The basis of my study is: First, that tuberculosis is a chronic infectious disease which passes through variable degrees of activity and quiescence, and is during such periods of activity accompanied by some degree of toxemia; and, second, that it affects the patient who is infected reflexly through the nerves which supply the lung, and generally through the action of the toxins upon the nervous system. In this, I am dealing with primary activities and not the secondary action which results from disturbed function.

which we have hitherto laid greatest stress in diagnosis, now that we understand their cause are in no wise characteristic of tuberculosis They are present in conditions of neurasthenia They indicate that the central nerve cells are or have been, the recipients of harmful stimu lation. They further indicate a preponderating periphereal expression through the sympatheti nerves. They are most pronounced during periods of activity of the disease, and disappea except they be due to nerve instability or som other toxemia when the disease process become

The above symptoms noted in Group II, with the exception of apparent anemia, are all subjective in character. To these should be added three important reflex objective symptoms, or what are more commonly classed as physical signs, thus: one, the diaphragm reflex which shows as a limited motion of the side of the chest which is the seat of inflammation; second, the motor reflex, affecting the muscles of the shoulder girdle, showing as an increased tension. of the sternocleidomastoideus, scaleni, trapezius, levator anguli scapulae and rhomboidei; and, third, the trophic reflex which shows as a degeneration of the muscles above mentioned and also of the skin and subcutaneous tissue over the neck, shoulders and chest as low as the second rib anteriorly, and the spine of the scapula posteriorly.

This grouping shows each symptom in something of its true value and in its relationship to other symptoms. I desire to emphasize that the group of symptoms due to toxemia, the ones on

This group of symptoms, then, when due to a tuberculous process, should be considered as evidence of toxemia only. Their absence or dis appearance does not indicate the absence o tuberculosis. The symptoms due to toxemia art of diagnostic value in tuberculosis only wher accompanied by symptoms of a reflex nature o those due to the disease per se, or by evidence derived by physical examination.

The symptoms of a reflex nature, Group II are based entirely on the visceral neurology of the lungs.

The lungs are supplied by sympathetic nerves from the upper five or six segments of the theracic portion of the cord, and these carry th impulse caused by inflamed pulmonary tissue back to the same segments of the cord, when it is transmitted upward into the cervical segments to mediate with the cervical spinal nerves. causing muscular contraction through the moto and pain through the sensory roots. The chic area of pain is in the third and fourth cervical zones which includes the areas of the neck and shoulder down anteriorly to the second rib, ard posteriorly to the spine of the scapula. This the only subjective symptom caused by refle impulses traveling from the inflamed lung over the sympathetic nerves.

The lungs are also supplied by the vagts nerve which belongs to the parasympathetic sys tem. Through it the lungs are brought into reflex connection with many other structures an organs supplied by parasympathetic nerves an produce symptoms in them. All of the commos reflex symptoms in tuberculosis point away from the lung and toward those organs which a bound most closely reflexly with it-the lary stomach, intestines, and heart. Patients wi tuberculosis are apt to consult the laryngolog and gastroenterologist rather than the tubercu losis specialist.

The parasympathetic reflex on the part the larynx shows as a disturbance in sensation and motion, producing local irritation, cough hoarseness, and certain disturbances in phontion. The disturbed function found in the gastr intestinal canal in chronic pulmonary tuberc losis, is the same that is found in chronic ga

pulmonary tuberculosis expresses itself through the visceral nerves, emphasizes the importance of this line of study as an aid to diagnosis.

Prognosis

The prognosis in tuberculosis has greatly improved with our increased knowledge: (1) of the disease, and (2) of the tuberculous patient. I desire to emphasize a fact that should be self evident but which seems to be generally overlooked; that is, that these early tuberculous infections do not always become quiescent, but without producing a frank clinical disease, manifest themselves as clinical entities in the way of interfering with the growth and development of the child. While they may not extend and produce active open tuberculosis, yet the bacilli multiply and invade adjacent tissues and produce toxins which prove particularly detrimental to the nervous system of the child, and often, sooner or later, cause open clinical disease.

These cases should be sought out and treated. They respond readily. I have found no type of tuberculosis in which the prognosis is so good. Children, relieved of active infection before the age of puberty, often go on to a normal develop

ment.

Early clinical tuberculosis should nearly always heal, under ideal conditions. It will heal in probably 20 per cent of cases by such simple measures as change of occupation, rest and tonic measures. If only we knew what patients were included in this 20 per cent, we would save them time and expense, but we have no way of judging; so it is our duty to treat every case of early clinical tuberculosis as serious, and provide those afflicted with the intelligent aggressive treatment which will restore health to nearly all. This is all the more important and urgent because the prognosis rapidly decreases as the disease extends; whereas 80 to 90 per cent can secure an arrestment of their disease in early clinical tuberculosis; the percentage drops to 50 to 70 in moderately advanced cases; and 30 to 40 in the advanced. These figures apply to patients treated under the best of conditions and with a wholehearted cooperation. Treatment under less favorable conditions without full cooperation will produce results correspondingly less favorable.

Treatment

It is impossible to give more than a few general principles of treatment without making this paper far too long. While it is unfortunate that we have not as yet found a remedy for tuberculosis which ranks with mercury and salvarsan in syphilis, quinine in malaria, and antitoxin in diphtheria, yet there is much room for encouragement in treating this disease by present day methods. Unfortunately present methods require much time devoted to treatment, are not generally understood by the profession as a

whole, and are poorly adapted to all patients, except those who will approach treatment with an intelligent understanding and cooperation. If only there were some specific medicine to give or some specific remedy to inject, then tuberculosis could be treated successfully by physicians generally; but until our scientists give us some such measure, practitioners in general will continue to say that they are unable to cure tuberculosis by open air and food, and will continue to feel pessimistic regarding its eradication; and its successful treatment will have to remain in the hands of those who give the disease special study.

There are two elements in the healing of tuberculosis: (1) the local stimulation of the focus of disease by the reaction which takes place between the bacillary products and the antibodies formed by the patient's tissue cells; (2) the formation of defensive substance, both general and specific, by the body cells.

The bacillary products which unite with the antibodies and produce focal reaction may be furnished by the patient himself from the bacilli which cause his infection; or may be introduced from without in the form of products known as tuberculins. The specific stimulation of the focus of disease by this reaction is a very important factor in healing. Tuberculin when administered intelligently will supplement the products furnished by the patient himself, and will hasten healing. My experience in its employment for many years leads me to believe that it will add at least 20 or 25 per cent to the average patient's chances of cure; and in many will be the determining factor in healing.

Whether tuberculins are used or not, the main point in cure is the life that the patient lives. Resistance must be kept high for a prolonged period of time, until healing takes place. How long this will be differs with the character and extent of the process; the underlying nervous, psychic and physical reactibility of the patient; the ability of the physician to outline an intelligent and sufficient line of treatment; and the willingness and ability of the patient to give a whole-hearted cooperation. It will be long enough under the best conditions, and is much prolonged under less favorable circumstances. Early cases require from six months to a year of treatment and should be under observation for a year longer; moderately advanced cases require from two to six months longer for treatment, and a correspondingly longer period of observation: and far advanced cases can rarely be dismissed in less than ten or twelve months, some even being compelled to spend two or three years in obtaining an arrestment,, after which they must still be observed for a period of two years or more.

The patient who desires to recover from tuberculosis must be willing to accept disappoint

If only the difficulties which are attendant upon obtaining a favorable result in this disease at any time after it has become a clinical entity, and the comparatively greater difficulty of doing so when the disease has become advanced, could be impressed upon both laymen and the members of our profession, so that physicians would be consulted early and early diagnosis would be made, then the time and money spent in the treatment of tuberculosis would be reduced by one-half; the percentage of favorable results would be increased three-fold; and invalidism. would be immeasurably reduced. This can be accomplished even with our present imperfect method of treatment, which, as previously mentioned, amounts to making the patient live so that his resisting power may be maintained at a high level in order that his body cells may respond with large quantities of defensive bodies and to keeping him so living until the diseases has time

to heal.

Factors which aid in keeping resistance high, are such as open air, good food in sufficient quantities, properly regulated rest and exercise, heliotherapy, hydrotherapy, various medicinal tonics, procedures which relieve symptoms and complications, among which must be mentioned artificial pneumothorax, and carefully applied psychotherapy. Each of these will, when properly applied, add its five, ten or twenty per cent to the patient's chances of cure. None of them should be considered as a "cure" for tuberculosis in itself. All are aids when properly employed, and many even can do harm when employed in a wrong manner. I do not hesitate to assert that what seems so simple a measure as "exercise," wrongly applied, has been responsible for more deaths in tuberculosis than any other single measure.

Tuberculosis and the Soldier

The world war brings several important probems as far as tuberculosis is concerned: 1, the problem of excluding active tuberculosis from the army; 2, the care of soldiers who become actively tuberculous; 3, the influence of the war on the problem as found in civil life.

The exclusion of tuberculosis from the army s greatly to be desired and yet difficult of ac

complishment because of the rapidity with which examinations must be made. Colonel Bushnell, who has long been a careful student of tuberculosis, set as the standard for exclusion, all appli

cants in whose chests are found "determinate"

rales. While this does not take into consideration the finer diagnostic work which has developed during the past few years, it does eliminate most of the frankly tuberculous at the beginning. If sufficient help were obtainable to inquire into the clinical history with reference to such symptoms as blood spitting, pleurisy, frequent and protracted colds, cough, and general nerve instability and loss of strength, examinations would be made more accurate. A point that could well be considered in determining whether a suspicious case should be taken into the army or not, is whether he is going to better his condition by entering the army. If so, he could be taken with little risk; if not, he should be rejected. A farmer boy in question should be eliminated; on the other hand, the city dweller who will be put on healthful outside exercise, should profit by it.

The effect of caring for the rejected draft men and the soldiers who return, should have an important influence on the amount of tuberculosis found in civil life. The problem of the returned tuberculous soldier has several important angles: 1, immediate efficient sanatorium care for all who can be helped; 2, infirmary treatment for those severely ill; 3, proper care after discharge from the sanatorium.

Realizing that tuberculosis heals slowly, treatattainment of a definite result. After this result ment should not be for a set period; but for the has been attained, then suitable light work with compensation should be provided, so as to turn the soldiers back into society capable of self support. If those who have secured a favorable result were given some light employment at which they could work part time and remain within their strength over a sufficient period of time to permit the disease to fully heal, relapses would be reduced to a minimum. The period of time would vary from one year to several years, according to the individual concerned.

The war should have a beneficial effect upon the tuberculosis problem in the United States. While the disease must be expected to increase in the European states in which the war has lowered the status of living and at the same time brought such overwhelming nerve depression, in America it should decrease because of our added opportunity of determining those who are infected between the ages of 18 and 46, and because of the care which is being given to rejected applicants and which will be given to returned soldiers.

THE COMPLEXION IN CANCER

E. M. PERDUE, A. M., M. D., D. P. H. Professor of Preventive and Tropical Medicine in Eclectic Medical University; Director Johnson's Pathological Laboratory for Cancer Research, Kansas City, Missouri.

In introducing the novel title of this paper it is the purpose of the writer to emphasize the value of clinical observation in the study of cancer. It is recognized that the experimental and not the clinical method is the vogue in all the great endowed, recognized and approved laboratories. So firmly have the experimental methods. become intrenched, that to do or even suggest the clinical study of cancer, is to call down upon the head of the investigator all the opprobrium of a so-called scientific and medical press which is controlled by organized medicine. In face of all this, we are bold enough to state that a clinical study of cancer not only brings out many important truths, but overthrows many of the hypotheses of the experimental research laboratories.

Cancer is a chronic alkaline autointoxication. When we first studied chemistry, we were taught that there were three states of matter: gaseous, liquid and solid. Now we know that there are at least four states of matter: gaseous, liquid, collodial and solid. Nature looks with such favor upon the collodial state that she has chosen it - exclusively for the presentation of all organic forms. With a few exceptions, organic colloids may be defined as protoplasm in combination with ionized water. The youth of every organism is characterized by an abundance of ionized water and a corresponding scarcity of solid matter. As the organism grows older, the tissues give up water and become more dense and solid. As alkalinity is the condition of all growth, the alkalinity increases with the concentration. All colloidal reactions are necessarily slow. The alkaline concentration of the tissues is slow. It is retarded by all conditions which hinder drying. It is accelerated by all conditions which facilitate evaporation. This evaporation of water from colloidal tissues is called deaquification. It is the process and mechanism of senility. The trajectory of life is indigenous and specific to every organism at its inception. Time is of the essence of the process. The time necessary to accomplish senility is a specific attribute of every tissue, be it vegetable or animal. Hence the age of ripening and of senility is past the middle life of the organism.

In all organisms, the appearance of ripening or senility can be hastened by deaquification. This is a matter of common knowledge and common observation in the ripening of grain. Agriculture is not hedged about by the prejudices of medicine. It is equally true of human tissue. It is so true, that for untold ages, our human organism has sought to adapt itself to climatic con

ditions for the very purpose of preventing t excessive deaquification of tissue and the atter ant irritation of the chemical rays of the st These facts are of great interest and importar in the incidence of cancer. In the incidence cancer, in the prevention of cancer, one of 1 most important facts is complexion. Despite great weight of authority to the contrary, sl cancers above the collar and below the wrist ba on blond men who lead an outdoor life exceed other cancers put together.

This statement is true for the United Sta and for all countries where a people of lig complexion is subjected to bright sunlight. T only regions of the earth having a blond popu tion are those regions having a large proporti of fog and moisture-laden atmosphere, the Brit Isles, Scandinavia, North Germany. The in genous populations of the rest of the world ha accommodated themselves to their sunlight varying degrees of pigmentation of the sk Among these peoples the incidence of cancer the skin is very low. White peoples who ha colonized countries of much uninterrupted st shine are the principal victims of cancer of 1 skin. This is especially true of the United Sta and the Australian Commonwealth. The abor ines accommodated to the sunshine of 1 United States have the brownish copper color skin of the American Indian; the native negrit of Australia are almost black.

A moist atmosphere absorbs the rays of t infra-spectrum and up to the red in the spectru and becomes heated thereby. The light rays a not absorbed by a moist atmosphere, but may greatly diffused. The rays of the ultra-spectr from the violet on through the rays too sh to be seen are absorbed by a moist atmosphe The rays of the ultra-spectrum are the ra which tan and burn. They are of the same natt as X-rays and the rays of electric light. T rays of the ultra-spectrum in tropical countr greatly exceed the rays of the same characteri England and Scandinavia. They are in mu greater proportion at high altitudes. Perso of white skin become sunburned on going from humid plains to the tops of high mountai Tyndall states that he became markedly tann by working under an electric light.

The first essential in the etiology of can of the skin is the production of the systemic co ditions of hyperalkalinity. As already indicate this is the physiological result of the natural p! cess of senility or growing old. This conditi can be hastened by constipation and defecti elimination. As the tissues are all colloidal, t process of deaquification is necessarily slo Deaquification is hindered by all agencies whi retard evaporation. Among civilized blond rac the chief agency retarding the process of deaqi fication is clothing. The skin under the clothi