victim to the listlessness induced by excessive heat. So far from being an exception, in the light of the foregoing discussion, it seems to the writer that such a result is just what should be expected. A frequent experience of physicians who deal with cases of pulmo- nary tuberculosis in health resorts apparently belongs to the same cate- gory. An invalid who leaves a favorable environment and returns to former scenes and habits may, for a time, lay on weight and acquire a feeling of well-being which seem to betoken a new lease on life. But too often the forces of disease advance under the mask of improvement, until vital resistance is hopelessly undermined. This may also be a basis, in part, of the popular impression that people may " wear out " a climate, at least in so far as an occasional change of residence is essential to maintain the normal health. Dwellers in stimulating high climates seem especially to feel the necessity for a descent, now and then, to lower levels. < Every change of environment leads to physiologic reactions which manifest themselves primarily as efforts of nervous coordination. The element of time is an important factor in the accomplishment of this vital adjustment. The process of physiologic adaptation to new physical conditions is commonly known as acclimatization. The perfection of acclimatization is measured by the machine efficiency attained by the living body; the resistance to its accomplishment is measured by the climatic physical differences to be overcome and by the individual and racial vitality of the reacting organism. The final outcome, whether the living mechanism increases in power or gradually succumbs to ob- stacles which it cannot surmount, is a problem of nutrition which involves as variables the vital forces of all living cells. The clinician who deals with impoverished constitutions has learned that physical and mental rest on the part of his patient is indispensable 666 THE PHYSIOLOGY OF CLIMATE in order that the physiologic powers may attain their new coordinations unimpeded. The physiologist has demonstrated that training, or gradu- ated exercise of functions in the direction demanded, is of paramount necessity to machine efficiency under radically changed climatic con- ditions. CLASSIFICATION OF CLIMATES It is impossihle to make a classification of climates in which the groups shall he qualitatively sharply distinguished from one another. Many schemes of division have been proposed, according to the point of view of the observer. It is curious to note that the most elaborate systems are but natural extensions of Aristotle's original conception, that the properties of matter are all derived from four elements — earth, air, fire, and water. The principal physical factors that determine climate are temperature, light, humidity, air movement, air density, water, and soil. Actual climates depend on various combinations of these factors. Medical climatologists have attempted to make their geographical survey along lines determined by the physiologic reactions of the or- ganism. Thus Weber ('04) makes a division into — I. Sea and Coast Climates. II. Inland Climates. A. Of High Altitudes. B. Of Moderate and Low Altitudes. Another common geographic division is into zones parallel to the equator. Thus: (1) Tropical, (2) subtropical, (3) temperate, (4) cold, (5) arctic. These schemata, when further elaborated, put in apposi- tion geographic and physiologic data in a form very convenient to the medical climatologist. Huggard ('06) in his important work proposes a purely physiologic basis of classification, and divides climates according to the demands made on the living body for the production of heat. As the rate of heat production is the surest measure of the activity of vital metabolism, the effect on this function is obviously the most important physiologic fea- ture of climatic action, yet Huggard's classification of climates, accord- ing to this single principle, although most illuminating, is probably the most complex that has appeared. As a matter of fact, the student of medical climatology must aim to learn not only the definite physiologic reactions to definite meteorologic conditions, but also the empiric bio- logic results of geographic distribution. In therapeutic practice we esti- mate the complex of climatic conditions that is best suited to a definite CLASSIFICATION OF CLIMATES 667 case, and then select that resort which most nearly fulfills the physical demands, after due consideration of its accessibility, social surroundings, and expensiveness. Our choice of a climate for an invalid is usually determined by our conception of the total demand for physiologic reaction made by tlie climate, and of the invalid's capacity to respond thereto. According to this principle, climates may be divided into two general groups, includ- ing (1) those which are sedative, or relaxing, or even enervating, (2) those which are stimulating. The main meteorologic factors in medical climatology are tempera- ture and humidity. Their relations are determined by distance from the equator, distance from the sea, and elevation above the sea; and, in turn, they determine the weatiier conditions in any definite locus. Dry air is nearly diathermanous. The sun's heat would penetrate such an atmosphere unimpeded, and, being absorbed by the soil, would raise its temperature accordingly. In a dry climate a solar thermom- eter, an instrument with blackened bulb suspended in vacuo, may show an extraordinary elevation of temperature when suspended in the sun's rays, but a peculiarly low degree of heat when moved a short distance into the shade. At night time, the earth rapidly returns its absorbed heat by radiation, and the air temperature falls very low. A person exposed to the sun's rays would both absorb and radiate heat rapidly; the sensation experienced might vary from one of comfortable warmth to intolerable heat. In climates where such conditions are approached it is possible, with shade temperature below 0° F., to sit in the sun in perfect comfort and without wraps. To him who sleeps in the open air in summer, the nights are always cool, but within walls which have been baked throughout the glaring day, the radiated heat may be oppressive for many hours. It is one of the most extraordinary features of dry, as contrasted with moist climates, that the range of sensible as compared with physi- cal temperatures is much less in the former than in the latter. That is to say, a given air temperature in summer in a dry climate would seem much less oppressive than the same degree of heat registered in a moist atmosphere. Conversely, the intensity and penetration of the win- ter's cold, as measured by sensation, is definitely increased, at a given temperature, by the amount of moisture in the air. M. W. Harrington ('93), formerly chief of the United States Weather Bureau, offered an explanation of these facts by likening the human bod3% in its reaction to temperature, to a wet-bulb thermometer. " The sensible temperatures depend on evaporation, and when evapo- ration takes place they are invariably lower than the shade temperatures given in meteorological tables. . . . The reduction of temperature 668 THE PHYSIOLOGY OF CLIMATE caused by evaporation depends on the rapidity with which evaporation takes place, and tliis in turn on the amount of moisture already in the air." Although there is much truth in this aspect of the subject, unfor- tunately, as pointed out by Phillips ('96), the problem is very much more complex than this conception would indicate, and we must con- clude with Phillips " that for the time being we have no index of sen- sible temperature, and the use of the indications of any one meteorologic instrument for such purpose can only give under the most favorable conditions but a rude approximation to the truth, and too remote to be of much practical service." In a personal communication to the writer, this author surmises that the nervous irritability of the skin is greatly enhanced by moisture in the air, and vice versa. This ingenious idea is capable of explaining largely the want of parallelism between tlie curves of sensible and physi- cal temperature. The problem is evidently one of psychology as well as physiology. Various areas of a person's skin may give the same subjective tempera- ture sensation, while, measured by the surface thermometer, they ex- hibit widely different degrees of warmth. The facts seem to indicate that thermal sensations respond to finer variations of a temperature when the skin is moist than when it is dry, and that the thermometric reading which corresponds at any moment to physiologically indifferent temperature sensation has a variable value, which is largely dependent on the mean of nervous reactions which have preceded the period of comparison. Huggard ('06) quotes from v. Hmnboldt practical observations which illustrate this subject : " We had not yet been two months in the hot zone, and already our organs were so sensitive to the slightest change of temperature that, though shivering with cold, we were unable to sleep, and to our astonishment we saw that our thermometer registered 31.8° C. (71.24° F.). In the year 1803, when we were at Guayaquil, the natives of the place complained of cold and wrapped themselves up when the thermometer fell to 23.8° C. (74.84° F.), while at 30.5° C. (86.9° F.) they found the heat oppressive. . . . From all these observations it appears that in low-lying tropical countries, where the temperature by day is almost constantly over 27° C. (80.6° F.), one finds it necessary to cover oneself up at night whenever in this moist air the thermometer falls four or five degrees." It is usually assumed that temperature sensations, so far as they are modified by moisture in the air, run parallel with the relative humidity. This physical relation no doubt regulates, cceteris paribus, the rate of evaporation of moisture from the skin, as from any other surface; CLASSIFICATION OF CLIMATES 669 nevertheless, the absolute quantity of watery vapor in the air cannot be indifferent to the skin and thermal sensations. Thus in the arctic regions, while the relative humidity is very high on account of the very low temperature, " the air is almost absolutel}^ dry, and yet no com- plaints are heard about the dryness of the air and there is no mention of its effects" (Ham, '03). The living body loses heat chiefly through the skin, according to the activity of the processes of radiation, conduction, evaporation, and convection. The latter factor is of very subsidiary importance in still air, but in moving air the latter two phenomena may be intensified to such a degree that the physiologic relations of a climatic locus may be chiefly determined by the wind. Gentle breezes, with a rate of move- ment between five and ten miles an hour, probably have great hygienic value, both in purifying the air and in acting as an agreeable physiologic stimulus. But strong winds, particularly when the humidity is high and the temperature low, have an extraordinary power of abstracting heat from the body and producing physiologic chill. A moist surface dries most quickly in a current of hot, dry air; but, as pointed out by Huggard ('OG), wind does not greatly increase the heat loss of the body to dry, warm air, but it greatly accelerates the abstraction of heat by cold air, especially when moist. " Clothing gives sufficient protection against dry, but not against moist, cold air." From the viewpoint of medical climatology, it would seem that the environment capable of producing the highest machine efficiency in any definite individual would be one in which the physical conditions excite a inaximal mean metabolism in all the living tissues, in which every physiologic function of the body is stimulated to its full capacity of reaction. The range of physiologic reaction may be greatly narrowed by disease, now in one tissue, now in another. In health the range of vital elasticity, so to speak, tends to continually contract with disuse of the respective function. In the hot, moist air of the low-lying tropics the mechanisms of heat elimination are exercised to the maximum, while the centers of heat production receive but a minimum of their normal stimulation ; there- fore, as cited by v. Humboldt, a very slight fall of external temperature surpasses the bounds of physiologic accommodation as measured by sensation. On the contrary, in the arctic regions, the heat-producing apparatus is whi})ped into excessive activity, while the machinery of heat dissipation is in very languid motion. On some intermediate iso- thermal lines we may expect to find a set of physical conditions which, for every given organism, will call out the largest reaction, and produce the greatest physiologic efficiency from every tissue element consonant with the full coordination of that element with its neighbors. 670 THE PHYSIOLOGY OF CLIMATE It has been pointed out that isothermal lines eonstnicted from the readings of the dry- and wet-bulb thermometers depart widely from parallelism. Whatever may be its explanation^ there is no doubt that what may be called the iso-aesthesodic lines, or curves of sensation, as concerned with temperature, depend more especially on conditions which determine the stand of the wet-bulb than of the dry-bulb instru- ment. If this be true, the estimate of the physiologic reactions induced by a given climate could be better made from a meteorologic record of humidities than of temperatures alone; and, manifestly, supposing a physical-physiologic equation to have been constructed from these data, the element of wind might enter and at once destroy the balance of the terms. It is an ideal of medical climatology, as the writer conceives it, to trace on the map of the world aesthesodic and kinesodic curves, the course of which would be determined by the integrated reactions of the sensory and motor functions, respectively, of the living organism to local climatic conditions. Such reactions would represent the phys- iologic mean of responses from all the individual mechanisms of the body. The aims of climatology, stated thus abstractly, are actually sought in climatologic practice. For example, in locating a patient suffer- ing from a lesion of the heart or kidney, the medical adviser seeks out that environment in which he conceives the physical conditions will throw the least possible strain on the affected organ. And in dealing with infections, such as tuberculosis, in which the welfare of the patient depends on the sum of his powers of " vital resistance," it is endeavored to select a climate which shall stimulate to the utmost the forces of physiologic reaction, considered as a whole. So complex is the living organism, that its reactions to the permu- tations of the meteorologic elements of climate cannot possibly be de- duced from known principles. Applied medical climatology must be built on a broad foundation of physiologic experimentation, harmonized with carefully sifted empiric observation. EFFECT OF EXCESSIVE ILLUMINATION From the beginning of the human race, light has been a symbol of material and spiritual good. Universal experience confirms the results of physiologic and bacteriologic experiment, which prove that light is indispensable to the welfare of sentient organisms, and unequaled in destructive effects on microbic enemies of the higher beings. Health resorts generally are, to a large extent, valued in proportion to the num- ber of hours of actual sunshine recorded in them. Nevertheless, there is HIGH ALTITUDES C71 fair presumption that tlie intensit}' of illumination may easily surpass a degree up to which it becomes beneficial. Woodruff ('05) has brought together a considerable array of facts to supi^ort the hypothesis that members of northern races, especially individuals having blond complexions, suffer materially when living in the tropics from intense solar illumination. His reasoning is based on assumed absorption of the sun's rays by the blond skin and excessive catabolism induced thereby. The pigment in the skin of brunettes and the darker races more or less eifectually screens the living tissues from the deleterious radiations. Huggard ('06) dwells on the element of temperature as determin- ing the ability of races to bear transplantation to foreign lands. " As a matter of fact," he says, " a man becomes acclimatized readily only in countries having very nearly the same mean temperature as the coun- try to which his race belongs. Individuals may live in seeming health in climates much hotter or colder than their own. But their posterity does not fare equally well ; their descendants melt away, and hardly a survivor remains to the third or fourth generation. The attempt to colonize directly a land having a mean temperature widely different from that of the native land of the colonists has always ended in fail- ure." It is very probable that the factor of illumination-intensity plays an important part in the ruling influence of insolation, as described by Huggard. According to Woodruff ('05), the deleterious influence of strong sun- light in the tropics is manifested especially on the nervous system, and leads to neurasthenia and associated disorders. This author's ideas, if true, should be of great value to the medical climatologist as a guide to a therapeutic selection of climates, not only according to the com- plexion but the temperament of his patients. But the problem is evi- dently much more complex than the presentation of Woodruff would indicate. HIGH ALTITUDES The factors of temperature and humiJity probably have much to do with increasing the sensitiveness of the skin to the luminous rays, and, above all, the equability of temperature and moisture, when their degree is high, must be potent as a cause of vital debility. Eesidence at high altitudes should, according to the assumption of Woodruff, furnish the prime conditions for the develoj^ment of the neurasthenic state. For in such resorts the sunlight is unrivaled in strength and duration, and especially rich in the very refrangible rays which are kno^^^l to chiefly affect metabolism in the skin, while at the same time the air is dry and cool. 672 THE PHYSIOLOGY OF CLIMATE "V\liile it is generally admitted that invalids of nervous temperament are apt to do badly at even moderately high altitudes, and that most persons, especially females, feel a need of change after prolonged resi- dence under such conditions, it is improbable that any one factor is of predominant importance in producing this effect. An experience of over seventeen years in Denver, near the fortieth parallel of latitude and at one mile above sea level, where the sunshine in winter is sixty-two per cent of a possible monthly mean of one hundred and eighty-eight hours, convinces the writer that the brightness of a winter's day induces an exhilaration which rather increases than decreases as the years go by. Neither can he recall, among the considerable number of pulmonary invalids that have come under his observation, any special relation of complexion to susceptibility to light, nor manifest bearing of this con- stitutional trait on the course of disease under conditions of high illumination. The pliysiologic effects of the various elements of climate have been determined chiefly by a study of extreme conditions. It is as if the therapeutic action of a series of drugs were required to be deduced from their toxic powers. The beneficial results of the open-air treat- ment in tuberculosis have especially impressed on medical climatology the truth that the physiologic response of the organism to change in environment is determined by very delicate reactions. Of two similar invalids in this class, the one housed in an ordinary bedroom, well warmed and windows closed, and the other resting under like condi- tions, but just outside the wall of the house, protected only from high winds, rain, and extremes of temperature, the probabilities would gi-eatly favor the recovery of the latter as compared with the former patient. Climatic therapy is founded on observations of this nature. Of late years tlie advance of medical climatology has received its chief stimulus through a study of tlie physiologic reactions incident to life in high altitudes. Systematic observations and experiments by trained physiologists, beginning in the laboratory of Paul Bert ('78) and leading up to the recent researches on Monte Eosa, conducted by the party headed by Zuntz and Loewy ('06), go far toward giving medi- cal climatology a foundation in exact knowledge. High climates in temperate latitudes embrace the special characters of widely different regions, with added qualities peculiar to themselves. There are found the intense illumination of the tropics, but the low humidity and variable temperature of inland deserts. Though the heat of the air, as measured by the thermometer, rapidly passes through wide variations, the sensible temperature may apparently oscillate less largely than under the equable conditions of a sea coast. In addition, the rare- faction of the atmosphere induces a special chain of physiologic reac- HIGH ALTITUDES 673 tions unparalleled by any other climatic environment. The monograph of Ziintz and his collaborators, which has already been reviewed by the writer (Sewall, '04), forms an admirable basis for the discussion of the vital effects of lowered barometric pressure. The futility of attempting to deduce the nature of physiologic reac- tions from a knowledge of the mechanical conditions involved is well illustrated in this field of study. Xearly a century and a quarter ago the great physiologist, Albrecht V. Haller, originated the " cupping-glass " theory of the effects produced on the circulation in the living through diminution of atmospheric pressure. That idea has continued to cling to the mind of student and layman alike. The facts of " caisson disease," a disorder produced by too sudden decompression after a sojourn in highly condensed air, are proof positive that gases dissolved in the body fluids may be liber- ated with destructive effects when the air tension on the surface of the body is suddenly diminished to a sufficient degree, very much as a bottle of aerated water froths when the cork is withdrawn. Most com- petent observers (Hill, '07) appear to agree, however, that, under, ordi- nary conditions of changing atmospheric pressure, the variations are so gradual that that equilibrium between internal and external air ten- sions is practically continuous. Nevertheless, the clinical observer at high altitudes is frequeftitly impressed with facts which seem to confirm the conclusions of H. Kronecker ('03). According to this author, the lowering of atmospheric pressure exer- cises an effect on the distribution of blood in the body in such a man- ner as to cause a relative accumulation in those superficial vessels which have the least mechanical support ; such are evidently the blood-vessels of the lungs. Therefore diminution of atmospheric pressure would lead to pulmonary congestion and a tendency to stagnation of blood in the lungs. There is, unfortunately, still wanting crucial demonstration of the facts pertaining to the distribution, rate of movement, and pressure values of tlie blood as influenced by air density. Wlien the lungs are at rest and the glottis is open, the air-pressure within the pulmonary alve- oli is probably practically identical with that on the surface of the body, and the tension of the l)lood gases very rapidly reaches the same value. Tins mechanical equilibrium would exist, under the same conditions, at all altitudes tolerable to life. At the onset of an inspiratory movement, however, there is at once a fall in the tension of the alveolar air, and the pressure on and within the body at large remaining the same, the expanding walls of the thorax act like a veritable cupping glass, drawing blood into the riglit heart and hmgs. The lack of tissue sup- port about the pulmonary capillaries, their remarkable distensibility 44 674 THE PHYSIOLOGY OF CLIMATE and possible freedom from vasomotor control, puts these vessels pecul- iarly at the mercy of mere mechanical disturbances. No diminution of atmospheric pressure affecting simultaneously the skin and pulmonary alveoli sliould be expected to cause a translation of the incompressible body fluids, simply because the pressure is uni- formly distributed. Pent-up gases, as found in the abdominal viscera, expand under such conditions according to known physical laws, and by upward distention of the diaphragm may cause symptoms. Again, if the fall of external air-pressure were extensive and rapid enough, blood gases would be thrown out of solution and, in the following lines of least resistance, might produce movements in the blood mass. There is, liowever, an easy physiologic explanation of the physical disturbances in the pulmonary circulation encountered under condi- tions of lowered barometric pressure. Such a change causes an increase in the depth, and usually in the rate of breathing. Therefore the me- chanical force which drives blood to the lungs is proportionately in- creased. But at the same time it is extremely probable that, under usual conditions, the coordination of the complex mechanisms of circu- lation and respiration is impaired so that the heart is unable to empty itself efficiently. The evidence that heart strain may easily be induced in high alti- tudes, particularly under conditions of muscular exertion, is founded both on common experience and scientific observation. Professor Zuntz and his colleagues especially call attention to the insidious onset and progress of cardiac dilatation under such conditions. This incapacity is manifested in persons who are unaccustomed to conditions of lowered barometric pressure. As a result of training and during the process of acclimatization, physiologic coordination is reestablished. Thereafter relative pulmonary congestion is only to be expected especially at high altitudes, because, as will be pointed out later, under such conditions relatively slight exertions are apt to load the lungs with blood faster than the heart can discharge it. It is clear that, though the left ventricle may considera1)]y increase its output, the excessive ratio of inflow to the riglit lieart would soon lead to distention of this viscus and to the distress of cardiac dyspnea. Paul Bert ('78), in his encyclopedic work on the physiologic influ- ence of barometric pressure, furnished the first evidence that life in high climates modifies the oxygen-carrying function of the blood when he showed that the blood of animals habituated to very high altitudes contained, per volume, considerably more oxygen than that of creatures living in the lowlands. For a decade the importance of Bert's researches was insufficiently recognized, but Viault ('90; '91; '91 A; '92). during observations made in the Cordilleras at an altitude of about 14,000 feet. HIGH ALTITUDES 675 found that at this elevation his red blood cells numbered about 8,000,000 per cubic millimeter, whereas three weeks before, at sea level, the count was but 5,000,000. A similar polycythemia marked the blood of people who had lived at the high level since birth. Herein was furnished the tirst positive evidence that residence in high climates produced a definite, tangible change in the living organ- ism. A considerable literature has since been built on this thesis, of Avhich admirable and critical summaries may be found in the works of Zuntz ('OG) and of Tissier ('06). Of the increase in the red Ijlood count as a result of ascent above sea level there can be no doubt. The only question at issue concerns the meaning of the polycythemia, whether it is due to a real increase in the number of blood corpuscles throughout the body or simply to a redistribution, which leads to turgescence of the superficial vessels from which the enumeration is usually made. In favor of the latter explana- tion are evidences that the conditions in high climates induce, at least in unacclimated persons, the accumulation of blood corpuscles in the vessels of the skin. Moreover, the increase of blood count with ascent, and its decrease with descent, follow almost immediately the changes in elevation. It is hardly conceivable that the processes of blood for- mation and destruction could be stimulated to such a rate. Again, Ambard (Tissier, '06), experimenting with dogs confined in pneumatic boxes, showed that even when the barometric pressure was reduced to 450 mm. Ilg., tlie blood in the femoral artery contained per volume rather fewer blood cells than at normal air-pressure. Investigations by Campbell and Hoagland ('01) on Pike's Peak, in Colorado, and similar researches in the high Alps (Zuntz, et ah, '06), have sliown that in the ral)bit, blood from the ear vessels contains a considerably larger proportion of corpuscles than that taken from the internal organs. In the lowlands no such difference is manifest. Xevertliolcss, trustworthy ol)servations support the conclusion that rare- faction of the air does, in fact, act as a specific stimulus to the cytogenic function of the bone mariow, leading both to increase in the number of erythrocytes and in the amount of hemoglobin in the body. The ])iologic reaction leading to this result develo|)s gradually, and ])robably reaches its maximum after a variable interval, it may Ijc of several weeks. Individuals differ greatly in the susceptibility of their hemapoictic tissues to the stimulus of rarefied air; young animals con- stantly show a greater relative polycythemia.^ ' Of interest in this direction are the recent findings of Webb and Wilh'ams ('09) of ;iii incroaso in tlio number of lymphocytes in hijili altitude. If oonfirmed this may explain, at least partly, the beneficial effect of hi^li altitude in tul)eiculosis, — Editcjr. 676 THE PHYSIOLOGY OF CLIMATE Most suggestive from a theoretic, and valuable from a clinical, stand- point, are the observations conducted by Professor Zuntz and his party on what may be termed the physiology of acclimatization. The sharply marked vital reactions which occur as result of removal to sufficiently high elevations, and which may be made to vary quanti- tatively according to the altitude, give to the study of high climates a peculiar biologic interest. It has been shown that in an ascent from the level of the sea the activity of the blood-forming organs is increased. According to the curve constructed by de Bouaille, the red blood cor- puscles increase rapidly in number up to the altitude of about 0,500 feet, then more slowly to 13,000 feet, and afterwards very slowly indeed. When we inquire as to the nature of the stimulus which excites this modification in metabolism, attention is necessarily directed to the low- ered oxygen tension of rarefied air. The most trustworthy observations and experiments seem to lead to the conclusion that relative oxygen deficiency in the air is the cause of the major physiologic reactions to lowered barometric pressure. Laboratory experiments show that when shed blood is placed under the receiver of an air pump, oxygen does not begin to break loose from its combination with hemoglobin until the air-pressure has been reduced to 300 mm. Hg., which corresponds to the barometric pressure at an elevation of 17,000 feet above sea level (Foster, '89). Many of the physiologic disturbances under discussion become well marked at less than half this altitude, where the partial pressure of oxygen in the air is amply sufficient to saturate the blood, provided the physiologic mechanisms are able to appropriate and distribute it to the vital tissues. For the present we must be content to explain the facts by analogy. Facility in any feat of skill requires the development by practice of new coordinations of the nerve-muscle functions. The very processes of secretion and digestion are specifically related to the nature of the aliment, and can be prostrated completely by a sudden radical change in the character of the food. The absorption of oxygen by the lungs, and its distribution to and appropriation by the tissues, is a chain of vital events not to be ex- plained by the laws of physics alone. Therefore, although the oxygen in the air at an altitude, say, of 10,000 feet, is amply sufficient to supply the necessities of the body, it is not strange that the living protoplasm should show some disturbance in adjusting itself to the reduction in the physical aid to absorption to which it had been habituated. It is self- evident that a physiologic adjustment which compensates a lowered oxygen pressure while the body is at rest may at once be thrown out of balance through the demands of muscular exertion. Thus it is HIGH ALTITUDES 077 found to be a constant fact that exercise in high climates produces a greater relative rapidity of heart action, respiration, and general metab- olism than is involved in the same expenditure of physical energy in the lowlands. The physiologic waste of energy is inversely proportional to the grade of acclimatization of the individual. It cannot be too strongly empha- sized that removal from a lower to a higher climate demands from the vital powers an extension of their coordinations. So imperative is this demand that the very structure of the body is altered in response to it. The increased hematopoiesis at high altitudes has already been dis- cussed. The work of Zuntz ('06) and his collaborators demonstrates, in addition, the extraordinary fact that in moderately high altitudes metabolism is so modified that there is a laying on of proteid material, even in persons of adult age — a fact without parallel in medical clima- tology. This modification of nutrition may still further progress after the person under observation has returned to a lower level. This fact furnishes an interesting physical basis for the long persisting benefit from a temporary sojourn in the mountains. Healthy people may passively ascend to considerable elevations with- out sensible disturbance of function; but even slight exertion, such as walking a few steps, is apt at once to excite disturbance of circulation and respiration, or, in extreme cases, precipitate the remarkable chain of events involved in " mountain sickness." When invalids seek the higher climates, the deleterious effects of overstrain of the vital powers are apt to outlast the act, and later cause disaster, A heart which is intrinsically weak is liable to dilate so gradually under the overloading induced by exertion that a fatal strain is experienced without the victim realizing its onset. Herein, probably, is the explanation of the not infrequent fatalities occurring among patients with pulmonary tubercu- losis, who think they may venture on their customary exercise directly on coming to a higher altitude. Such persons sometimes unnecessarily go to pieces with symptoms of acute pulmonary edema, precipitated, it may be, by very slight exertions. The bright sunshine and the crisp, dry air at high elevations are stimuli which primarily excite the ner- vous system, and indulgence in a motor response which is proportionate to the sensory stimulation is prone to overtax the vital powers. The physiologic response to the physical conditions encountered in high climates throws special strain on the sensory and coordinating tissue — the nervous system. We find in experience, what might have been expected from theory, that persons of unstable nervous temperaments are apt to have their morbid symptoms exaggerated at high altitudes. Clinical experience shows, however, that with freedom from excitement and exercise and 678 THE PHYSIOLOGY OF CLIMATE proper manipulation of the factors of irritation, there is often, in such cases, to be achieved the good without the ill effects of life at high levels. It has been abundantly demonstrated that the physiologic effects of high altitudes are such as indicate stimulation of all vital functions with an intensity whose maximum is very high and whose range may be wide. Acclimatization consists in the development of physiologic coor- dinations within wider limits than usual, as well as in anatomic growth of the tissues which must chiefly bear the burden of excessive function. Careful, gradual preparation of the powers preliminary to ordinary ex- ertions at high altitudes is as important an aid to acclimatization as is the course of training found necessary by an athlete before entering on a physical contest. . Practical medical climatology seeks to define the climatic conditions which Avill favor the development of maximum machine efficiency from the physiologic functions of the body, taken as a whole, in men of every variety of constitution. It is important to bear in mind that, as in human society, so in the community of cells forming an organism, the optimum activity of each individual element which contributes to the best interests of the l)ody as a whole is that through which it gives the utmost help to the purposes of its associated neighbors; or, in the language of field sports, it is only through " team work " that an aggre- gation becomes a successful unit. Therefore, in making a climatic prescription for a definite individual, the medical adviser considers the interests of the weakest function to be paramount. A debilitated heart or kidney may need as thorough relief as possible from the exigencies of its functions ; accordingly, in such a case it is usually sought to fix on a climate characterized by a moderate and equable temperature, a fair amount of humidity, and an environment offering stimuli, of what- ever sort, varying in frequency and intensity only sufficiently to keep the mind pleasantly interested. These are the physical conditions con- stituting what is termed a sedative climate. i^ccording to the nature and range of intensity of physical stimuli involved in the environment, the physiologic effect may vary from tonic and bracing to one promoting lassitude. On the other hand, in chronic s3^stemic infections, such as tuberculosis, whose cure is founded, appar- ently, on the products of vital reactions of living tissues to stimulation, experience confirms the theory that, midatis mutandis, the most favorable environment, such as an outdoor life, is one in which the physiologic re- sponse of the vital tissues is pushed toward an extreme. Such conditions determine the stimulating climates, especially as manifested in resorts at high altitudes. THE PRINCIPLES OF PHYSIOLOGIC REST 679 In the infinite variety of more or less morl)id conditions which de- pend on general vital depression from too continuous effort, or when there is debility of one or another of the vital functions without distinct disease, the safest climatic therapeutic advice is founded on the known psychic effects of geographic change. THE PRINCIPLES OF PHYSIOLOGIC REST While nothing is more certain tlian that tlie functioning powers of an organism demand for their development exercise in overcoming re- sistances, nevertheless therapeutic experience has established the truth that in many morbid conditions the only safety for the individual is to be found in a condition approaching absolute rest. In local septic infections it is easy to see how muscular contraction, with its attendant acceleration of tlie circulation, can disseminate the materies morhi and poison the whole body. Though even in this sim- plest case the rationale of successful treatment is obscure enough, the general principle is clear that the healthy organism, undisturbed by functional demands, has extraordinary power to remedy purely local evils in its various parts. Indeed, the very fact of its existence is crucial evidence that a given organism is endowed with a power of constructive metabolism sufficient to have overcome innumerable assaults of opposing forces. When we recognize the importance of physical rest as an aid to the " resistance " powers of the body in its struggle with infectious disease, it is not difficult to believe that in those intricate disorders arising from maladministration of its nervous and psychic forces the broader princi- ples of physiologic rest must be invoked to accomplish a cure. Lombard, in measuring a series of knee-jerks, has shown that the height of the contraction is at once increased when a sound, so faint as not to be consciously perceived by the subject, breaks the stillness of the air. This is a concrete example of what is doubtless a general truth that every known physical agent, not to mention unknown forces, inevitably ex- cites the sensorium when of sufficient intensity to cross the threshold of irritability of the peripheral afferent nerves. These stimuli, more- over, invariably overflow from the recipient sensory centers, and radiate in currents of greater or less intensity throughout the motor and cen- trifugal districts of the nervous system. It is capable of satisfactory demonstration that such conscious and subconscious stimuli may operate as pathologic irritants, for they exert upon the nervous system essentially the same disastrous influence as does physical exercise upon the inflamed or infected tissues at large. While it is relatively easy to secure pos- tural quietude through the so-called "rest treatment,'' it would seem 680 CLIMATIC THERAPEUTICS impossible to prevent the coruscations of sensory impulses throughout a hyperirritable nervous system. Nevertheless, the therapeutist finds that Nature has provided for her kinetic energies a balance which we know as Inhibition, through which activity may be restrained, conserved, or annulled. It is evident that this field of his labor has become that of ps3Thology, and the assertion may jferhaps be ventured that, through the application of what may crudely be included under the term " suggestion," the forces of inhibition may be aroused to restrain and direct the dispersive energies of the neurons. The marvelous clinical rehabilitations which are daily placed to the credit of " psychic " ministrations represent nothing more than the superiority of the inherent, sustaining, conservative resisting powers of protoplasm when freed from what may be called adventitious vital friction. In short, functional metabolism throughout the body has an unmeasured range of adaptability to its normal tasks when freed from aberrant nervous impulses. Such freedom constitutes rest. On reflec- tion it is clear that rest in the sense here involved is not different in kind from that exercise whose energy is not lost in friction, but is directed to functional uses. CLIMATIC THERAPEUTICS By W. JARVIS BARLOW HISTORICAL ASPECTS It is interesting to read the translations from the Greek and Latin, and note how much the ancient authorities — Hippocrates, Galen, Celsus, and Paulus ^Eginetes — studied the conditions and factors of climate, and their effect on epidemic and chronic diseases, their views on the air of various places, the water, dust, soil, and so on. Hippocrates, the father of medicine (470 B.C.), speaking of air, water, and places, says: " Whoever wishes to investigate medicine properly should proceed thus : In the first place, to consider the seasons of the year and what effects each of these produces (for they are not at all alike, but differ each from themselves, in regard to their changes) ; then the winds, the hot and the cold, especially such as are common to all countries, and then such as are peculiar to each locality. You must also consider the quali- ties of the waters, for as they differ from one another in taste and weight, so also do they differ much in their qualities." He also lays emphasis on the situation of the town or city in respect to the prevailing winds, the rising sun, and the amount of sunshine. In the matter of HISTORICAL ASPECTS 681 soil, he says that one should understand and be particular whether the place is marshy, well wooded, and has a sufficient water supply, and that by knowing these things one will not be in doubt as to the treatment of disease, or make as many mistakes as if he had not been in possession of this knowledge. Among the aphorisms of Hippocrates which were discussed by Galen and others there are announcements, true in all ages, that are generally accepted in modern times. Some apply to special climatic therapeutics. " The changes of the season most engender diseases, and in the seasons great changes either of heat or of cold, and the rest agreeably to the same rule." " Of natures (temperaments?), some are well or ill adapted for summer and some for winter." ISothing can be truer than this in our modern teaching. " Of diseases and ages, certain of them are well or ill adapted to different seasons, places, and kinds of diet." " Of the constitutions of the year, the dry, upon the whole, are more healthy than the rainy, and attended with less mortality." " Autumn is a bad season for persons in consumption." " The spring is most healthy and least mortal." Althougli these aphorisms were written many years be- fore Christ, nothing truer can be said to-day. A. Cornelius Celsus, born 25 B.C., whose medical writings in Latin are so well knowTi, in speaking of phthisis stated : " But if the distemper is more violent, and there is a true phthisis, it is necessary to oppose its beginnings, for if this distemper continues long, it is not easily overcome. If the patient's condition allow, he must take a long sea voyage, change his climate, taking care to remove to a grosser one than that he leaves, and therefore from Italy to Alexandria is a very agree- able change. ... If the weakness will not admit of that, it is very proper to sail in a ship, but not too far; but if any circumstances ren- der the sailing unfit, the body must be moved on a litter or some other way. ..." Paulus zEgineta, who wrote in the seventh century after Christ, laid special emphasis on pure air and the fact that the different qualities, such as heat, cold, dryness, or humiditj^ have not the same effect on all; that it is a matter of temperament with regard to the benefit derived. Thus it is seen that not only a change of surroundings, but a change of climate, Avas recommended in the earliest records. Often the benefit that such change brought to the patients was attributed to nonatmos- pheric elements. Springs were frequently sought for their mineral effects, agricultural districts for their dairy products, vicinities of for- ests for their healing qualities. The scientific application and appre- ciation of climate as such, and its effects on disease, belong to more modern days and have gone hand in hand with the study of meteorology. 45 682 CLIMATIC THERAPEUTICS Eichard Morton (1637) (Osier, '04), in speaking of the prevention of tuberculosis, advocated " open, fresh, kindly air, and such as is free from the smoke of coals." Benjamin Eush, in 1793, writing on the palliative treatment, says: " The first remedy under this head is a dry situation. . . , The higher and drier the situation which is chosen for this purpose the better. . . , Much has been said in favor of sea voyages in consumption. In the mild degrees of the disease they certainly have done service; but I suspect the relief given or the cures performed by t^liem should be con- fined chiefly to seafaring people, who add to the benefits of a constant change of pure air a share of the invigorating exercises of navigating the ship." GENERAL DEFINITION OF CLIMATOTHERAPY Climatotherapy is the application of climatic factors in the treat- ment of disease. Meteorologically considered, climate may be said to depend on (1) distance from the equator, (2) the elevation above the sea level, and (3) the distribution of the land and water over the surface area. The amount of sunshine, heat, and humidity will be dependent on the above factors. In all diseases, but especially in tuberculosis, many other factors, independent of atmospheric conditions, must be embraced within the term climatic treatment. The individuality of the patient, his environ- ment, his resources, his intellectuality, his mental attitude, and the stage of the disease must be considered before a change of climate is advised. Then, too, it must be remembered that one place may offer ideal atmospheric conditions for a climatic change, while it gives unfit or no accommodations, with poor food and little comfort. All these factors not dependent on meteorologic conditions are included in the term climatotherapy, and in this sense the subject will here be treated. IS THERE A SPECIFIC CLIMATE FOR PULMONARY TUBERCULOSIS ? No climate is a specific for this disease. In choosing a climate, individualization must be the kej^note of treatment. The old idea of a particular zone or a climate conferring immunity to tuberculosis has been generally given up. There is still reason and good authority to believe that tuberculosis exists less in dry regions, either in dry forest places or in elevated and low-lying desert lands. Such places are rela- IS THERE A SPECIFIC CLIMATE FOR TUBERCULOSIS? 683 tively free from tuberculosis because the inhabitants live out of doors, in the pure air, in localities not yet contaminated by settled districts. When these places are thickly populated and cities are formed, tuber- culosis is no longer rare, even among the natives. In other words, it is the social life and unhygienic conditions which beget the spread of tuberculosis and not the climate that prevents it. This is shown in the American Indian, when taken from his native environment and placed in settled districts or under changed social conditions. The increasing mortality from tuberculosis of the American negro (Brandt, '03) since the war also verifies this point. Before the war he was well housed, cared for, living an agricultural life. Since the war the negroes have drifted into the cities, living under most unhygienic conditions. Havard ('05), Assistant Surgeon General, U. S. A., writing on the mortality in tropical climates, shows that it is more the local social conditions than any factor of climate that is responsible for the great prevalence and mortality of tuberculosis in Manila and Havana. Treatment of tuberculosis by climate requires more than merely the study and knowledge of the meteorologic conditions, and yet in no other disease does climate play so important a therapeutic role. Climato- therapy is the close study of individual tastes for each and every patient, and in fact all conditions that arise in relation to the place selected — atmospheric, topographic, sociologic, ps3^chic, and economic. Too much stress has been laid on temperature, humidity, and altitude to the exclusion of other factors, such as social and hygienic conditions, proper and congenial environment. More and more are we studying the individual requirements of cli- mates for tuberculosis, and a patient should never be advised to make a change without a knoAvledge of the conditions to which he will be subjected. It is not so many years ago when it seemed necessary to send the patients to a climate heralded for some specific quality, and a relaxing climate, like Madeira, was the favorite choice. Then came the inland climates, and later the tonic and stimulating effects of the high, dry, cold air of the Alps and Eockies; and more recently, still, has come the realization that tuberculosis can be treated successfully in any locality. Some modern therapists deny the efficacy of any cli- mate, one holding (Flick, 'OG) "that there is absolutely nothing in climate in tuberculosis." The difficulty lies in the fact that the pendu- lum swings too far whenever anything new in medicine is exploited, so that when cures are made in the moist climates there are those who seem to lose sight of how much more might be done with the added climatic factors. Fortunately, the pendulum has swung back to a more rational position, so that to-day, with our individualization of treat- ment, every factor, climatic or nonclimatic, is utilized. 684 CLIMATIC THERAPEUTICS PRINCIPAL TYPES OF CLIMATE The classification of climates has always been a difficult matter to all climatologists. A method based on geographical position (distance from the sea and distance from the equator) offers less complications than one dependent on physiologic or therapeutic effects. It is the purpose, here, to arrange the types in the manner that appeals most to the writer — i. e., distance from the sea — giving the climatic factors com- mon to the various types. With this thought in mind, the following classification is presented : f A. Sea voyages. I. Ocean. J B. Island. Ic. Coast. II, Inland. . 'A. Low altitude (up to 1,000 feet). B. Medium altitude (1,000 to 3,000 feet), C. High altitude (3,000 to 6,500 feet). D. Deserts. The meteorologic factors of these different typos will be taken account of as each group is considered in turn. The chief elements that give character to any distinct climate are temperature, the degree of mois- ture (for practical purposes confined to relative humidity), the wind conditions, and the atmospheric pressure. Among elements of minor import might be named the electric phenomena of the atmosphere. Other factors that have influence on the climate of small areas are the character of the soil, whether dry or moist, distance from or nearness to bodies of water, size and nature of forests, vegetation, density of population. Nonporous, damp soil may be detrimental, because by it the humidity of the air in such a region may be changed ; too dry a soil, if there is much wind stirring, may not be beneficial on account of the dust produced; nearness of large areas of water changes the wind con- ditions. Large forests give protection against winds, and on the other hand, when coolness is needed, prevent the breeze from reaching the place. They are often a protection from dust and pathogenic organ- isms. Much vegetation produces humidit3^ I. Ocean Climates. — Here temperature, according to latitude, varies less than with inland climates. The general characteristics and im- portant properties of ocean climates ai-e pure air and freedom from dust and pathogenic organisms; in general, they are moist and equable. The evenness of the temperature is characteristic; the difference of the temperature between day and night, for both summer and winter, is less than the inland climate, and in southern latitudes the temperature is PRINCIPAL TYPES OF CLIMATE 685 equable the year around, modified more or less by the Gulf Stream aud other strong ocean currents. The physiologic properties of the ocean climate, according to Schroeder and Blumenfeld ('04) show that the heart action is strengthened and that the pulse is slowed, for the moist air and air currents cool the skin and lead to the contraction of the blood-vessels. This, in turn, reflexly leads to increased heart action and dilatation of the blood-vessels of the skin, and finally to a cutaneous hyperemia. The ocean climates, in gen- eral, have a sedative and relaxing effect on the nervous system. The mucous membrane and skin are more active. The increased pressure leads to increased depth and slowing of respiration. The metabolism is considerably augmented, and, on account of the respiration, more carbon dioxid is thrown out. With this change of metabolism comes an increase of weight, and an increase of blood cells and hemoglobin. This important effect on metabolism is a matter of individuality. Many persons, sick or well, who have made a change to an ocean climate, with whom such a climate agrees, may show just such results, while oth- ers will not improve at all in the same climate. Based on this adapta- bility of the individual to particular climates, Pluggard ('06), in dis- cussing types of climate, states that " the tonic or relaxing character of a climate turns chiefly on the ability of the organism to adapt itself to the requirements. Other things being equal, that climate is most tonic which demands the greatest amount of tissue change that a given organ- ism can permanently yield." He shows that a climate that is tonic and stimulating to one person may be relaxing and sedative to another, and vice versa. (a) Sea Voyages. — On a voyage with favorable weather conditions, one may, for a long period, experience the general characteristics of the ocean climate, receiving the benefit of outdoor life in the purest of air. On the other hand; the weather conditions may be unfavorable, with rain and high winds. In general, this type of climatic treatment is only applicable in the earliest stages of tuberculosis, when there are no con- stitutional symptoms, or for arrested cases. In both instances the pa- tient should be proof against seasickness. The objections to ocean trips are that a sufficiently long voyage, under unfavorable weather conditions, may cause much confinement, and this, with the poor food too often found on the ships that go to semitropical and tropical countries, may cause disastrous effects. When a sea voyage can be made in a sanatorium ship, types of which have been constructed on the Continent, then such a sea voyage may be free from many of the drawbacks which ordinarily are a part of these voyages. (&) Island Climates. — The climates of small islands possess practi- cally the same characteristics as the ocean climate, and besides, persons 686 CLIMATIC THERAPEUTICS can be made more comfortable on an island and not suffer from seasick- ness. The smaller islands are not recommended for tuberculous persons, because of the disadvantage of poor accommodations and poor food, and isolation of the patient, which too often leads to nostalgia. One of the advantages of living on an island or on the coast is that sea bathing is possible, but this only applies to patients in the arrested stages of the disease, for those with active trouble should not bathe in the open sea. Sea bathing may be stimulating if not indulged in excessively. The first bath should be short, a mere dip of two or three minutes; longer bathing may cause much depression. If the limit of endurance has been ex- ceeded, it will be marked by a chilly feeling, vertigo, or nausea. The larger island, with mountainous districts, adds much to the scenic effects and beauty by presenting an elevated region in close prox- imity to the ocean, but the climate no longer partakes of the island character, but resembles more the ocean type. (c) Coast Climates. — The coast region gives equable moist condi- tions, and practically offers the only ocean climate for selected, indi- vidual cases of tuberculosis. The atmosphere, most of the time, is cool and damp, often foggy, especially along the western coast of the United States and Xorth Sea. Cermany. Places with coast climate have the ad- vantage of being accessible, and are often provided with suitable resorts, in wliich it is agreeable to live and where excellent accommodations may be found, with occasionally a sanatorium for the treatment of tuberculosis. Many coast climates may be warm and moist during the summer months, depending on prevailing Avinds — the land and sea breezes — which make the climate equaljle. During the day the breeze blows from the sea to the land, and during the night from the cool land to the sea. The physiologic properties of the ocean climates, given above, apply espe- cially to this ty2:>e. The cases to be sent to such places should be indi- vidualized, just as for all other climates. The indications may be grouped as follows: (1) The most favorable are early cases of tuberculosis without fever or marked constitutional symptoms. (2) Incipient eases with early and slight hemorrhages. (3) Chronic fibroid cases, with or without bron- chitis or emphysema. (4) Old people with phthisis or a recurrent at- tack. ( 5 ) All cases complicated with cardiac or renal disease. ( 6 ) Young children with pulmonary or bone lesions. (7) Cases with marked nervous symptoms. II. Inland Climates. — The temperature varies generally, according to the season, the distance from the ocean, and the proximity to the mountains, as well as the distance from the equator. In general, the mean temperature decreases with the distance from the equator. As the altitude increases the atmospheric pressure decreases, the humidity PKINCIPAL TYPES OF CLIMATE 687 lessens, the changes of temperature between day and night increase, and the sun's rays become more intense. (a) Low Altitude. — Generally speaking, the climate in a low alti- tude is moist and cold in winter, moist and hot in summer, the mean temperature diminishing with the distance from the equator, being more equable according to the proximity of the ocean climate and drier ac- cording to the relative position of the mountains. (h) Medium, AUitudc. — The climate here is warm, moderately moist in summer, cool and moderately dry in winter. In places where the rainfall occurs only in winter the climate is warm and moderately dry in summer, these factors being modified by local conditions such as forests, winds, soil, and vegetation. (c) High Altitude. — Here purity of air is the dominant feature. The temperature is cool and dry in summer, especially in altitudes over 4.000 feet; cold and dry in winter, but modified by local conditions. The climate is characterized by the changes incident to diminished air pressure, by abundance of sunshine, snow, rain in showers, and electric storms in summer time. In former times ozone was considered an important factor. There seems now, however, no scientific evidence that ozone is liberated anywhere in such quantities as to be of special service. The physiologic effects of the high altitude consist of an increase in the respiratory and cardiac functions and an increase in the appetite and general metabolism. Muscular power and the secretions of the mucous membranes are diminished. The nervous system is stimulated. The effect on the blood has long been a matter of dispute. The blood-pressure is held to be decreased slightly (Huggard, '06). The amount of hemoglobin is increased. The white cells do not increase. That there is an increase in the number of red blood cells is acknowl- edged, but the question at issue is. How much is apparent and how much is real ? The theories that have been brought forward to account for this increase are based either on changes in the peripheral circulation (Campbell and Hoagland, '02), by changes in the density of the blood (Grawitz, '95), by error in instruments used (Brlinings, '03), and by changes due to the improved general health, either from a ])rolonged life of the red cells (Fick, '95) or by formation of new blood elements (Schaumann and Rosenquist, '97). There is, undoubtedly, some in- crease in the number of new blood elements formed, but hardlv as great as the blood counts would indicate. It is an interesting fact that the increase in the number of red cells is most marked in tlie first few days, reaching its maximum in the first month, and then the number rapidly diminishes on descending to lower levels. Woinzirl ('03) has shown that cold is an important factor in the production of the blood 688 CLIMATIC THERAPEUTICS changes at high altitudes. It should be remembered also that stimu- lating climates other than those of altitude, through their effects on appetite and metabolism, lead to an increase in blood formation (Scliroc- der and Blumenfeld, '04).^ The stimulating effects of altitudes ma}^, however, be dangerous in that the demand made on the respiratory, circulatory, and muscular apparatus produce a definite strain on the system, and if the patient is not sufficiently robust, or if he is injudicious in exercising before being acclimated, serious results may follow. In the selection of an altitude for cases of tuberculosis local conditions are as important as is the consideration of the constitutional symptoms. Indications for high altitudes are: (1) Incipient cases, with or with- out fever; (2) cases beyond the incipient stage, with infiltration or beginning destruction; (3) cases with early hemoptyses or laryngeal cases; (4) cases with pleurisy or with old pleuritic exudate. x\ny of the above, with or without constitutional symptoms, are suitable for altitudes varying from 4,000 to 6,000 feet. The contraindications for high altitudes are: (1) Too great an in- volvement or softening in both hmgs ; (2) cavity formations with much hemoptysis; (3) cases complicated with kidney or heart disease or dia- betes; (4) cases with marked emphysema (asthmatics) ; (5) the very 3'oung tuberculous ; ( 6 ) fibroid cases, with dyspnea ; ( 7 ) advanced laryn- gitis; (8) excessively nervous patients. The indications and contraindications enumerated al)ove have the support of many authorities. There are various opinions for and against sending hemorrhagic cases to altitudes of over 2,000 feet, on account of the greatly diminished air pressure. The writer's opinion is that hemorrhage, of itself, is not a contraindication, except that in advanced cases, with frequent hemorrhages and cavity formation, with a history of much bleeding, medium and high elevations are not indicated. Camp- bell ('02) states that altitude does not apparently increase tlie mortality of hemorrhagic cases, but in his series of 250 patients the nonhemorrhagic cases had the advantage over the hemorrhagic in the improvement. {d) Desert Climates. — To this type belong the inland climates of low and medium altitudes. A few desert places of value in the United States are below sea level. These are characterized by an abundance of sunshine, purity of air, low humidity, frequent winds and dust storms. The disadvantages of this type are the unpleasant winds, at times accompanied by much dust and sand, unsuitable accommodations, poor food, which often lead to nostalgia and mental depression. * The increase of lymphocytes in high altitudes as well as their effect in improv- ing patients, noted by Webb and Williams ('09) should also be noted here. — Editor. PRINCIPAL TYPES OF CLIMATE 689 The indications: for desert climates are: (1) Patients with compli- cating bronchitis and emphysema, especially those with abundant secre- tion; (2) albuminuria or kidney lesion.'^; (3) far advanced cases and those of the third stage, that seem unfit for any other climate, may do surprisingly well. From what has been said concerning the indications and contra- indications of climatic treatment, the results of such treatment are dependent not only on climatic elements, but on the individuality of patients. Schroeder and Blumenfeld (04) summarize their view (see Table I, below) of this subject as follows: "There are climatic factors of eminent importance in the treatment of tuberculosis. We can find TABLE I > Comparison of Results in Tuberculous Treatment. (Summary) ^■arikty of Climatk Total Nwniber of Cases First Stage (Turban) Second Positive and or Third Favorable Stages ! Results Negative or Un- favorable Results Names of Resorts (iROUP A. Sea Climate and Coast Climate 3455 835 24.7% 2620 75.3% 2515 72.8% Madeira, Arcachon, West Riviera, 940 Entire Riviera, Norderney, Danish Coast, 27.2% Norwegian Coast, Sea Voyages. Group B. Interior Land Climate 3322 1221 36.7% 2101 63.3% 2815 88% 507 12% Grabowsee, Bedfort, Belzig, Lohr, Altena, Engelthal, Ruppertshain. Group C. Altitude 3257 .... 1222 37.5% 2035 62.5% 2856 87.7% 401 12.3% Schoemberg, Climate up to 3,000 feet Friedrichsheim, Goerbersdorf, Albertsburg. Group D. Altitude Climate abo\ e 3,000 feet 2271 .... 953 41.5% 1318 58.5% 1898 83.8% 373 16.2% Neu-Schmecks, Davos, Zurich, Asheville. ' These stati.stics are from Schroeder and Blumenfeld ('04) and show the results of treatment in sea and land climates of different kinds. In considering these figures, the difficulties encountered in making comparisons between patients in different stages must be kept in mind. 690 CLIMATIC THERAPEUTICS them on the seacoast, in the interior, in various levels ahove the sea. But there is no specific climate for phthisis. Only elements which assist our therapeutic endeavors are to be found in every climate of the moderate zone. In sea and altitude resorts they may act too power- fully and become harmful. The strictest individualization is therefore necessary when they are recommended. It ought to become the common property of all physicians that nothing can become more harmful to tuberculous patients than the routine belief in a specific influence on tuberculous processes through climate." GENERAL UTILIZATION OF CLIMATIC TREATMENT From what has been previously written in this chapter, it is evident that in choosing a health resort, the nonclimatic factors as well as the meteorologic elements must be considered. As there is no climate spe- cially suited for all tuberculous patients, no simple rule as to the best climate can be followed strictly. Patients who do not react to the extra demands of a cold climate will do better in a semitropical region. For instance, young, robust indi\iduals with tuberculosis, sent to a cold, dry mountain resort, Avill find living in the open air easier, and will have better appetite and digestion, and Avill improve more than the weak and old with a similar type of disease, these latter improving more in a mild, warm climate of lowered elevation. In choosing a resort, the factors to be considered are: 1. Atmospheric conditions. 2. General topography. 3. Social environment. 4. Economic circumstances of the patient. 5. Psychic condition of the patient. 1. The elements of atmosphere in their relative importance are: (1) Purity of air; (2) percentage of sunshine; (3) pressure of air; (4) the amount of humidity; (5) the temperature and its variations, diurnal and otherwise; (6) the winds, their severity and whether laden with dust or other impurities. 2. In regard to the topography, the place (1) should have a dry, porous soil; (2) should be protected from strong winds by hills or forests; (3) should be free from dust; (4) have sufficient open grounds, and (5) a view and vegetation pleasing to the eye. 3. Under social environment are to be considered (1) the size and density of the population; (2) the general sanitation; (3) the restric- tions and health rules governing invalids; (4) the number and extent of industrial activities, all of which may be factors in the making or marring of the climate of a resort. GENERAL UTILIZATION OF CLIMATIC TREATMENT 691 4. The economic factor is a most important one, for the cost of living is everywhere increasing, and what were once considered luxuries are now placed among the comforts of life. Has the resort to which the patient is to be sent good accommodations? Suitable and hygienic houses and homes, w^here the proper food can be obtained, are also necessary, and for many patients light amusements and pleasurable diversions are additional factors. It must be known that good medical attendance can be had at all times. To obtain these ends the patient should be in command of sufficient money to give him the necessary comforts for at least one year. 5. The psychic element is by no means to be underestimated. The patient should strongly desire the life of the particular resort chosen, and be mentally in harmony with what such a climate offers. An element may act as a psychic depressant to one patient and have the opposite or no eifect on another. It is easily comprehensible that con- tinued cloudiness and fog is depressing, but a stronger psychic force is working when, as happens, patients find a cloudless climate and abundant sunshine monotonous and irritating. It is unwise to send patients to places where the surroundings produce depression. The psychic element in many cases is so strong a factor that it must be recognized and successfully met. The physician who individualizes most carefully will have the best results. He will not send a patient who has been used to comforts and luxuries to a climate meteorologically ideal where the surroundings are uncongenial, the accommodations mea- ger, and the food poor; nor will he send an active, easily tempted tem- perament to an ideal resort where any phase of fast living is easily obtained. H. P. Loomis ('06) has aptly put it tlnis: "Each case is to be studied, not as one having a certain disease which is ordinarily benefited by such and such a climate, but as an individual with distinct tem- perament, inclinations, and personal, peculiar phases of the disease." Bullock ('02), in speaking on the same subject, writes: " So impor- tant do I consider the psychic status in any given case, that if a patient persists in a pessimistic viewpoint, occasion is taken to have a talk, the purport of which is that ' it might be better to go somewhere else ' ; for, without the cooperation of our patients, ' in spirit and in truth,' there is so little to be gained that the game is hardly worth the candle. . . . The psychic element in the treatment of the tuberculous is well illus- trated by conditions at the government sanatorium at Fort Bayard. Patients are ordered there for treatment ; the opportunity to get well is not sought, it is thrust on them. The regime at Fort Bayard, from a scientific viewpoint, is above criticism; nevertheless, because the pa- tients belong to a class who do not appreciate anything forced on them. 692 CLIMATIC THERAPEUTICS no matter how good, the psychic state opposing rather than favoring recovery, the results will never be comparable to those obtained in an institution where the opposite state of mind prevails. In spite of this great disadvantage, the patients who have really appreciated the oppor- tunity to get well have been sufficiently numerous to demonstrate beyond cavil the superlative advantage of a favorable climatic environment in the application of the principle of modern phthisio-tberapeutics." OPEN AND CLOSED RESORTS For so long a time has climate been looked on as a factor in the treatment of tuberculosis that, according to the mode of life followed by the patient, the terms open and closed treatment have come into use. The closed resorts are those where patients avail themselves of the climatic treatment in institutions or sanatoria, and the open resorts those in which patients pursue the treatment outside of institutions — in homes or hotels or wherever they choose. That the sanatorium, combined with climatic treatment, gives the best results for all early active cases is beyond question. Of the factors which help toward the good results of this combined climatic-sanatorium treatment, there is no doubt that the sanatorium methods — that is, the attention to diet, exercise, hydriatic measures, and regulated mode of life in the open air — have more to do with the good results obtained than anything in the climate itself. In the early days of the sanatorium doctrine it was claimed that the tuberculous must be treated in such an institution, situated in some special climate. Later, as the results of sanatorium treatment in all kinds of climate became known, this view was modified, and it was claimed that all consumptives were to be treated in institutions, because proper modes of living were almost impossible in an open resort. This extreme view is to-day somewhat modified, for we have come to a more rational view in realizing that there can be no rule or dogma for all cases. We know now that some do better in the home, under suitable regime, and that others improve more in sanatoria, irrespective of cli- matic advantages or disadvantages. It is to be remembered, however, that the attainment of the hygienic- dietetic and other needs enumerated are dependent not solely on the possession of well-constructed buildings in suitable places, but more on the guiding hand of the institution — namely, the medical director. The results will be largely dependent on him, while the grouping of buildings and patients enables him to carry out the work more easily. Babcack ('07) says that without good accommodations and the attendance of skilled phthisio-therapists, the home climate, with all OPEN AND CLOSED RESORTS 693 its drawbacks of weather, is preferable, and again that the average physician is not sufficiently informed concerning the best methods of utilizing the home climate, or he will not take the trouble to so im- press and instruct his patients that good results in the home may be rendered possible. A change of scene is nearly always desirable for every consumptive, and such a beneficial change may be made by moving the patient to the top floor, to the roof, or by utilizing a porch, or by moving him from city surroundings to the suburbs or country. Such changes are all that can be had, for the present, by the great mass of tuberculous people, the majority of whom are poor, and who must have the best treatment at the least possible expense. There is no rule for the rich. Cases must 1)6 individualized and treated according to the individual characteristics and requirements of the patients. For instance, given a group of rich patients, with each member of the group in approximately the same stage of the disease, some should be treated at home and others sent to a resort. "With our increased knowledge of the results of home treatment, some will do better in the home or in near-b}^ sanatoria than in far- distant institutions, for the following reasons : At or near home such patients may be made more comfortable, have adequate accommodations, better food, be happier through nearness of family and friends, and be less depressed than if in the presence of sick people. The disad- vantages of home treatment are that it is often difficult to control the patients and keep them to regular habits, and prevent the worry con- sequent on domestic and business cares. Frequently, too, the family becomes an obstacle to the desired ends through lack of cooperation with the physician. In general, when patients have insufficient means to meet the extra demands of removal and the proper life in a suitable climate, it is best to have them remain at home, no matter what the local climatic condi- tions may be. In sending a patient to a resort, the question naturally arises. Where shall he live? The large hotels are to be avoided, since they offer too great temptations for irregidar habits and are less adapted for the out- door life. Many of the large hotels also state that they do not receive tuberculous patients. What is meant, however, is that they do not accept, as guests, persons who are in the open stage of the disease. There is usually no objection to persons who have had tuberculosis and who have no bacilli-laden expectoration or show signs of active trouble. All these things considered, with our present knowledge of the correct regime for the tuberculous, it would seem best that the patient rent a house or go to a good boarding place, remaining under the constant super- 694 CLIMATIC THERAPEUTICS vision of a competent physician. Or when the health resort hoasts of a sanatorium, the patient may enter such an institution. Whether a patient is to have institutional or noninstitutional treatment depends on the individual case, except that a patient who is always bright, cheerful, and sanguine is likely to do well in either location. The advantages to those who go to the sanatoria are that more often the patients there make a business of the treatment. It is easier to keep habits and rules because others are doing the same. The mental train- ing, in the way of hope and encouragement, given to patients is also productive of great beneficial effects. The disadvantages of sana- torium life to not a few are the homesickness, the monotony of the food and care, and the depression caused by the presence of other sick people. The advantages to many who live in the open resorts are: Freedom, through daily change of routine, Avhich is always stimulating; the grati- fication of mental and physical tastes, and the greater variety of amuse- ments and entertainments in their hours of exercise and rest (which, however, may work for good or harm), and the individual choice of medical attendants. It will be understood from the foregoing that the decision as to the relative value of open and closed resorts is no easy one, since so many factors other than the purely climatic ones must be taken into consideration. Here, as elsewhere, statistics give only a limited view- point of the relative value. Table I (page 689) gives the results of treatment obtained in dif- ferent types of climatic resorts drawn from various sources, all but about one third of the patients belonging to the coast group, having been treated in closed institutions. TABLE II Results of Treatment in Insurance Sanatoria of Germany Public i\ Closed S.\NATOKI.\ Favorable Results Able to Return to W() : 75(75.8%) 5( 0.6%) 3( 3.0%o) (0%) 12 (75%) 4( 2.5%) 397(40.8%) .^,65(58.0%) 12 ( 1.2%) Results of Treatment AT Augusle Viktoria Slift Sanatorium 437(69.2%) 181(28.7%) 13 ( 2.1%) 4.30(45.9%) 428(45.6%) 80 ( 8.5%) 29 ( 5.1%) 299(53.3%) 234(41.6%) Complete recovery. . . Partial recovery Negative 896(42.0%) 908(42.6%) 327(15.4%) As regards the interjiretation of the above figures, to use Eoepke's own Avords, " that is, the number of first-stage patients treated at the Lippspringe Bath (open resort) are three times as great as at the Sanatorium (closed resort). The number of second-stage patients 696 CLIMATIC THERAPEUTICS treated at the Lippspringe Bath is four and a half times less than those treated in the Auguste Viktoria Stift Sanatorium ; and yet, in spite of the much worse material at the sanatorium, the results of treatment were much better than at the bath." Concerning the criticism of the German sanatoria by Cornet, the opinion seems to be that he has somewhat overdrawn the picture. It is true that these institutions have cost an enormous amount of money and the permanent results obtained have been less than has been desired, but the great educational value of such institutions and the real benefit derived by hundreds of the patients treated should stand as sufficient reward for the efforts expended. THE SELECTION OF A SPECIAL CLIMATE OR RESORT From what was said in the section dealing with tlie general utiliza- tion of climate, it will be understood that not only are the meteorologic conditions to be considered in the selection of a health resort, but the social conditions also. Patients with limited means are not apt to do as well in distant resorts as those who can purchase the comforts needed. It must be remembered that the climatic advantages of particular re- sorts are apt to ])e magnified l)y those who are interested in their success. On the other hand, the patient must be told that every cli- mate has, at times, some unpleasant weather. Here, as in many other things, experience is often the best teacher. To know a climate and its therapeutic advantages, the meteorologic and social conditions must be studied, and this often cannot be done in less than several months. Speaking generally, the high, dry climate, with freedom from wind storms, where snow and rain come in showers, and which possesses the greatest possible amount of sunshine, is recognized as the best place for uncomplicated cases of pulmonary tuberculosis. It is unfortunate that such climates are not more equable than they are, but equability is a factor usually found associated with moist climates. The indications and contraindications for different types and degrees of pulmonary tuberculosis, which were presented in the section dealing witli types of climates, suggest to what extent the physical condition of a patient may influence the selection of a special resort. In addition to possessing the advantages due to changed meteoro- logic conditions, a proper resort should have suitable accommodations for leading the out-door life, and should have good food and pleasant surroundings. Under such conditions, with freedom from business and home cares, and with the mental and physical stimulation from the changed surroundings which the patient is given, there should then be. THE SELECTION OF A SPECIAL CLIMATE OR RESORT 697 with proper medical supervision, a fair chance for improvement. If the patient pursues the climatic treatment in an institution, he learns, in addition, while caring for himself and watching others, what is the best mode of life to follow. Some of the disadvantages of going to a distant resort are the great expense involved, the long journey, the temptations created by too great an amount of amusement or exercise, and the fact that often the place chosen is not the one most needed by the patient. This last fault, however, may often be laid at the door of the physicians who, owing to their own lack of knowledge of the subject, give their patients most indefinite directions as to where to go. Another disadvantage is that the patient, after undergoing a course of treatment, finds he cannot return to his former home because of the great difference in climatic factors. With regulated methods, the good results of treatment of incipient cases at a suitable climatic resort should be at least ten per cent higher than in closed sanatoria in the damp, changeable climate of the East, Gardiner ('01) placing the figure at fifteen per cent. Henry ('06), in discussing types of climate from the standpoint of temperature, gives the following grouping: " Classifying as warm those regions having an annual mean tempera- ture of G0° [F.] and above, it will be found that such regions embrace the southern portion of North Carolina, South Carolina, Georgia, Flor- ida, the Gulf States, the southwestern portion of New Mexico, southern Arizona, and the greater part of California, excepting, of course, the mountain districts. " Classifying as temperate those regions having an annual mean tem- perature between 50° and 60° [F.], it Avill be found that such regions embrace the greater portion of the Middle Atlantic States, the Ohio Valley, Tennessee, the southern portions of Indiana and Illinois, all of Missouri, Kansas, Oklahoma, and .southeastern Colorado. " Classifying as cold those regions having an annual mean tempera- ture of 40° to 50° [F.], it will be found that such regions embrace the northern tier of States, including the northern portion of Indiana, Illinois, all of Iowa, Nebraska, South Dakota, "Wyoming, and the moun- tain districts of the West." The classifications of resorts according to distinguishing meteorologic factors are always imperfect and unsatisfactory, but in keeping with the usual vogue such a grouping is here presented : Cool and moderately moist: Canada, Adirondacks, Catskills. Cool and dry: Colorado; higher altitudes of New Mexico, and a few in Arizona; high altitudes of the Alps, Engadine (Davos, St. Moritz). 698 CLIMATIC THERAPEUTICS Cool and moist: Coast of Maine; much of Canada; mountains of North and South Carolina and West Virginia. Warm and dry: Medium and low altitudes of New Mexico and Arizona and western Texas; southeastern part of California; Mojave Desert; upper and lower Egypt, and mountains of South Africa. Warm and moist: Florida, Bermuda, Madeira, Canary Islands, South Africa, and Southern California. Warm and moderately moist: Most of South Carolina; Georgia; in- land of Southern California; Kiviera; southern Spain; north coast of Africa. Warm and moderately dry: High elevated regions of Southern Cali- fornia, except southeastern part; northern and central Italy, ENUMERATION OF RESORTS The space allotted to this sul)ject does not allow the presentation of the advantages and disadvantages of the large number of places in our own country and abroad which have become noted as resorts favorable for the treatment of pulmonary tuberculosis. The extent of the United States is so vast and the formation so great, with TABLE IV Cities Boston, Mass New York,- N. Y. . . . Philadelphia, Pa. . . . Charleston, S. C Atlanta, Ga Pensacola, Fla New Orleans. La. . . . Galveston, Tex St. Paul, Minn Detroit, Mich St. Louis, Mo Cincinnati, Ohio. . . . Memphis, Tenn Cheyenne, Wyo Denver, Colo Salt Lake City, Utah Portland, Ore San Francisco, Cal . . San Diego, Cal Santa Fe,N. M Yuma, Ariz 15 37 42 11 1,052 12 8 6 758 593 466 553 268 6,056 5,219 4,293 20 28 40 6,180 137 .a H t >< M EAN Monthly Temperature a "-5 >> 93 3 j3 05 < 05 a; c 3 ►-5 >-5 3 3 < u % Hi a Oi m a O o Z S 31 27 28 35 45 57 66 72 70 63 53 42 32 33 30 31 38 48 60 69 74 73 66 56 44 34 31 32 34 40 51 62 72 76 74 68 57 45 36 33 50 52 58 65 73 79 82 81 76 67 58 51 25 46 46 52 61 70 76 78 77 72 62 52 44 24 52 56 60 67 74 80 81 82 78 70 60 54 33 54 57 63 69 75 81 83 82 79 70 61 55 33 53 56 62 69 76 82 84 83 79 72 63 57 31 12 16 29 48 60 67 74 72 62 50 32 20 33 24 25 33 46 58 67 72 70 63 52 38 29 31 32 34 44 57 66 76 80 78 70 59 44 36 32 32 35 43 54 65 74 78 76 69 57 44 36 33 41 44 52 62 71 78 81 80 73 63 51 43 33 25 26 32 41 52 61 67 66 57 46 35 29 31 29 32 39 48 57 67 72 71 63 51 39 33 30 28 33 42 50 58 67 76 75 64 52 40 33 32 39 42 47 51 57 62 67 66 61 54 46 42 32 50 52 54 55 57 59 59 59 61 60 56 51 32 54 55 56 60 62 65 68 70 66 64 59 56 30 29 32 40 47 56 66 69 68 61 51 39 31 28 54 59 64 70 77 85 92 91 84 73 62 56 C 05 03 a 49 52 54 66 61 68 69 70 45 48 56 55 62 45 50 52 53 56 61 49 72 ENUMERATION OF RESORTS 699 moimtains, inland seas, deserts, various latitudes, and the two oceans, that any type of climate may be found. For a complete knowl- edge of the subject the reader is referred to the larger works on climatology.^ To show how widely meteorologic factors differ, the monthly and annual temperature means of cities in different sections of the country (Henry, '06) is herewith presented (Table IV). These temperature means are the averages of observations taken by the United States Weather Bureau (Henry, '06) over periods of thirty years or more, and give somewhat of an idea of the temperature con- ditions met with in different parts of the country. Figure 175, showing the isotherms or lines of equal average temperatures for the year, pre- sents similar knowledge in somewhat different form: Fig. 175 — Normal Surface Temperature for the Year in the United States. The following table (Fig. 176) shows the amount of rainfall by inches for tlie four seasons of the 3'ear for twelve different cities in the country, and enables one to note at a glance the difference in rainfall ])recii)itation for these various regions (Henry, '06). •A very useful book in this connection is the "Directorj' of Institutions and Societies Dealing with Tuberculosis in the Ignited States and Canada," published by the National Association for the Study and Prevention of Pulmonary Tuberculosis, and which contains a list, by States, of the sanatoria in the United States and Canada, and the capacity and charges of each. 700 CLIMATIC THERAPEUTICS MEAN RAINFALL (in inches & by seasons) FOR DIFFERENT PARTS OF THE UNITED STATES. • PLACE • VINTER SPRING SUMMER FALL SARANAC LAKE, NY 74" ^^ II b' ^_ PHILADELPHIA. PA q.7' <1 5' II 1" 15' ASHEVILLE. N.C q.7" 111' iS.fc" 4L. AIKEN. S.C. iij" lib' |I5 5" i£^__ COLORADO SPRINCS.COL 8" 1 4.5" 7 0' 1.0" ALBUQUERQUE, NM i>o- I 13" • 3 4" ^i^' SANTEFE, NM. t 0" t ^ 33- PRESCOTT. NM 4.S" ^ ^ 3 0' PHOENIX, ARIZ 2 1- [■"■ i"*' ■'' YUMA, ARIZ. ■ 4' 4" Ob' LOS ANGELES , CAL ^^B 10)' O.l' ZJ' SAN DIEGO. CAL 5 4" 2 4' 3" ■ Fig. 176. — Seasonal Rainfall in American Health Resorts, Compared with Philadelphia. In the enumeration of resorts which follows, and which makes no pretense to comprehensiveness, our own country will be taken up first, various parts of the United States being considered in turn. Foreign resorts will also be discussed briefly. UNITED STATES RESORTS New England States. — Although one State in this section — Massa- chusetts — has been especially prominent in its official activities in the prevention of tuberculosis through its State sanatorium efforts, one would never send a patient to the New England States because of the climatic advantages there offered. The climate throughout the year is character- ized by great changes of temperature and of the atmospheric conditions. The cold of winter and, except in the mountainous regions, the heat of summer, on the whole, render this region undesirable from the phthisio- therapeutic standpoint. During the summer months, the interior portions of Maine and the White Mountains of New Hampshire present suitable -conditions for ENUMERATION OF RESORTS 701 arrested cases, and for patients in the incipient stages without consti- tutional symptoms, Maine presents attractive features to those wishing diversions, owing to its fine, large forests and many lakes, which make excellent hunting and fishing possible. More agreeable, during the summer, though not so beneficial to many patients, is its seacoast, the air being exhilarating even when fogs prevail. Along this coast may be found many pleasant places where the heat is never intense. The Adirondack Mountains. — The northern part of ISTew York State has an altitude of 1,500 to 3,500 feet. On account of the pioneer work of Dr. E. L. Trudeau, this section is internationally considered as a suitable resort for the tuberculous. The same cool and moist conditions prevail here as in the mountains of Maine and New Hampshire. The good results obtained have been due, however, to the open-air treatment methods of Dr. Trudeau rather than to special climatic ad- vantages. Purity of air is an important factor. The winters are cold, with much snow, when the air feels dry and bracing; the summers, in general, are cool, with much moisture. Oppressive heat occurs occasion- ally in summer, lasting, however, only a few days. As in all other eastern resorts, great changes of temperature take place. The region is studded with many small lakes, well wooded, and has an abundance of pure water. On the whole, the average weather is of the cool and cloudy kind, and one is stimulated by the crisp air. The principal resort is Saranac Lake, and a short distance from it is Trudeau, where the Adirondack Cottage Sanatorium stands. Weather conditions of the four seasons covering a period of twelve years are as follows : TABLE V January 1, 1894, to December 31, 1903 Saranac Lake. N Y Essex County (Altitude. 1.620 Feet) Winter Mean. Spring Mean . . Summer Mean Fall Mean Annual Mean . Mean of Mean of Mean Amount of Rain in Inches Number Mean the Maxi- the Mini- of Days Average Tempera- mum mum with 01 Depth of ture Tempera- tures Tempera- tures or More Rain Snow 17 27 6 7.4 42 60.4 41 52 29 7.8 35 20.-) 64 75 52 11.6 36 0.0 45 55 35 8.8 35 10.7 42 52 31 35.6 148 91.6 Direc- tion of Pre- vailing Wind West. West. West. West. West. Adirondack Cottage Sanatorium (1,750 feet), some distance from the town of Saranac Lake, receives only incipient ca.ses, and is intended only for poor people or those with moderate means, and all api)lieations 702 CLIMATIC THERAPEUTICS have to be made through the town office in Saranac Lake. It is well protected from strong winds, and has a beautiful outlook. The accom- modations include every comfort for the nominal sum of $5 a week. This institution is especially mentioned, as being one of the great achievements of Dr. Trudeau's life. By means of the results obtained in it and through his work in the prevention of tuberculosis, this great man has been an inspiration to a large number of men in similar institutions in our country. The M'ork done l)y the Adirondack Cottage Laboratory, under the excellent guidance of Dr. Trudeau, has been as notable as the results ol)tained in the sanatorium. Tliere are excellent hotels and boarding houses in Trudeau where invalids are well cared for. Other resorts are Paul Smith's, Lake Placid, and many smaller places where good accommodations may be had. Around several of the towns and along many of the lakes camp life during the summer is made a very attractive feature. Sea Breeze, near New York, with a typical eastern ocean climate, has shown what good results may be ol:)tained at the seashore in the treatment of tuljerculous diseases of children. That there is special value to be derived at the coast for children is now recognized. France was the first country to establish seaside sanatoria for children, and England has similar institutions. Brannan, in speaking of the ef- fects of this climate on joint tuberculosis, writes : " The strength- ening effect of the sea air was such that operations such as must constantly be resorted to in tuberculosis of tlie bones, joints, and glands, when patients live in cities, are rarely necessary. . . . Sev- eral patients wlio were unable to walk when they came, at tlie end of two or three months were able to run about and play with the others." The senior surgeon of the institution, after fifteen years' experience, says that the knife plays a secondary part to climatic and general influences. New Jersey. — The northern part of this State is more or less hilly and well wooded, and the towns are adapted for suburban residences. There are three places — Lakewood, Morristown, and Summit — that pos- sess climatic factors for a winter residence to invalids who cannot go far from New York. Lakewood, altitude 60 feet, farther south, near the ocean, has sandy soil and a climate that partakes of the ocean climates. It is more equable, has a greater numl)cr of sunshiny days, and is well protected by pine forests. The season extends from October 1 to June 1. According to Schauffler's record for five years, the percentage of days with sunshine averaged eighty-four. The place is supplied with fine hotels, but is too fashionable to l)e a good resort for tuberculosis. Morristown and Summit, altitude 500 feet, and to the ENUMERATION OF RESORTS 703 nortliwest, are colder in winter and cooler in summer. They are quiet places, with comfortable homes, well suited for the outdoor life in an eastern climate. Pennsylvania is another example of eastern climate. The weather conditions for Philadelphia, as a type, may be contrasted with others of the South and West. The Blue Ridge Mountain region lx)asts of pure, comparatively dry air most of the year, with porous soil, but its resorts are better in winter, since the summers are usually hot. Among them may be men- tioned Delaware Water Gap, altitude GOO feet, and Glen Summit, alti- tude 2,000 feet. Near the latter place, in Luzerne Covnty, is the ^Vllite Haven Hospital, for poor consumptives in early stages, with accommo- dations for 100 patients. The following record for Philadelphia (Henr}', 'OG) extends over fifty years : TABLE VI Philadelphia. Pa. (AUitude, 42 Feet) (a 0. S .JL. 00 5 o CI t a) a us cacc a ..H C3 S ?'3 Eo es < 3 "a CI "a; < la P-. Winter ^lean. 34 41 27 9.7 34 17.1 76 69 156 53 N. W. Spring Mean . 51 60 42 9.5 36 4.1 70 64 224 55 N. W. SummerMean 74 83 66 11.9 32 0.0 73. 67 275 62 s. w. Fall Mean. . . . 57 64 49 9.5 28 1.0 77 70 203 60 N. W. Annual Mean 54 62 46 40.6 130 22.2 74 67 215 57 N. W. The Appalachians. — This chain of mountains, almost paralleling the Atlantic coast, extends from the New England States, on the north, to Georgia, on the south. The greatest elevations are in the southern part, and there the altitudes of the various resorts of this range are sufficient to lower the prevailing temperature in the warm season of the year. All along the Eastern States the elevated regions of this range influence the climate of that section, rising in New York to 4,000 feet in the Catskills, to 5,000 feet in the Adirondacks, and in New Hamp- shire to 6,000 feet in the White Mountains. In the south Atlantic States, North and South Carolina have many elevated regions on this range which climatically are well suited for the treatment of tuberculosis. The places vary from 1,000 to 3,000 feet in altitude, and are adapted for patients who may not be sent to high altitudes or too near the coast, or who cannot endure severe cold. 704 CLIMATIC THERAPEUTICS Great and sudden changes of temperature throughout the Appala- chian range may occur at any season, as in other eastern climates. Asheville, elevation 2,255 feet, with a population of about 20,000, is the principal resort of North Carolina, and is beautifully situated, being surrounded by hilly country and fine forests, which add much to its attractiveness. It has the general characteristics of mountain places, possesses a good climate all the year round, the summers being more equable than the winters. The summer is cool and comparatively dry, the mean of the maximum temperatures being 82° F., with relative humidity of 65° to 70° F., and an annual rainfall of 42 inches. The winters are cold, some days having frost and snow, which is light and disappears quickly. The mean of the minimum temperatures is 29° F., which gives a better idea of the winter range than the mean average. Excellent accommodations, several sanatoria, and plenty of amusing diversions may be had. A patient not accustomed to high altitudes, or one who may indulge in the outdoor life, should choose Asheville. The weather conditions of Asheville (Henry, '06) for twenty-four years were as follows: TABLE VII August 1, 1857, to December 31, 1903 Asheville, N. C, Buncombe Co. (Altitude, 2 255 Feet) Mean Tempera- ture Mean of the Maxi- mum Tempera- tures Mean of the Mini- mum Tempera- tures Mean Amount of Rain in Inches Number of Days with 0.01 or More of Rain Average Depth of Snow in Inches Direc- tion of Pre- \'ailing Wind Winter Mean Spring Mean Summer Mean .... Fall Mean Annual Mean 39 54 71 55 55 50 66 82 68 66 29 43 60 44 44 9.7 11.1 13.6 8.2 42.6 27 32 36 21 116 14.8 1.5 0.0 Trace 16.3 West. West. West. West. West. Southern Pines, N. C, altitude 700 feet, a resort with the low in- land type of climate, about 100 miles from the coast, is milder than Asheville and less stimulating. The winters are moderately cold, with some snow. The place is well protected from winds, and has a sana- torium for pulmonary tuberculosis. Ail'en, S. C, altitude 565 feet, is probably the most popular resort in the State of real value to the tuberculous. The variations of tem- perature and the relative humidity are less than in other sections of the State. The winters are mild and well known for the great number of sunny days. The town is well protected by forests, has limited accommodations and a sanatorium — the Aiken Cottages — for the poorer class. The winter mean temperature is 48° F. ; mean of the maxima, 56° ENUMERATION OF RESORTS 705 F. ; mean of the minima, 39° F. ; relative liumiclity, „ 2 5 0) a 6 0> J. tion of Pre- vailing Wind Winter Mean Spring Mean . Summer Mean. . Fall Mean Annual Mean 47 64 80 63 63 60 79 94 77 77 33 50 68 50 50 1.4 0.9 4.4 2.6 9.3 9 5 20 13 47 2 0.1 0.0 3 2.4 58 38 55 60 53 32 15 26 31 26 N. W. N. W. E E. N. W. ENUMERATION OF RESORTS 713 Arizona lias climatic advantages similar to those found in Xew Mex- ico. In general the winters are warmer, the summers hotter, and the mean humidity is less. The high altitudes have snow in the winter, and there is no section of the State entirely free from frost. Unlike Xew Mexico, the Pacific coast makes its influence felt here, and tliere are two rainy seasons, winter and summer, though the greatest rain- fall occurs in July and August. The least precipitation is in the southern and southeastern part, amounting annually to less tlian three inches. The advantages of Arizona are (1) pure air; (2) the great amount of sunshine; (3) the dryness; (4) the mild winters; (5) in the ele- vated regions of the northern half, cool summers; (G) few bad storms of any kind. Mean temperature is 60° to 65° F. ; relative humidity, 30 to 50 per cent. This mean temperature gives little idea of the actual heat that exists in some places during the summer, when the tempera- ture in the lower district is 110° to 120° F. At Fort Mojave a record of 127° F. was made in June, 1896. The objection to Arizona is that it is lacking in modern towns or places where suitable accommodations may be had. In most of the towns it is almost impossible to get first-class food or care. Except in a few i-esorts, there is an insufficient water supply. Dust storms and high winds occasionally occur in spring. The .summers are uncomfort- ably warm anywhere except in the highest altitudes. Prescott, altitude 5,260 feet, and Flagstaff, altitude 7,000 feet, for all year round resorts are the two places recommended. Part of the summers may be hot, and the spring may have dusty days. The accom- modations are not good in either place. Flagstaff is beautifully situated, having nearby forests of tall pines and many interesting canons. Of the lower elevations recommended for winter climates only, the principal resort is Phcenix, with an altitude of 1,087 feet. This town is favorably situated, and well kno^^^l for its mild winters, low humid- ity, and large amount of sunshine. A distinguishing and valuable char- acteristic is the absence of wind and dust storms. Here suitable accom- modations may be had, and good care is given to the invalid; but the place is not prepared to care for a large number, and arrangements had best be made before going. Tempe, near Phoenix, has the same climatic advantages. Tucson, altitude 2,400 feet, in the southwestern part of the State, has an ideal winter climate, and can be recommended from December to April. The accommodations have improved in the last few years, and patients needing this medium altitude always improve. The following tables for Phoenix and Prescott, types of low and high altitudes of Arizona, are here given: 714 CLIMATIC THERAPEUTICS TABLE XIII Phcenix, Arizona. Altitudk, 1,087 Fekt Record from January 1, 1896, to December 31, 1903 (Henry, '06). Temper.-vture Precipitation Humidity i a) c P» ? — u. Seasons 0/ J2 ^ 2 ler of itliOOl es or Rain (L .2^ 3s S 3 ,- i a! < SCO r^ c3 5- 2?^ f. §£ = = K** 5 0) m. > Winter Mean 53 66 39 2 2 9 61 32 E. 79 243 Spring Mean 67 82 53 1.0 o 45 19 E. 85 338 Summer Mean .... 88 102 74 1.9 12 45 19 E. 86 369 Fall Mean 72 86 57 1.7 8 53 28 E. 86 297 Annual Mean .... 70 84 56 6.8 34 51 25 E. 84 312 TABLE XIV PrescottJ Arizona Altitude, 5.260 Feet (Henry, '06). Record from 1876-1903. (Irregularly.) Temperatdre Precipitation Average Depth of Snow in Inches c 55 11 0) 0.^ Seasons d.S a Number of Days with 0.01 Inches or More Rain 1^ Winter Mean Spring Mean Summer Mean Fall Mean Annual Mean 37 50 60 53 52 50 67 86 70 68 23 36 55 38 38 4.5 2.8 5.3 3 15.6 15 11 23 11 60 13.2 7.4 1.8 22.4 58 47 49 50 51 s. w. s. s w. s. w. s. w. There are places in Arizona and in southern California, east of the coast range, that are ahove and below sea level, and as dry as any places where there is abundant sunshine. These are really desert climates, examples of which are Yuma, Ariz., with an altitude of 140 feet, and Palm. Springs, Cal. It is unfortunate that there are few accommoda- tions for invalids, and that the summers are intensely hot. California. — The northern part of California (McAdie, '02) is mountainous and picturesque, with much moisture for the abundant vegetation that is present. It is mostly uninhabited, and in general unsuited for tuberculous patients except for two or three months in the summer. At that time of the year the elevated parts in the Mt. ENUMERATION OF RESORTS 715 Shasta region are coo! and iiivi^^orating. These mountainous districts are only used as a sojourn for summer outing by a few patients who need a cool, elevated place as a change from the inland regions or the warm places of southern California. Southern California (Edwards, '02) — that is, the part of the State hounded on the north by the mountains which meet the coast at Point Conception, al)ove Santa Barbara, and on the east by the coast range — is tlie region which mostly concerns the phthisiotherapist. All of this district partakes, more or less, of a coast climate, modified l)y nearness to the Colorado desert and Arizona. Places on the coast and up to 1,000 feet elevation are cool, moderately moist in fall and winter, warm and moist in spring and summer. The afternoons are always less moist than the mornings, and a])proach relative dryness. Inland 60 miles, or at about 1,000 feet elevation, it is warm and luoderately dry in winter, hot and moderately dry in summer. Although it is said with truth, owing to the diversified topography, that slight changes of location may give one a very different climate, it is impossil)le to live in an}- degree of comfort in many of the regions. Some have no accommodations, others no suitable food, and others no vegetation of any kind. Practically, the regions where one can find comfort, contentment, and happiness throughout the whole year are along or near the coast, and these regions are not as desirable climat- ically for tuberculous patients. The humidity is fairly — that is, mod- erateh^ — high, and is increased by the rainy season in winter and by the fogs in the dry summer season. The fog formation along the Pacific coast has always been consid- ered peculiar, and is especially frequent in the spring and summer within 40 miles of the coast. This interferes somewhat with the amount of sunshine, although the high fogs usually disappear before noon. The weeks that occur without fogs are uncomfortably warm, and occa- sionally there is a hot, dry wind from the northeast, laden with fine dust. On the whole, the climate for the year is more equable and comfortable than other coast climates in the United States, with cool nights throughout the year. Thunderstorms or strong winds are com- paratively rare and never severe. There is a cooling breeze from tht^ ocean by day, and from the mountains by night. California is soothing, while Colorado is stimulating (Fisk, '01). The indications for sending patients to this region are those given under Coast Climates. Los Angeles, altitude 287 feet, is about 15 miles from the coast, and is well kno\vTi as the metropolis of southern California. It is as at- tractive as any city of like size in the western country. Its population in the past ten years has more than doubled; in 1007 it was 280,000. It is well supplied with all the attractions and comforts of a modern city. 716 CLIMATIC THERAPEITTICS Its great dovclopment in the past few years has gradually lessened its desirahility as a health resort. The dust and dirt have inereased with the growing industries. Eastern people, once visitors, often settle per- manently. It is more difficult than formerly to get accommodations for tuberculous patients. At present it is best to send patients to the foot- hill districts and the sparsely settled inland places, where the humidity is somewhat less and the air free from dust and contamination. Like Denver, howcn^er, a person I'ccovering from tuberculosis near this region lias the advantage of being able to enter business life. Pasadena, altitude 800 feet, is nine miles northeast of Los Angeles, and more suitable for winter residence. This town, too, is rapidly growing out of the resort class, but its outlying districts are still Avell adapted for open resort treatment. It is one of the most charming residential places on the continent, with beautiful homes and well-kept grounds. Tuberculous patients who come to southern California will, as a rule, do better in the foothill regions of Pasadena and the San Gabriel Valley, up to and including Eiverside and Eedlands. Places along this region vary from 800 feet to 2,500 feet, and the farther away such places are from the ocean the less fog and the more heat. Suitable places are AUadena, Sicrm Madrc, Monroria, Ontario, San Bernardino, and Redlands. The fii-st four are comfortable throughout the year, with some hot days in summer. Altadena and Monrovia are each supplied with an excellent sanatorium. Riverside, San Bernardino, and Redlands are suitable winter resorts, but too warm in summer. Of all these places, Redlands, altitude 1,200 feet, has the best winter cli- mate, with good accommodations for incipient cases. It is difficult in any California resort to get accommodations for advanced patients. The climatic conditions are such that one can live outdoors with comfort, day and night, the year around, and l)e comfortable under blankets every night of summef. The weather statistics of Los Angeles (Henry, '06) will serve as a guide for this region. (See Table XV.) San Diego, altitude 40 feet, has the warmest winter and coolest summer of any town in southern California. The humidity is, how- ever, higher than in the inland regions, though the mean temperature, compared with Los Angeles, is nearly the same. The absolute minimum temperature for San Diego during the winter is 32° F. ; for Los An- geles, 28° F., and the absolute maximum for San Diego in summer is 94° F. ; for Los Angeles, 106° F. The relative humidity, compared with that of Los Angeles, is high — 80 per cent a.m. and 75 per cent p.:\r. This difference is about the same for all seasons, though the rain- fall is much. less. There are few places for tuberculous patients in San Diego, and one had best make arrangements before going. The country ENLMEKATION OF KESUKTS 717 TABLE XV 1877-1903 TEMPKR.A.TURE Pkecipitation Mean hu.miditv (U 1 "q CIS h (2 Los Anueles, o M = Cal "o.S j: ^oS-S . - r^ c^ Altitude. 287 Feet g c 55 $5 JCS .>s .ti 5i2 1? l§ s 5^ c S IS a; 5^^ = a>'3v i- s Q ►-. tf s < Winter Mean... . 55 66 45 8.9 18 67 64 74 N. E. 227 Spring Mean. . . . 60 70 49 4.3 14 83 64 66 W. 263 Summer Mean . . 70 82 58 0.1 1 88 62 74 w. 319 Fall Mean 65 77 52 2.3 6 75 65 77 w. 263 Annual Mean. . . 62 74 51 15.6 40 78 64 73 w. 268 districts back of San Diego are attractive climatically, and one can find mountain places (Julian) up to 5,000 feet, but they are too primitive for tuberculous patients. Santa Barbara, altitude 1.30 feet, has much the same weather con- ditions as San Diego, though not so equable; the winters are slightly colder and the summers warmer. There are often severe winds from the ocean, and altogether the place is inferior to San Diego. In other wa3's, however, this town is the most attractive place on the coast, and gives excellent accommodations. The nearness of the mountains to the ocean makes a picture unsurpassed in southern California. One may live at Santa Barbara, near the ocean, at an elevation of 800 feet. The disadvantages are the fogs and winds. There are places in the foothills near Santa Barbara (Ojai Valley) which are protected and more suitable for consumptives, but the accommodations are poor and the food is bad. FOREIGN RESORTS Mexico. — From a climatic standpoint, the mountain regions of Mexico aie more suitable for lung cases than southern California. The winters are dry, mild, and agreeable, with much sunshine. In the ele- vated regions, Mexico City (7,215 feet) and Guadalajara (5,100 feet) are the two places most suitable for Americans, where, on account of the size of the cities, comforts may be obtained. Contrary to the gen- eral impression, the summers are more agreeable than the winters. 'I'he chief objections are the trip to and from Mexico, the difTicully in obtaining suitable accommodations and food, and, in many places, the unsanitarv surroundings. 718 CLIMATIC THERAl'El'TK'S Canada. — The Canadian Kockics and British ColiuulMa (Hinsdale, "02) have a boldness of scenery unsurpassed in this country, and might be said to resemble the Alps. The summers are cool, dry, and bracing, and the region has the advantages of a mountain climate, but is too extreme for winter residence. Its great disadvantages are the difficult transportation and no winter accommodations. In Ontario the climate is influenced by the Great Lakes, and it is cool and moist through the summer; the winters, though intensely cold, are relatively dry, and the sharp changes met with in the United States are wanting. Gravenhurst is a favorite resort for the tuberculous, and near it is situated the well-known Muskoka Cottage Sanatorium, altitude 800 feet, established in 1897. Madeira, an island 350 miles from the northwest coast of Africa, long considered the best winter place for tuberculosis, is an example of an island type of climate, being more equable and drier than is usual. It is no longer a favorite resort, except for those needing such a sooth- ing, relaxing atmosphere. Its great charm is the beauty of its scenery, and the mild climate, free from winds and dust. Canary Islands. — These islands are 200 miles south of Madeira, are warmer, have more wind and dust, but otherwise the climate is similar to Madeira. The indications for all these coast regions are those given previously under Coast Climates. Europe. — The Alpine region has acquired the greatest reputation for the altitude treatment of tuberculosis. The best kno^vn and most im- portant resorts are St. Moritz (altitude 6,000 feet), Davos-Platz (alti- tude 5,352 feet), Arosa (altitude 6,100 feet), and Leysin (4,700 feet). St. Moritz (Klebs, A. C, '06) and Davos have the greatest reputations, and are noted for their stimulating effects and general attractiveness. Both can boast of fine, pure air, great dryness, cold winters and cool summers, with freedom from strong winds and dust storms. Patients who can go to this climate make the greatest gain in the dry, cold, stimulating air of winter. Indications are the same as for the high altitudes of the Eocky Mountain region. The resorts along the European coast are so numerous that space permits but brief mention of a few of the better known. The French and Italian Riviera are favorite winter resorts, especially for English people. They are protected on the north by mountains, and the air has an agreeable, soothing effect. The French Eiviera is less protected from cold wind than the Italian Eiviera. The contrast of the blue sea near the high mountains is not unlike a few spots on the California coast. One must expect rain in the season — twenty-five to thirty days— ENUMERATION OF KESORTS 719 from ^'ovemher to A})!'!!. The rain ofli'U comes in .sliowors, leaving llio skv clear and blue. Cannes, Monte Carlo, and ^Ice are most expensive; the social life and amusements are too great temptations for those seek- ing health. Sice is the largest town, and less attractive than Cannes. Mentone is warmer in winter, better protected from wind; a quiet, dull place, and better suited for patients. Bordighera and San Renio, on the Italian Riviera, have the same advantages for the invalid as Men lone, but are more attractive, and are growing in fame as health resorts. Southern Spain has several resorts climatically similar to the Kiviera; they are less frequented, but some find them more agreeable. For inland climates of medium altitudes, suitable for consumptives both winter and summer, some of the German resorts may be particu- larly mentioned, these places having gained their fame largely from the excellent sanatoria established there. Of such resorts may be men- tioned Goehersdorf (altitude, 1,700 feet), where Brehmer established his sanatorium in 1859; Falkenstein, which his pupil, Dettweiler, made famous; Hohenhonnef and the Black Forest region, with Walthers col- ony at Nordrach, Wehrawald, Selwmberg, etc. In the south of France are to be found Pan, Biarritz, and others. Russia.— Iw Russia, a good winter climate is found in Yalta, on the southern coast of the Crimea, which is well protected by hills and re- sembles the climate of Madeira, but is too warm in summer. For tuber- culosis the year round the inland climates situated in the Caucasus — Ahhas-Tuman (altitude 3,505 feet) and Borjon, with excellent hotel accommodations — are popular. Africa. — In this country two regions offer advantages — Egypt and South Africa. Egypt offers a dry and equable climate, but suitable only in the winter season — from December to May. The region from Cairo to Assouan ofPers the best accommodations. Xear Cairo the rain- fall is very slight throughout the year. In lower Egypt, Helouan, near Cairo, is a desirable resort. In upper Egypt are Luxor and Assouan, the latter being drier and more healthful than the Cairo region, and being also the cleanest, driest, warmest place in all Egypt. The mos- quitoes and flies are the great drawbacks in Egypt, especially in the spring. South Africa. — The southeastern coast is the best knowm portion, April to October corresponding to the winter or rainy season. Resorts wliich may he mentioned are Durhan on the coast. Cape Town and the Transvaal in tln^ interior. Johanneshur source of infec- tion may be somewhere on the lower extremity — about the genitalia, around the anus, or within the pelvis — Imt quite frequently no original focus can be detected. Tlic disease may attack both deep and super- 730 TUBERCULOSIS OF THE LYMPH (iLANDS ficial glands and exliibits a marked tendency to spread upward tlirougli the lymphatic structures surrounding the iliac vessels. As in tuberculosis elsewhere, operative intervention, in order to be of service, must be thorough, which often means a large opening and an extensive and difficult dissection. In order to follow the disease into the pelvis, an incision must be made extending from the spine of the pubes to well beyond the anterior superior spinous process of the ilium, with division of Poupart's ligament near its internal end. The unopened peritoneum can then he retracted upward, exposing the vessels and the glands surrounding them as far as the bifurcation of the aorta, if necessary (Lennander). The patient should be warned that a species of elephantiasis of the lower extremity and genitalia may follow an operation in which all the inguinal lymphatics have been removed, although such an unfortunate complication is uncommon. TUBERCULOSIS OF LYMPH NODES IN THE AXILLARY REGION These glands may become enlarged in connection with those of the neck, or the focus of infection may be situated on the fingers — an "ana- tomic tubercle," for instance — or in the mammary gland. Extensive and careful operations are necessary, which must be car- ried out with due reference to the large vessels and nerves of the part. The incision should be sufficiently large, and not pass through the axilla itself, but above the anterior axillary fold, as in carcinoma of the breast, in order to avoid embarrassment of shoulder motion arising from hypertrophy and contraction of the scar. CHAPTER II TUBERCULOSIS OF BONES AND JOINTS By L. L. McARTHUR TUBERCULOSIS OF BONES Tuberculosis invading bony structures differs in no wise from tu- berculosis in otber parts of the body except in so far as the histologic structure of the tissue influences the growth or is influenced thereby. It seems unnecessary to repeat what has already been said elsewhere in this volume of the microscopic patholog}', or to enter into a discussion of it, and therefore attention will be directed to practical factors met clinically. It is now universally accepted that there can l)e no tuberculosis without the bacillus of Koch. A definite understanding as to the manner in which infection occurs will serve to make clear many other- wise obscure points in this disease. Infection occurs only through the circulation. Many writers speak of primary bone and joint tu- berculosis. This must not be understood m the sense of entire ab- sence of other foci in the individual, since postmortem examinations reveal other discoverable foci in seventy-nine per cent of the cases (Koenig). In the remaining cases (twenty-one per cent) no other focus could be found. It has been proved ex))erimentally and clin- ically that the bacillus can pass through the intestinal mucosa with- out discoverable lesion, thus gaining access to the mesenteric lymph stream, and then to the general circulation. Clinically, therefore, it is pro])er to consider a bone or a joint tuberculosis as a single manifesta- tion (often a metastasis) of a multiple infection, and hence attention must be given to the general as well as the local treatment of the disease. Joint or bone tuberculosis presupposes that the bacilli are floating in the blood stream, or leucocytes containing them. That such is the case has been demonstrated <'xj)erimentally, clinically, and pathologically. Su(,'h floating oi-ganisms become arrested in the bones or joint imder two diflcicut conditions: (1) In the arterioles; (2) in the ')lunt venous terminals. 731 732 TUBERCUI.OSIS OF BONES AND JOINTS In the Arterioles. — Under certain conditions — as, for example, a liquefying lymph gland — a clump of organisms gains access to the cir- culation, and later lodges in a hone arteriole, wholly or partially plug- ging it and producing an infarct in the area heyond. This infarct usually is wedge or cone shape, the base of the cone being directed toward the articular surface. As this is a bacterial embolus, and the newly formed hemorrhagic infarct is an excellent culture medium, the latter becomes tuberculous and constitutes a common type of focus seen in bone. Anatomically this is peculiarly true of the arterial terminal twigs which nourish the articular ends of long bones, thus determining the shape of foci occur- ring here. Such foci, as a rule, undergo the characteristic degenera- tions of tuberculous tissue elsewhere. They may become surrounded by granulation tissue, itself tuberculous, thus constituting a tuberculous sequestrum. These sequestra are never so sharply defined as are the sequestra of an acute osteomyelitis, but can occasionally be lifted out en masse. Karely such an infarct may become inclosed by a capsule of ivorylike hai-dness — the eburnated infarct. In Venous Terminals. — There is to be seen in the vascular distri- bution to the epiphyseal cartilage of bone a condition scarcely found in any other part of the body, that of the termination of the blood- vessels in blind cul-de-sacs, these pouches resting with their blunt ex- tremities directly against the cartilage. It is easily understood how the sluggishness of the circulation in such a blood-vessel as this might favor the lodgment and growth of siich infective elements. Clinically this is just what is observed; the majority of tuberculous bone foci occur in close proximity to, and usually on the joint side of, the epi- physeal cartilage. Only rarely do Ave find the tuberculous process involv- ing primarily the shaft. When this does occur it forms the so-called tuberculous osteomyelitis (osteitis sicca tuberculosa) ; it is usually pro- gressive in character, and of serious prognosis. The infective elements having gained lodgment in the manner de- scribed, the characteristic tubercles soon form. Occurring in bony struc- ture, however, they induce, probably by pressure, a calcareous absorption. Just as a varicose vein may, by pressure, groove the tibia, so the tuber- cular granulations in their growth dilate the cavities in which they lie, until the bony lamellae which comprise them are partly or wholly ab- sorbed, with a resulting osteoporosis, often demonstrable by the X-ray. The bone is replaced by tuberculous tissue which, when degenerated, seeks an exit. The caseous material escapes in the form of a granu- lar semifluid detritus along the lines of least resistance. If the tuber- cle is transformed into fibrous or calcareous material, it then may be- come encapsulated, lying dormant until a trauma excites renewed activ- TUBERCl'LOSIS OF BONES 7.S3 ity. It i.s almost incredible liow Inug the local process may remain quiescent. It is probable that in every case of bone tuberculosis there exist other etiologic factors than the tubercle bacillus. Trauma is the most Important, and it may occur in the form of heat, cold, and also toxins, or even other infective processes. The young articular ends of bones are more easily traumatized than is the shaft ; hence the frequency with which tuberculosis localizes there in the young. Sometimes the granular detritus makes its way into a neighboring joint, or it passes out through the bony lamella to the surface in close proximity to the joint. If, in the latter case, surgical measures are resorted to promptly, the joint may be saved from infection and neces- sary incision and drainage. ^^hen the contents of the tuberculous abscess escape into the adja- cent soft parts, a so-called cold abscess forms. Unlike abscesses pro- duced by acute infective agents, it is extremely slow in formation and slow in perforating the skin (since the tubercle bacillus induces no such cytolytic action as do the acute intlammatory organisms). The con- tents of the abscess consist of a few leucocytes, many fat granules, fine bone fragments, the so-called " caseous matter," albumin, and other products of degeneration. The cardinal signs of inflammation are also wanting, especially as to local temperature, pain, and redness. Only when the inflammatory process involves the skin follicles is there red- ness, and even then it is only a dull liluish-red. If mixed infection occurs, as does occasionally happen, then the clinical history rather than the local appearance aids in determining its nature. The skin having been broken, or opened by the surgeon, tistulte result. The sinuses leading to the tuberculous foci are lined by tuberculous granulation tissue, and their orifices present the dull gray, pale, edematous, often diphtheroid, appearance which is so typical. These siniTses may persist for weeks, months, or years, and when they heal they may cicatrize so strongly as to make the deep craterlike scars so often seen. Treatment. — The only rational treatment of localized tuberculosis of bone is surgical. Whatever the procedure employed, and it will, of course, vary for different bones, it must he radical to be efficient. TUBERCULOSIS OF SPECIAL BONES Cranial Vault. — I'ntil the surgeon has learned to appreciate prop- erly the fact that the disease spreads in the vascular layer of the diploe far beyond any external evidences, liis operative intervention will be futile. It is al)solutely essential to remove the external plate until all of the granulating layer has been uncovered, and the normal vascular 734 TUBERCULOSIS OF BONES AND JOINTS area is exposed on all sides. Healthy ai-eas ai'e easily recognized. The disease usually presents itself as a painless, fluctuating, nonfebrile mass beneath the scalp, which on opening presents the characteristic of a " cold abscess " — a cheesy, flocculent pus. Ribs. — Here, as in the cranial vault, the disease is of the rapidly infiltrating type, with the point of inception most frequently at the cartilaginous Junction. Until the periosteuni has perforated and the cold abscess begun to form, it nuiy escape detection by the surgeon, or be unsuspected by the patient. Clinical experience has shown that the old " caries costarum "' need no longer be a " bete noire " to the surgeon. It is known that the dis- ease spreads beyond the apparent localization, and partial ojx'rations, curettings, etc., for the radical re- moval of the gi'eater part of the rib have been abundant. Spontaneous fracture occasionally results. Sternum. — Tuberculosis of the sternum, though five times less fre- quent tlian tuberculosis of the rib, presents similar conditions. It is somewhat singular that these bones escape early infection, persons of middle age being the ones chiefly affected. The thickening of the sternal periosteum, and the collec- tion beneath it of tuberculous de- tritus, presents at first a tumefac- tion (cold abscess), usually with- out redness, that later terminates in a fistula. Througli these fistulas softened bone is usually to be felt. Perforation of the sternum fre- quently occurs, with the production of a mediastinal abscess. Vertebrae. — Because of the frightful deformities, as well as spinal-cord involvements, which tuberculosis of the vertebras may produce, early recognition of its presence, with the mechanical and surgical treat- FiG. 177. — Case of Pott's Disease. (Sea Breeze, Coney Island.) TUBERCULOSIS OF JOINTS 735 nient wliicli that ini{)lies, was insisted on bv Pott ( 17T!»). When the pres- sure absorption of the unusually light spongy cancellous tissue by a tuber- culous osteitis takes place, the result is a flattening, and the well-known deformity. This is peculiarly the tuberculosis of early youth (second to fifth years), probably because of the greater liability to trauma here than in other bony areas. Motion, too, being persistent, varied, and continuous, proves a constant irritating factor of serious moment. Oc- casionally a necrosing tuberculous osteitis results in rapid death of the bonia without the formation of excessive granulation tissue, due probably to embolic arterial infarcts. Here, as elsewhere, is observed the cold abscess, which, influenced both by gravity and the fasciae, results in tlie best-kno^^Ti of all cold abscesses, tlie psoas al)scess. TUBERCULOSIS OF JOINTS We may now pass to the consideration of tliis disease as it affects the articular ends of long hones, tuberculosis of the smaller bones, except the vertebra^ l)eing of less clinical importance. Knowing the anatomic peculiarities of the epiphyseal circulation, it is easy to understand why the infection so frequently attacks the articular side of the epiphyseal cartilage, where the blood current is slower and the vessels terminate in blunt extremities. Likewise clear is the sequence of joint involve- ment, since escape of tuberculous detritus takes place more easily into the joint than through the denser outer layei- of the shaft. We find, therefore, a large pro])ortion of joint invasions occurring in tliis manner. Joint tuberculosis always affects either (1) the neighboring hone or (2) the synovial membrane. The cartilages, the ligaments, the capsule are never the primary site of infection. Symptoms. — When the joint becomes thus invaded from the bony side there can be no characteristic prodromal history, since the deter- mining factors of size, location, rapidity of growth of the infective focus, as well as the gradual or sudden emptying into the joint of the infective material vary so widely. Hence, in these cases the first definite manifestation may be impairment of motion or swelling of the joint. Tubercular foci in bone are slow to produce clinical symptoms, the invasion of the more sensitive joint structures or the periosteum often being the first thing to attract the attention of tiie patient. When this occurs there may be a fixation of the part, due to muscular spasm. Contractures which in certain joints limit motion in certain directions are very significant. If these contractures persist or the disease pro- gresses, certain characteristic postures or deformities result that are considered pathognomonic. Too frequently pain is so slight as to be ignored by the patient, or it is ascribed by the physician or patient 736 Tt'BERCrLOSlS OF BONES AND JOINTS to rheumatism, "growing pains," etc., when if all available diagnostic means were utilized, such as the X-ray, inoculation tests, the opsonic index, v. Pirquet's test, Calmette's reaction, or the search for other foci, many a joint might be spared invasion and there would be fewer cripples. That heredity exerts some influence is probable, though congenital tuberculosis is extremely rare. The physical -condition of the patient does not necessarily bear any relationship to the tuberculous joint; the patient may be in perfect health otherwise. This may be true even when there is ^ collection of pus in the joint, or when the patient has an incipient pulmonary tuberculosis. Prognosis. — It must ever be borne in mind tbat a real or symp- tomatic cure may take place, and that tlio tuliercular foci may become encapsulated and dormant. Some authorities claim that in sucli cases there will be a recurrence within fifteen years; others, I)efore the age of forty-five. Direct danger to life is present in the purulent forms, and through septic infection of tuberculous abscesses, which may lead to acute fatal septicemia or p3'emia, or to sucli chronic sepsis as may ultimately cause the death of the patient through degenerative changes in the viscera. As a general rule, death results in forty-six per cent of suppurative joints, in twenty-five per cent of the nonsuppurative, usu- ally from some acute invasion of the lungs, kidneys, intestines, by the same process. Those joint invasions developing from bone foci never heal spontaneously, and rarely by nonoperativc treatment. In twenty- five per cent (55 out of 200) of the cases appropriate for conservative treatment, a movable joint is secured there])y. The characteristic of a tuberculous joint is the tuberculosis of its synovial membrane. This may be primary in the sense that the tubercle bacilli were l)rought to the joint by the circulation (about eleven per cent), l)ut it is often secondary to an infection extending from a bony focus in close proximity to the joint structures. No matter how the infection occurs, the synovial membrane presents the same changes. As in other serous membranes, the first effect of the tuberculosis is to produce an exudate, in this case of a sero-fibrinous nature. Koenig considers the fibrin the most important constituent, since this coagu- lates and makes de])osits on the various surfaces of the joint. These fibrinous dejjosits usually become organized, capillaries extend into them from below; miliary granulations appear; free particles likewise become fused, fibrous, and ultimately constitute the ricelike bodies or sago grains of a tuberculous joint. The newly formed tissue, granulating in char- acter, may rise from the surfaces of the joint like a papilloma. Whether the watery constituent of the exudate remains to produce a hydrops, or whether it is absorbed, leaving behind the newly organ- ized tissue, is of small importance. It is only in the very early stage TUBERCULOSIS OF JOINTS 737 that the freshly deposited fibrinous material is seen, and it is then that local medication may be effective. In the later stages, when the vascular proliferation from the s3-novial membrane has become marked, ulceration of the cartilage and exposure of the bone beneath may take place. The cartilage, therefore, plays only a passive part. When the joint infection has had its origin in a bony focus, or in a large cheesy focus in the synovial membrane, a purulent joint may result — that is, in the sense of a " cold abscess." " Why the pus occurs we do not know. The bacilli are not the cause, since they are rarely to be found. Since other bacteria are not the cause, we are of the opinion that the formation of toxins by the tubercle bacilhis causes the caseous suppuration" (Koenig). Motion may be said to favor its formation and development. The pus, although containing few leuco- cytes and fewer bacilli, is still very infectious (spores?). In 1894 Koenig wrote: "It would be undoubtedly a great advantage if one could early recognize the osteotubercular cases and those in which a spontaneous healing could not be awaited, for then an early operation, with the patient in good condition, offers the ideal results." In 1899 the writer called attention to the extreme value of the X-ray as a diagnostic aid in supplying this desideratum, for with it it is often possible to determine the size, location, and type of bony infil- tration. The wedge-shaped focus is not always shown by this means. That there does exist, in about a third of the cases, more than one bony focus can often thus be demonstrated, and it is of great surgical import. A clear understanding of the general characteristics of a joint tuber- culosis, in the three forms in which it manifests itself, will render easy the application of that knowledge to tuberculosis of special joints, in which the clinical course will vary as the function, the structure or location prove determining factors. These three varieties, to use Koe- nig's classification, are: 1. Hydrops: Hydrops serosus, hydrops fibrinosus. 2. Tumor alhiis: Fungous, granulating joint, "white swelling" (a late form of hydrops). 3. Tvhrrcnlous suppurative arthritis. When the primary synovial tuberculosis has advanced beyond the fibrinous stage to the organized granulating stage, with or without the hydrops remaining, there results the second variety, or tumor albus ("white swelling"). We here find more or less destructive ulceration of cartilage, perforations of or loosening of it from the Ijone beneath by a tuberculous osteitis. The joint becomes lined with granulations, sometimes so pedunculated as to give to this stage tlie name fungus, or villous. Kecovery is still possible, but alwaj^s with imperfect mobility. If, as sometimes occurs, the fluids are absorbed, the condition is termed 48 738 TT'BERCULOSIS OF BONES AND JOINTS a di-v ai'lliritis, or arthritis tubereiilosa sicca. In eitlior case \hv joint takes on a spindle shape 1)ecaiise of muscular atropliy, thickening of tlie periarticuhir tissues, and atropliy of the shaft. Tumor alius is not confined to the knee, with which it is usually associated, but it may affect any joint. Following either the hydrops stage or the tumor albus, and more rarely developing spontaneously, as if from an acute miliary infection, is the third variety of this joint affection — the purulent tuberculous arthritis. In this variety the joint is filled with a purulent fluid; its synovial membrane is covered with a tuberculous exudate, in which miliary bodies are to be found. The purulent variety, whether orig- inating from a bony deposit breaking into the joint or primarily from the synovial membrane, has a mortality, as compared with the non- purulent forms, of nearly two to one, no matter whether treated con- servatively or by operation. Diagnosis. — As in tu])erculous processes elsewhere, there is an even- ing rise of temperature to aid in the diagnosis. While, usually, a joint invasion is single, it may become multiple. When this occurs, the vary- ing degrees of advancement of the process will likewise assist in deter- mining the nature of the lesion. These multiple nuinifestations go to prove that miliary tuberculosis is not always fatal. This agrees with the experience of the writer, who has observed the acute miliary tuber- culosis provoked by a resection of the hip-joint terminate in recovery, even when the case presented tlie classical symptoius of tuberculous meningitis. If we do not consider the (|uestion of function, it can be stated that the large nuijority of joint invasions heal symptonuitically. It is agreed that pain is not characteristic, many of the joints l)eing surprisingly free from pain, considering the objective involvement. Sore- ness on pressure at the articular margins, associated with a pronounced synovial thickening; the peculiar, grating "feel" of the slipping of rice bodies or synovial fringes between its layers, aid in the diagnosis, but are not absolutely pathognomonic. The only ab.^olutely positive evi- dence in the early stages will l)e by the demonstration of the bacillus in the fluids withdrawn. Positive results ol)tained by the inoculation of animals are also valuable. This may be tested during the period of conservative treatment or during the preparation of the joint prior to operation. Among the newer aids to diagnosis, two are of special importance, and promise much for the future. They are (1) v. Pir- quet's phenomenon and (2) Wright's determination of the opsonic index. Koch's demonstration that tuberculous individuals react to tuber- culin in a specific manner has largely been abandoned because of untoward, even dangerous, sequelce. V. Pirquet, however, has re- cently shown that the routine abrasion made preliminary to vaccina- TUBERCULOSIS OF JOINTS 739 tion against sinal]i)OX, if nioistciu'd with iulicvculin (Kocli), will, in a tuberculous iudividual, produce a characteristic local reaction. To de- termine the normal reaction to such a scraping away of the epithelium, two areas, an inch or more apart, are scraped lightly. Only one of these is moistened with tuberculin; the other serves as a control. If the individual is nontuberculous, the two abrasions react alike; if he is tuberculous, a reddened area, becoming more or less crusted, appears. The reaction occurs during the first tw^enty-four hours. Sufficient ex- perimentation along these lines has already been done to demonstrate that the method, while not infallible, is very suggestive, particularly when applied to children under six years of age. Wright demonstrated that the phagocytic activity of a tuberculous person's leucocytes to tubercle bacilli varies from the normal, and that this variation is caused by the opsonins. Their presence in the serum prepares the bacillus for ingestion by the leucocyte. Their ab- sence leaves the bacillus uningested. Hence, varying amounts of opso- nins cause varying degrees of phagocytosis. By comparing the serum of the individual suspected of being tubercnlous with the mixed sera of several individuals known to be free from tuberculosis, there is obtained an index to the diagnosis and to the treatment. This Wright has named the opsonic index. Drs. Lincoln and Vail have proved that there is a normal tuberculo-opsonic index, and that the diagnostic value of variations from the normal is extremely great (eighty-five per cent), when several careful examinations have been made, thus corroborating Wright's, Douglas's, and Bullock's claims. The writer is convinced that persistent fluctuations from the normal index are diagnostic of tuberculosis. (The details of this subject are more elaborately treated elsewhere.) Hence, in a given joint, if there is an active tul)erculous process there will be found departures from the normal index, usually lowered, sometimes raised, occasionally fluc- tuating. Indeed, the fluctuation is very significant when, having de- termined the patient's index beforehand, the suspected joint is mas- saged; for by so doing the exciting factors of opsonin production nuiy !)(' driven into the circulation, thus changing the index, usually raising it nuirkedly. Treatment. — In a majority of the cases the X-ray serves as an aid in deciding whether there is much hope of recovery from conservative orthopedic measures. In this condition, more than in others, is it necessary to consider every factor to individualize. Surgical interven- tion is indicated — ( 1 ) When the constitutional condition of the patient shows a pro- gressive deterioration under treatment. This may mean (a) sepsis, from absorption of the products of a mixed infection in the joint or 740 TUBERCULOSIS OF BONES AND JOINTS sinuses; (b) amyloid degeneration of the viscera; (c) pulmonary inva- sion; (d) diarrhea. (2) The age of the patient should influence the decision, reluctance to operate in very early youth and after thirty growing progressively greater; in youth, because the danger of disturbance of future develop- mental centers becomes greater, therefore the end results are worse; in later years, because clinical experience has shown that adults bear joint resections poorly. (3) The environment of the patient should be a factor in deter- mining earlier operation. However illogical it may at first thought appear to make one rule for the rich and another for the poor, it still is practical and necessary to consider the fact that the child of a day laborer cannot undergo the long, expensive trial of orthopedic and climatic measures, occasionally justifia1)]e in the child of the rich, only to submit to resection, with its attendant expense and delay, in the end. (4) Since, as before stated, it is often possible, by means of the X-ray, to locate the disease and to determine the exact part and propor- tion of joint affected, it is conceivaljle how, witli a location favorable for removal, an unusually early operation might be justified. Conversely, how in the absence of evident 1)one disease the case should 1)e treated as one of primary synovial tuberculosis. The writer has always pro- tested against the routine treatment of any joint, first by mechanisms, then by mechanisms plus injections, and finally by operation. Surgeons have too frequently been satisfied with a diagnosis of tuberculosis of a joint (without regard to whether it be (1) osteotuberculosis of one or both bones, (2) primary synovial tuberculosis, or (3) tuberculosis near the joint, but not in it), and then proceeded contentedly to the application of mechanical devices for the rest and protection of the joint, with or without iodoform injections, and without regard to the exact location of the infective center. Those eases that are cured by Mosetig's glycerin-iodoform and its analogues are cases in which the disease was primarily synovial in origin, and remained so. This is the only form in which there may be a restitutio ad integrum, and the time necessary tliereto, even in simple cases, is often one to two years ! It is reasonable to assume, and the assumption is borne out by clinical experience, that the beneficial action of iodoform is essentially by contact. Hence, it is not reasonable to expect that a focus buried in the articular end of a bone, whose products have broken through some minute opening into the joint, will be influ- enced essentially by iodoform thrown into that joint ! Hence the neces- sity for refinement in diagnosis and the determination whether it is an osteotuberculosis or a synovial infection. Since anatomic and path- ologic findings and clinical experimental evidence teach that only a \ TUBERCULOSIS OF JOINTS 741 small projxjrtion of case?^ are of primary synovial origin, it follows as a corollary that only a small proportion will be cured l)y iodoform treatment. Time has shown that it was essentially in those cases in which the iodoform came in contact with the diseased surfaces — i. e., synovial tuberculosis — that healing occurred. In these large tuberculous abscesses of joints the contents should be removed prior to the iodoform injections, though this may even require at times small incisions, the material being too flocculent to flow through needles. Hence, it is well to limit injections to those joints wdiere the clinical history and the X-ray examination showed the case to be one of synovial tuber- culosis. Of course, the intelligent physician will in no case neglect any of the other factors, general or local, which tend to improve the patient's condition; hence, immobilization of the joint, in so far as is indicated; the use of Bier's hyperemia; alternately flooding the diseased area with opsonins; minute doses of tuberculin T.ll. (yoVo mgm.) to stimu- late the production of opsonins; the actinic rays of the sun (in larger measure found in X-rays) to increase metabolic changes in the embry- onal tissues present, will all favor healing. The extremely beneficial action of direct exposure to the sun's rays cannot be emphasized too strongly. Healing usually takes place by fibrous cicatrization. When, how- ever, the healing is complicated by a cold abscess, often noted under the Bier treatment, proper surgical care of the same should be instituted early — i. e., evacuation under aseptic precautions. It should be recalled that Bier excepts hydrops as not being amen- able to his treatment, and urges not too prolonged fixation. In the case of the knee- and ankle-joints he urges operative treatment earlier than in other joints, because the principal goal — a functionating joint — is here least often obtained by passive hyperemia. Otherwise his re- sults have been so good that army service was almost enforced on some of his patients. When the tuberculosis is in such close proximity to the joint as to simulate joint disease, even when sinuses exist, such a joint may be spared resection if the surgeon traces the sinus to its source before incising the joint. In this way the writer has saved four hii)-joints presenting almost all the classical joint symptoms (see special joints) due to foci situated in the ilium close to the acetabular margin, but external to the joint. Broca, too, emphasized this fact. " When the diagnosis can be made of isolated ca])sule disease (tul)erculous fibroma) it should be treated like a new growth — removed" (Koeiiig). Wlii'ii surgical intervention is indicated (and it is in ncai-ly fifty per cent of cases) For a tuborcnlmis joint, what shall be (lie pi-occdure? 742 TUBERCULOSIS OF BOx\ES AND JOINTS Either (1) Extirpation of the synovial membrane (arthrectomy), (2) Excision of the joint (resection), or (3) Amputation. Arthrectomy has been tried with success in those cases of synovial tuberculosis which have resisted the usual conservative treatments, and c(msists in the thorough removal of all diseased synovial tissue. Care must be taken to ol)tain the most desirable position for the ankylosis which usually occurs. In every useless position correction should at the same time be made. When the disease has been of osteal origin, one can sometimes make a partial arthrectomy if the focus be small, or, if extensive, it may require the resection of the articular ends, pre- serving, if possible, the epiphyseal cartilage, since on this future growth depends. In the lower extremities the epiphysis nearest the knee, and in the upper extremities the epiphysis farthest from the elbow, exert the greater influence on future bone growth. In adults with suppurative joints arthrectomy gives a lower mor- tality than resection, probably because the vessels of bone are not opened. When the structures in and about the joint are too extensively involved, or when the mixed infection is producing a dangerous toxemia, or when there is amyloid degeneration of other organs, it may even be necessary to amputate the member to save the patient's life. In these healed joints with ankylosis, at some later period, Murphy has demonstrated how excellent functional results may be obtained by the interposition of the subcutaneous cellular tissue between the articular ends. TUBERCULOSIS OF SHOULDER-JOINT Occurrence. — Altliough tuberculosis of the shoulder-joint is relatively rare (knee six times as frequent), either variety of invasion may be met with, ranging in frequency, respectively, (1) bony focus in humeral head, (3) primary synovial tuberculosis, (3) bony focus in glenoid process of scapula. Symptomatology. — Aside from some vague sense of pain and dis- comfort about the shoulder, there may be, in the early stage of the first and prevailing form, practically no other symptom. An X-ray picture may reveal the location and extent of the focus, the nature of which could then be confirmed by the methods mentioned in the preceding pages. If the lesion has invaded the joint, thus infecting the articu- lation, or if the disease primarily invaded the synovial membrane, there tlien follow effusion, swelling of joint, limitation of motion, and severe pain. Eice l)odies are found next in frequency to knee. .\n early involvement or destruction of the biceps tendon, with the resulting cold TUBERCULOSIS OF JOINTS 743 al)scess course, is determiiii'd liy the same. When the caj)siihir perfora- tion is near the insertion of tlie other tendons, sinuses develop and fol- low the course of these tendons. Differential Diagnosis. — The slow onset, the ahsence of marked fe- bi'ile disturbances and redness, aid in differentiating the condition from simple rheumatism; absence of gonorrheal history or discharge, with normal gonococcal index, differentiate it from gonorrheal arthritis, while the low tuberculo-opsonic index, the character of the aspirated fluids, their infectivity to the joints or peritoneum of the animals, together with the family history, the slight evening rise of temperature, will make reasonably clear the character of the infection. Prognosis.— Clinicians agree that the mortality of shoulder-joint in- fections exceeds that of other joints, though in an indirect manner — i.e., by pulmonary (forty per cent) or other fatal internal invasion. Koenig considers the prognosis for healing very unfavorable. Earely do the fistulas close up. Conservative treatment fails to help the caries sicca, and the best prognosis is found in those cases in which the disease can be removed by operation. Operation is attended by twent3'-five per cent mortality, directly or indirectly ; seventy-five per cent of patients have more or less useful joints, limitation of abduction, elevation, and rotation being the chief deficiencies. Treatment. — If the diagnosis is made prior to the invasion of the joint, too much time should not be wasted in conservative treatment, fixation, etc., but early surgical intervention is necessary. When there is evidence of slight bono involvement, and yet joint effusion, enlarge- ment, capsule thickening (often detectable at the bicipital groove, where it occasionally is localized), and other factors going to make up the symptom-complex of tumor albus are present, iodoform-glycerin injec- tions may prove efficacious. The writer has seen such joints restored to apparent perfect function thereby, even with jirogressing pulmonary invasion and double psoas abscess in the same individual. The possibility of occasional tuberculosis of the subdeltoid bursa, without joint involvement, must be borne in mind. When abscesses and fistula? exist, nothing remains but surgical inter- vention, Avhich should seldom be limited to opening of the abscesses, curetting the fistulte; a resection slmuld be done. Experience teaches that milder procedures yield poorer results here than elsewhere. The shoulder and the hip do not permit of em])loying Bier's treatment. TUBERCULOSIS OF CARPUS AND TARSUS invasion of llicsc areas witli Ihr inrcclivc clcnicnls occuis in a man- ner similar to that descrilx'd in the case of the lai'ger l)ones and joints. 744 TUBERCULOSIS OF BONES AND JOINTS Occasionally a single bone or joint is involved, and the surgeon may, by early interference, save the remaining unaffected joints. (The scaphoid is exempt from primary disease.) Here, however, because of the very small size as well as the intimate relationship of one wdth another, and the frequent existence of but one synovial membrane for several articu- lar facets, it is rarely possible to decide whether the invasion has been primarily osteal or synovial. In either event, both early become merged. The treatment does not differ from that employed elsewhere, but inasmuch as there is usually both bone and synovial involvement, the injection treatment is rarely employed. Protection from trauma, im- mobilization, exposure to direct sunlight (after the removal of the bony foci of the process has gone on to the formation of a cold abscess or fistula), will give the patient the best chance, ultimately checking the process and leaving a useful, if impaired, part. TUBERCULOSIS OF HIP-JOINT True cases of primary synovial tul)erculosis of the hip-joint are rare, and seldom are adapted to the iodoform-injection treatment. When it does occur, however, the effusion is less, the pathologic changes are less marked, the granulations about the cartilaginous margins are less extensive, the amount of fibrin is less, and fewer rice bodies are ob- FiG. 178. — Characteristic Position of Tuberculous Hip-Joint. Muhiple fistulae. served than in the knee-joint or other joints. The caseous products from the primary .synovial form (or from that of osteal origin) tend to accumulate about the neck of the femur, close to the trochanters, thus producing a tumor nuiss whose volume is increased liy the thickening of the synovial meml)rane, and it can usually be palpated prior to per- foration of the capsule. From the fact that tuberculosis of this joint is observed twice as frequently in tlie male as in the female, the inference is drawn that trauma is a strong exciting factor. Likewise, its occurrence before TUBERCULOSIS OF JOINTS 745 the i\'^v. of lil'twii, ill eighty \h'V cent of ;ill casos, emphasizes thai it manifests a predilection for the early period of life. In fifteen j)er cent of the cases trauma is the exciting cause, but infective fevers such as scarlet fever (three per cent) occasionally supply that factor. Hip-joint tuberculosis does not pursue a definite course. It may alternately improve or relapse, whether treated by the best-recognized conservative methods or left nntreated. Since the synovial type of the disease is so rare, it is not strange that Riedel found seventy per cent of operative cases with sequestra — i. e., bony foci. Because of the superficial resemblance of the normal ossific centers, while being transformed into bone, to tubercular sequestra, care must be taken not to remove these and not to disturb the epiphyseal car- tilage. This is especially to be remembered in patients between the ages of two and ten years. Elsewhere reference has been made to the occasional simulation of chronic hip trouble by foci outside the liip. Hence, the preliminary step in every fistulous hip should be to determine the exact point to which the tract leads before proceeding to make the classical incisions for partial or total joint resection. Sequestra. — A large proportion of all cases operated on (seventy per cent — Kiedel) are found to contain bony foci in the form of soft- ened tubercular sequestra, requiring removal to effect a cure. The re- semblance, on superficial examination, in the early years of life of the normal centers of ossification to these tubercular foci has occasionally led to their removal, with a loss of future growth. Only when they are distinctly tuberculous should they be removed. As mentioned elscAyhere, the bony focus is occasionally outside of this joint, either in the ilium, trochanter, or neck of the femur, but in such close proximity to the joint as to produce most of the usual hip-joint symptoms. If the surgeon fails to determine prior to his radical intervention the points to which the sinuses lead, he may find himself in the unpleasant predicament of opening a joint as yet unin- vaded. In the absence of a distinctly demonstrable "bony crepitus,'' the sinus or sinuses should be traced to their proper origin. By ob- serving this practice, two to three per cent of the hip- joints will escape unnecessary opening. When such foci break into the joint, and the condition is recognized early, the prognosis of operation is favoral)le. The X-ray here renders good service by showing the clear-cut, smooth, articular surfaces, as yet unmarred Ijy the destructive changes so common in the later stages. If the X-ray shows an extensive osteal focus, it would be futile to employ palliative measures. 49 746 TUBERCULOSIS OF BONP:S AND JOINTS Symptoms. — Puiu, witli partial or complete fixation of the joint, may he said to be the first as well as the most important symptom to attract attention. This pain is a soreness provoked by motion or weight rather than a sensation independent of such conditions. (Noc- turnal pains occur through movements while the musculature is dor- mant.) The occurrence of contractures in certain muscles or groups of muscles is to lie awaited, but tliese are no longer regarded as so ly]ucal or signidcant as was foiincrly taught. Their existence for any protracted ])eriod results in atrophy; licnce the flattening of tlie glu- teals and obliteration of the gluteal fold. The pain may be referred by the patient either to the hip- or knee- joint. In the latter case it is due to a reflex passing along the nerve trunk supplying sensation both to the hip-joint as well as to the an- terior aspect of the thigh and knee. This may be the only pain com- plained of by the patient. Provoked by the friction of the affected surfaces, involuntary muscular contractures occur which serve to min- imize it. Unlike all other joints, however, the ball-and-socket type has all its articular surfaces in constant contact; hence variation of position cannot wholly relieve the affected area from pressure. At the same time the muscular spasm increases the undesired pressure and friction, which here, as elsewhere, ends in pressure atrophy, with absorption either of the femoral head, if that be the chief site of invasion, or of the acetabular margins, or both, unless prevented by appropriate sur- gical intervention. As a corollary to the above, absorption of the l)ony head and neck, or acetabular margins, and shortening (fifty per cent of cases) ensues, made evident by actual measurement and subjective findings. As the acetabulum becomes more shallow, partial or complete luxation of the femoral head may result with a change from the early outward to the late inward rotation. Rotation, then, is an early sign of hip-joint involvement. For a long time Bonnet's experiments have been ac- cepted as explaining this rotation, since they showed that the position assumed was that in which the largest amount of effusion in the joint could be accommodated with least tension — i. e., abduction, slight flexion, and outward rotation — to be followed, in the later stage, by abduction, marked flexion, and inward rotation. The latter is the more serious because it is indicative of more extensive disease. Occasionally this stage is observed in the begipning without the preceding external rota- tion. It is indicative of an extensive, painful bony focus. When the disease has its origin in the acetabulum, it occasionally happens that the Y cartilage, with its accompanying wormian bon(% succumbs to jhe destruction, followed by perforation and pelvic (cold) abscess. TUBERCULOSIS OF JOINTS 747 Next to pain, in symptomatic importance, is tlie limp, which, seen a few times, assumes considerable significance when associated with the other factors. Swelling can nsually be determined by palpation over tbe anterior aspect of tlie femoral neck quite early in tbe joint in- volvement. Altbough all these symptoms — ])ain, painful spots, swelling on tbe anterior surface of joint, and limitation of motion, eitber active or ])assive — may disappear after rest in bed; they point to some definite patbology. Diagnosis. — So much has been written on this phase of the sub- ject that passing reference only will be made to tbe nontuberculous (ten per cent) hip-joints, of which the acute infection coxitides in the young adult offer such diffi- culties in differentiation. They are usually caused by the Staphy- lococcus albus or aureus. In the history the point of systematic invasion must be sought after. Tbe high temperature, the acute onset, the sudden, severe pain, and the absence of ossific change shown by the Rontgen ray will usually settle the diagnosis. On several occasions tbe writer has been able, by aspirating the hip- joint with a long needle paral- lel to tbe femoral neck, to se- cure synovial fluid containing tbe staphylococcus, the Bacillus typhosus, or tbe streptococcus. A his- tory of scarlet fever, measles, or gonorrhea has aided in the differ- entiation. It must not be forgotten that almost tbe entire symptomatology of a tul)('r( iiU)Us hi])-joint 7nay be simulated in hysteria. Treatment. — 'I'rcatmont of this form differs only from that of other tubercular joints, because (1) of the weight it supports, hence rest and extension; (2) securing tbe greatest function by selecting the most Fig. 179. — Multiple Fistula Open- ings OF Tuberculous Knee. 748 TUBERCULOSIS OF BONES AND JOINTS useful position, if limitation of motion occurs; (3) forbidding use of the limb until all tenderness has disappeared, even that produced by- blows on the knee, over the tro- chanters, or by direct pressure over the acetabular rim. TUBERCULOSIS OF KNEE-JOINT The general description of joint tuberculosis was written with the knee-joint in mind, hence only data of special interest need be mentioned. It is more frequent in males (ten per cent), is seen in the first two decades of life (fifty-five per cent), with trauma an exciting factor (twenty per cent). The knee is peculiarly adapted to the formation of poly- poid growths, hence they and the rice bodies are most often seen here. The latter also attain an unusual size. Both of these are more easily felt in this joint than elsewhere, especially over the con- dyloid margins, with the joint held at right angles. Atrophic changes occurring in muscles relatively so much larger make more pronounced the spin- dle-shape of a tuberculous knee of prolonged duration. This some- what characteristic shape is not always indicative of tuberculosis, however. In the early stage (hydrops) motion is usually excellent; dur- ing the fungus stage it is the reverse, even passive motion be- ing restricted. There is slight flexion, with outward foot rota- tion, with final backward tibial luxation. In so large a joint, supporting so much weight, we may logically expect an ultimate mixed infection Fig. 180. — Plaster-of-Pari-s Splint WITH Fenestra. TUBERCULOSIS OF JOINTS 749 because ol' tlie constant irritation of the intlauied surfaces, deterniining the lodgment of organisms floating in the blood stream. Indeed, fifty per cent of all such cases become thns complicated, rendering the prog- nosis more grave. Of 720 patients observed for eighteen years by Koenig, 430 recovered, with useful limbs, but only 11.7 per cent were func- tionally perfect. CHAPTER 111 PRIMAKY TUBERCULOSIS OF MUSCLES AND FASCIA By LEONARD FREEMAN This is a rare affection, Ijut few cases having been reported, al- though secondary involvement from an adjacent focus — for instance, in the glands or fascia — is common enough. Primary infection takes place through the blood, and usually results in the formation of a cold abscess. This may be opened, curetted, and drained ; but it is, perhaps, better to extirpate the diseased tissue completely, if this can be done withoiit sacrificing the muscle to too great an extent. Tuberculosis of fasciae is frequently associated with tuberculosis of lymph glands, bones, and joints, although primary infection rarely oc- curs. The disease is difficult to eradicate except by a thorough opera- tion, which may necessitate the extensive removal of the affected fascia from between the muscles or from beneath the skin. Treatment by Bier's passive hyperemia may be tried in suitable cases, as may also vaccination with tuberculin, according to Wright. 750 CHAPTER IV TUBERCULOSIS OF THE BEAIX AXD ITS MEMBRANES By L. L. McARTHUR THE MENINGES Until within a very few years, meningeal tuberculosis was con- sidered as an incurable affection wholly within the province of the internist. That there begins to be doubt as to the accuracy of this view is partly due to tlie revelations which surgery has made in the cure of similarly affected serous membranes elsewhere, partly to the few but authentic cures Avhich surgical intervention has brought about. Here, as elsewhere, invasion is almost invariably through the circu- lation, since the bony vault protects so well against direct infection that extension to the membranes by contiguity is the rare exception. This being true, there follows, as a corollary, the existence elsewhere in the body of a tuberculous process. It is a clinical fact that over four fifths (eightA'-three per cent) of all cases occur during the first five years of life"! Until recently the surgeon, for practical purposes, classified menin- gitis into two general classes: (1) the tuberculous and (2) the non- tuberculous. The diagnosis made, he has been too content to rest : but aggressive interference in cases heretofore regarded as hopeless has given some encouragement for the future (Duret). Though the anatomic differences between tuberculous and the nontuberculous meningitis are quite definite, the clinical differences are not always sufficiently definite for easy diagnosis. Diagnosis. — With the recent advancements in laboratory methods, the nontul)orculous cases can be separated from the tuberculous. Symptoms. — The s3^mptomatology of meningitis being wholly de- pendent on the irritation of the inclosed nerve tissue, there is no single pathognomonic symptom. Quincke's lumbar puncture has enabled us to disregard many symptoms common to all meningitides, as well as to detect those running an almost symptomless course (Zappert says sixty-six per cent). A normal cerebrospinal fluid should contain no cellular elements. In tuberculous meningitis lymphocytes are prevalent, 751 752 TUBERCULOSIS OF THE BRAIN AND ITS MEMBRANES more especially in the later stages; in the very early the polynuclears prevail. This is the end result of many observations, and thus limits the value of the cytodiagnosis taken alone. In the majority of cases (seventy per cent) the tubercle bacillus can be found in the fluid. Failure to find the organism with the micro- scope may require inoculation to be positive. The agglutination tests of Arloing are not constant, but when positive are valuable as confirma- tory evidence. Moreover, the extent of the lesion bears no regular re- lation to the severity of the symptoms. Three cardinal symptoms attend a meningitis: Headache, vomiting, and constipation. Continuous and distressing headache, accompanied by vomiting with- out indiscretion in diet, explosive in character, with little or no nausea, and associated with an obstinate constipation, is the usual status found. Ballance adds to this two groups, those presenting {a) symptoms of fever and impaired nutrition; {h) symptoms which are the clinical ex- pression of the irritation of the subjacent cortex. These are: (1) Psychic; (2) motor; (3) sensory; (4) vasomotor, and (5) tho.se due to destructive action on nerve cells. Under these headings would come irri- tability, disturl)ance of sleep, cri cerebral, headache, vomiting, Kernig's sign, ocular or facial paresis, rise of temperature, slowed pulse, stiff neck, etc. In most cases of tuberculous meningitis the onset is insidious, rarely fulminating. In location, chiefly involving the basal membranes, it may extend to the vertex, or be localized to a given area, producing positive localizing symptoms. Its duration, varying from seven to fourteen days on the average, may extend to several weeks. The exudate is of grayish-yellow color, with scattered nodules, the basal nerves being ensheathed therein. The membranes of the Sylvian fissure are similarly infiltrated, the cerebrospinal fluid is increased in quantity, the ventricles dilated, and their spendyma showing miliary bodies. Thickening of the latter may be sufficient to occlude their exit. It is rarely found in the form of a tuberculous abscess. Such infectious diseases as whooping cough, measles, etc., prove favoring factors. Treatment. — So extremely fatal has this disease been regarded in the past, that the diagnosis made, interest and activities on the part of the medical men ceased. Eealizing that the dangers of the disease have in no wise diminished, the siirgeon has come to understand that here, as in the similarly desperate conditions — e. g., of general peritonitis — a certain small percentage of cases can be saved by heroic measures. In less severe cases, less radical procedures offer some hope where heretofore there was none. Ballance has called attention to the fact that loo frequently in the THE MENINGES 753 past tlic sur^ieal ett'orts lo check a meningitis have ceased ■with drainage of the dura, though the tuherculous disease involves the pia and the subarachnoid spaces. Such surgery he compares to drainage of tlie pleura for pericardial effusion. Hence, the Sylvian lake, the ventricles, the basal areas, or the spine, should be drained when proper indications exist. While the conditions differ (because of many added factors of danger) from those of tuberculous peritonitis, still something may be hoped for from proper surgical interference. While not an advocate of operative interference in every tuberculous meningitis, nor of drainage through and through with lavage of the cavi- ties bathed by the cerebrospinal fluid, the writer is convinced that the withdrawal of the excessive quantity (10 to 30 c.c.) either by spinal puncture, trephine openings, or ventricular tappings may, by the reduc- tion of cranial pressure and by the escape of infective elements, prove the turning point in an otherAvise fatal case. Indeed, cases begin to ac- cumulate that have been saved by such methods. Surgery as applied to any given case should at least be considered, and then only rejected when the local or general conditions render all efforts futile. It not infre- quently happens that a meningitis is but the terminal stage in a hope- less lung, peritoneal, or bone tul)erculosis. Intervention here, as elsewhere, must be based on the conditions pres- ent. When there exists a localized, circumscribed meningeal tuberculosis, with definite focal symptoms, operative interference offers the only radi- cal means of betterment. Again, in accidental changes incident to a healed circumscribed tuberculosis, this surgical removal may prolong life, or improve the ]iatient's condition. As in the pleura or peritoneum, so here the tuberculous irritation of the serous membranes results not in- frequently in excessive fluid exudate, the presence of which soon results in destructive changes in the nerve tissue pressed on. Here mechanical means offer the onh- practical hope — hence the spinal aspiration of Quincke becomes a therapeutic measure. Unfortunately, the disease in nearly half the cases results in an occlusion of the iter a tertio by an involvement of the choroid plexuses; hence intracranial pressure cannot always be thus reduced. We are then compelled to employ cranial drainage in one of several Avays. In the bal)e, tapping the venti-icles through the lateral angles of the fontanelle; in those requiring it a trephine opening with extracranial drainage, after the author's method, or subdural drainage after Ballance, has given bene- ficial results. This emphasizes the fact that we have a chronic diffuse, as well as an acute tuljerculous meningitis. To the former group most cases of hydrocephalus belong. To reduce the pressure from the accumulated fluids, Ballance has recently recommended the suspension of a small right-angled tube from 754 TUBERCULOSIS OF THE BRAIN AND TFS MEMBRANES the (liiral iiieiubrane, one end of the tube being inserted into the hiteral ventricle, the other remaining subdural, thus converting an internal into an external hydrocephalus. The writer devised years ago an almost identical procedure, the chief difference being that the tube was flanged, the flange resting on the external surface of the parietal bone, through which a drill had made a perforation just large enough to permit of its jiassage into tlie ventricle. By this means the fluids escaped into the cellular tissues I)eneath the scalp, causing an edema of the same, slowly and gradually relieving the pressure, and benefiting the patient, with less chance of displacement of the foreign body. Mikulicz reported sev- eral cases treated by this method. Spontaneous cures, though rare, have been observed. Laboratory examination of the fluids removed by any of these meth- ods have proved the desirability of the procedure, since infective elements and their toxic products are thus eliminated. Moreover, cytologic exam- inations and inoculations have demonstrated some curable forms, while yielding confirmatory evidence. THE BRAIN Tuberculomas {Soli tan/ Tubercles) — those large, usually solitary masses of tuberculous matter composed of nodes undergoing character- istic degenerative changes — are found embedded generally in the nervous tissue. They have their origin always in the meninges, a fibrous strand form which can almost invariably be demonstrated. They may be mul- tiple (twenty per cent). Although multiple, one tumor alone may pro- duce symptoms, the others being " latent " or in " negative "' zones. They may attain the size of an orange. They rarely follow surgical tuberculosis, and are of very slow growth. In their growth they press apart the adjacent nerve structures, have but little intimate connection with them, and, when producing localizing symptoms, have been success- fully removed, the patients living one, two, four, six, and even eight years. They occur more frequently in the cerebellum. Alessaudri reports twenty-one cerebral and five cerebellar tuberculous tumors operated on with rather favorable results in the cerebral cases. Greater fatality attends the cerebellar tumor, due to (1) late interfer- ence; (2) deep situation; (3) undeveloped technic. They produce symptoms common to all V)rain tumors (headache, papillary edema, choked disk) ; they may also produce focal symptoms; and in addition they will probably show a reaction to either Calmette's, V. Pirquet's, or Wright's tests for tuberculosis. While presenting in their clinical history or physical examination evidences of other healed or active tubercular foci, the less marked the T1IJ-: BRAIN 755 general pressure symploms, the more sure the local diagnosis. Too niueli emphasis cannot be laid on the significance of the early appearance of the focal symptoms, but in the absence of all localizing symptoms the tumor probably occupies one of the negative zones — e. g., right frontal corpus striatum, lenticular nucleus, anterior portion of the optic thalamus, or cerebellar hemisphere. What has been said of the brain and its mendjranes liolds true of the spinal cord and its coverings. In most cases of spinal tuberculosis the disease is an extension from above. About sixty-five cases have been collected in Avhich it was localized in the cord. When so localized the symptoms are dependent on the parts involved. A tuberculoma here produces similar pressure symptoms to those of any other tumor, and when its presence can be diagnosed, offers greater hope of benefit than the tumors more commonly found in this region. CHAPTER V IXTE8TINAL TUBEKC UL08 J S By L. L. McARTHUR General Considerations. — Intestinal infection l)y the tubercle bacillus is now so well recognized that discussion is limited to when, liow, or why it occurs, and the influence of treatment on it. In commencing the study of intestinal tuberculosis we are confronted at once by the natural subdivisions pathologists make, based on their findings. I. Primary Intestinal Tuberculosis. II. Secondary Intestinal Tuberculosis. With many thousands of autopsies and hundreds of observers to con- firm the observations, it has been demonstrated that, while the vast ma- jority of cases of intestinal tuberculosis are secondary, there are quite a number of cases of true primary intestinal tuberculosis without other discoverable lesion. With the reopening of the question as to the atrium of infection in the individual, the later, more painstaking observations show that through the intestinal tract a far larger proportion (twenty- one per cent) of cases occur than had been deemed possible. A definition of the term " primary " should here be given. Several years ago the writer stated that it is impossible, clinically, to predict the location of the absolute primary focus, and call that " primary " which is the apparent site of inception of the disease. Thus an orchitis, a Pott's disease, or hip disease may clinically be primary, while the post- mortem findings prove them secondary to some focus in a mediastinal or cervical lymph gland or other unsuspected area. The term primary must now be limited to those cases in which there is no other recogniz- able lesion from which the infection could rationally have occurred. The number thus to be classified is constantly increasing, while the number of cases of general tuberculosis in which the atrium of infection Avas the intestinal tract exceeds present belief. It will thus be seen that true primary intestinal tuberculosis must be due to direct infection of that tract by the ingestion of tuberculous foci, while the secondary occurs from the deglutition of infective matter coming from simihir active processes above, in the same individual. Practically, babes long at the breast and milk-fed infants are the only 756 GENERAL CONSIDERATIONS 757 ones afflicted with true primary intestinal tuberculosis, sinci; the}' are the ones exposed to the most commonly infected foods, and their in- testinal tract is least resistant to such invasion. While both Eisenhardt and Fenwick found only 1 case in 1,000 autopsies on adults which they considered primary, they also demonstrated by the same series that few cases of tuberculosis of the respiratory tract escape an ultimate secondary intestinal tuberculosis. Eisenhardt in his 1,000 autopsies of tuberculous adults found 503 cases wath intestinal infection; 489 had cavities and 74 had none. Indeed, the intestinal lesion is usually over- shadowed by the pulmonary disease. But inasmuch as the presence of cavities — and, therefore, bacilli in the sputum swallowed — determines so regularly the intestinal infection, the absence of cavity formation w^ill have a decided prognostic value in those cases coming to the surgeon for aid. These persons will, as a rule, be over twenty-five years old, and more often males than females. From the painstaking monograjjli of Fiirst one can secure a com- plete resume of all the arguments for and against the intestinal tract as the primary route of infection in tuberculosis. The occurrence of intes- tinal tuberculosis being admitted, there is need for a clear understand- ing of how, where, and why this happens. Fiirst tabulates the various modes by which the human being may become infected with tuberculosis, as follows: (1) Aerogenous; (2) enterogenous; (3) amygdalogenous ; (4) lymphogenous or hemogenous; (5) dermogenous; (G) hereditary and congenital. Of these the first two are of special interest. Aerogenous. — The respiratory tract, so universally accepted in the past as the principal route of invasion, has of late been proved by ex- periment, by clinical observation, and by postmortem findings not to infrequently be enterogenous in origin {vide Baumgarten's cases and experiments). Recently there has arisen almost an antithesis in the belief held for the twenty-three years following the reports of Koch and Baum- garten of their discoveries, as to the infectivity of the milk of tuber- culous cows. This is consequent on the reopening of the question by Koch himself, and the apparent assumption by him of a diametrically opposite view to the one first held. I say apparent, because he does not deny what he formerly claimed to have demonstrated, but he insists that the transference of the bovine type of infection to the human being is of far less frequency than he had taught. Though the identity of the human with the bovine tuliercle bacillus had been universally accepted, Koch's London address threw a shadow of doubt over the matter. There has been a division of scientists into two groups, with Koch heading the dualists. Even the dualists hesi- tate to advocate the abandonment of all those precautionary inspections 758 INTESTINAL TUBERCULOSIS of meats, milks, and animal foods for wliicli every government lias made such splendid provision in their bureaus of animal industries. The in- numerable reseai'ches and reinvestigations stimulated by this reopening of the question have demonstrated the intimate relationship between the two organisms, and have proved the ])0ssibility of enterogenous infection with the bovine organism, which is distinguished by the term "pearl" bacillus, l)ecause it induces " Perl such t " — l)ovine tuberculosis. rt is at postmorl(Mn examinations that the greatest surprises, the strongest confirmations, the surest evidences of the atrium of primary infection manifest themselves. They furnish us with our most positive ]u-oofs as to the varying modes of invasion. In this disease the pathol- ogist can frequently determine which is the older and which is the more recent process. Cicatrices, calcifications, encapsulations, and adhesions are evidences of the older process, while the miliary bodies and acute inflammatory processes are of more recent origin. These pathologic anatomic findings give indubitable proofs that figures alone must con- vince us that the enterogenous infection is not only possible but proved. Often an autopsy held on children dead of measles, scarlet fever, or diphtheria, has revealed an unsuspected tu])erculosis, while affording a convincing proof of both the site of the primary invasion, and after that, equally instructive evidences of its latency, duration of virulency, or spontaneous healing. The painstaking investigations of Kossel, Nageli, Heller, and v. Hansemann have given the astonishing result that every second or third individual has, at some time in his life, accjuired and recovered from a tuberculous infection. This without its having ever been suspected or detected. But these evidences have, by their site and solitary char- acter, demonstrated beyond cavil the door of entrance; for example, the finding of solitary caseous hmiph glands in the mesentery beyond the cicatrix of a healed intestinal ulcer, but without other discoverable forms, is proof of a primary enterogenous infection. A review of the records of autopsies made (as was done by Fiirst) shows a great variation in the presence or absence of tuberculosis, but I)y eliminating all probabilities of error, and accepting only the most conservative estimates as to frequency, it is very evident that in every 100 postmortems held on children dead from whatever cause, 29 or 30 deaths have been from tuberculosis. Frequency. — During the first three months of life intestinal tubercu- losis has scarcely ever been observed. In 446 postmortems held from 1