into "stages" is of little advantage, and often misleading. The text-books, for example, treat of the preliminary stage, the cavity stage, the final stage and so on, in this way, just as if every case of tubercular infection displayed these various stages in order, according to schedule. Experience has brought to my notice no disease of the human body that runs its course so deviously and with so little regard, as it were, for "typical text-book regularity," as tuberculosis. There are patients who remain for years-I might say decades-in the so-called preliminary stage, and whose death in the end is not the result of tuberculosis at all. Then again there are lungs in which cavities develop with rapidity, in spite of which the patients in question may live for years in comparatively good condition. In other instances death has intervened but shortly after infection without having given the lungs time to reach the socalled second or third stage. There are in fact many circumstances attendant each case, which render some simple, some difficult.

on

External conditions, such as the place of dwelling, nourishment, manner of occupation, temperament, and principally the greatly varying powers of bodily resistance are the deciding factors, and render the manifestations and progress of the disease favorable in one instance and unfavorable in another. It is but natural that in the treatment of those suffering from pulmonary tuberculosis the physician must take all these factors into consideration. Although I have questioned the advantage of dividing the disease into clearly defined stages, I nevertheless believe in one stage that in which there is hardly anything to be found in spite of the most painstaking auscultation and percussion, and in which the physician's instinct alone

warns him to be on his guard. As soon as his percussion has discovered infiltration, his auscultation bronchial or other pathological respiratory noises, his microscope bacilli in the sputum, then of course the disease is no longer in its preliminary stage but has reached that of pronounced pulmonary tuberculosis, from which point the mode of living, favorable or unfavorable as the case may be, conditions of climate, or of mind and body, must decide how great or how rapid the progress of the disease is to be; the most important factor of all being the patient's security from other forms of infection.

The treatment of pulmonary tuberculosis must accordingly be directed, above all things, against those conditions that threaten to render the case an unfavorable

one.

The ambulatory treatment then, as practiced at the dispensary of the German Hospital-the proper subject of this article-is as follows:

The dispensary consists of six rooms situated in a building presented to the hospital with high generosity by Mrs. Anna Woerishoffer. It is entirely separate from the other hospital buildings and intended exclusively for those suffering from tuberculosis of the lungs or pharynx. That all these rooms are equipped according to the modern rules of antisepsis and that good ventilation is provided for, need hardly be stated. There is a large waiting room, well supplied with benches; pure, cold drinking water is conveniently at hand and the wash rooms and toilets are sanitary. At this point I wish to call attention to the cuspidors here in use, which are almost ideal in their simplicity. Instead of using one of the many patented and complicated spittoons, we use a simple enamelled bowl half filled with

an antiseptic solution; it possesses the advantage of a large opening, tending to lessen the possibility of the patient's expectorating to one side, and also that of being easily emptied and cleaned.

On admission, each patient is cautioned by the attendant (1) if possible, not to cough, and (2) if the coughing cannot be checked, to use the cuspidor. The effect of this prohibition is astonishing; no coughing is heard which goes to prove the amount and frequency of unnecessary coughing and expectorating in daily life. A trained nurse receives the patient, and takes the history of the case, being recommended to take particular notice of such points as may indicate that pulmonary tuberculosis has set in. Personal experience has taught me that a knowledge of the patient's manner of living and of employment during recent months is of more importance than his family history. Further matters of import are whether the patient has suffered from previous illness and of what kind, particularly whether he or she has ever had pneumonia or pleurisy, has ever had blood spitting and if so with what frequency. In the case of females I make inquiries as to births and miscarriages and as to whether the patient had been chlorotic during puberty. I further I further inquire as to the number of children born, whether any of them have died, and if so from what causes. And although I do not attach the same amount of importance to the question of heredity where pulmonary tuberculosis is concerned as other physicians do, still I consider it worth while to know whether the patient was a first, second, third or fourth child, and so onit having been demonstrated by experience that the later children, those born later in the life of the mother, possess less power of resistance.

The pulse, temperature and weight of the female patient is then accurately recorded by the nurse. Medical examination on the naked body is made, a proceeding which I consider of the greatest value. I endeavor to diagnose each case without relying on the bacteriological test, for but too frequently does the absence of bacilli lead us into error. At the risk of being regarded as old-fashioned I confess that I personally lay more stress on careful percussion, auscultation, palpation and inspection than I do on bacteriological investigation. The inspection of the chest alone often reveals symptoms from which conclusions as to a diagnosis may be drawn. Very frequently it may be observed that when the chest is fully inflated the expansion on one side, in the triangle formed by the clavicle, the sternocleidomastoid and the insertion of the scapular muscles, is slightly less than on the other; or on the other hand on deep inspiration, particularly in the case of thin individuals, a marked diminution of respiratory motion will be found in one or the other of the intercostal spaces. This symptom is often found in cases where pleurisy has been undergone and where the pleura have remained thickened but not to such an extent as to render this ascertainable by percussion or auscultation. Palpation of the thorax is restricted to the intercostal spaces and through the location of sensitive points becomes of value in examination. Percussion and auscultation of the thorax and the clavicular cavity still remain the most valuable methods of examination as in the time of Skoda and other masters. I have become accustomed, in percussion, to tapping as lightly as possible on the firmly applied finger. It is only in this way that slight differences of sound may be detected. In the case of lean patients and unfortunately enough it is most

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often with these that we have to deal—I frequently employ direct percussion of the chest wall. I do not consider the method of combined percussion and auscultation at the same time as of much value; be the percussion ever so slight, the stethoscope will report sounds that are often misleading. It is hardly necessary for me to mention that the best instrument of examination is after all the ear itself. Whether the investigation is carried on with the unaided ear, the stethoscope, the phonendoscope, or with other assistance, depends on individual preference for one or the other of these methods.

To interpret correctly what is heard, is the principal thing.

It is furthermore not my intention to treat of the various respiratory sounds, as I assume that it is more important for the practitioner to draw proper conclusions than to exercise his powers of nomenclature upon them. One exception may be made in this instance, in the case of that "unbestimmtes Athmen," a cross between bronchial and vesicular breathing which is often found in the preliminary stages of pulmonary tuberculosis and to which Jacksch called attention years ago. Only after the physical examination has been completed, when the diagnosis has so to speak been well established, is the sputum examined for bacilli, in order to confirm it. Thereupon the nose and throat of the patient are examined, and there is hardly a case in which abnormalities of one kind or another cannot be discovered-which however are not by any means invariably connected with the pulmonary trouble. About fifteen per cent of those treated in one year at the ambulatorium were declared hopeless and turned to such hospitals as provide for these cases, or visited at their homes two or three times a week by our

nurses.

These keep us informed as to the condition of the patients and endeavor to make them as comfortable as possible during the short period which the unfortunates still have to live. Where necessary, our nurse provides the sufferer with milk and other nourishment and sees to it that sanitary regulations are observed in order to prevent infection as far as the healthy members of the family are concerned. Of the remaining eighty-five per cent, half are cases which may be improved, while about fifteen per cent of the entire number of patients are cured to such an extent as to enable them, with some restrictions, to follow their vocations.

Before I take up the subject of our methods of treatment, I wish to state that at our dispensary both Pirquet's

and Calmette's tests have been used in doubtful cases. My experience has not been encouraging and I am of the opinion that although a positive reaction is of confirmatory value in connection with all the other tubercular symptoms, still it is very often misleading, while a negative reaction is of no definite value whatever.

Our therapeutic methods consist mainly of dietetic and hygienic regulations and of symptomatic medicinal treatment. In cases where there is a rise of temperature, be it ever so slight, absolute rest is ordered. Throat irritation is relieved and I do not hesitate to prescribe narcotics in large doses when necessary, in those cases where I apprehend that each coughing spell may serve to irritate newly formed cicatrices. Usually however small doses of codein are sufficient to allay the desire to cough. they are not, morphine or heroin is employed. It may frequently enough be observed that the simple order to refrain from coughing will suffice, by which however I do not mean to say that sputum which

If

may without particular effort be dislodged should be retained. In cases of hemoptysis, even those of the slightest degree, absolute rest is prescribed and narcotics employed. The patient is advised to remain in bed at least six or eight days after the bloody appearance of the sputum has ceased. Where nourishment is inferior, and loss of weight systematically recorded in spite of progress otherwise favorable, guaiacol is used together with arsenic, to good purpose. Of the preparations of guaiacol I prefer styracol above all others. It is a white, odorless and tasteless powder which has been used to good effect in doses of 0.6 to 0.9 gm. particularly in cases where the stomach and intestines were involved. A convenient manner of taking is in the form of tablets of 0.3 or 5 grains, which should be chewed for better purposes of absorption. In afebrile cases, the styracol also affected expectoration beneficially. We have used quinine effectively against fever, and atropin and agaricin as well as alcohol baths with varying success against the oppressive night sweats. Mercury injections, as recommended in recent years by Wright, were employed in various cases at our dispensary but with little success. The same may be said of tuberculin injections. Nevertheless I do not at all desire to call the effectiveness of these methods into question, but would state at the most that they are not adapted for use in conjunction with the ambulatory form of treatCareful preliminary measures in each individual case must be taken where tuberculin is to be used, and only a daily. or still more frequent taking of temperature can indicate just what dose may be effectively or at least harmlessly administered. Frequently treatment with tuberculin must be abandoned for several days and then, with greatest caution, begun

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again. And as the patient under the ambulatory system is often seen and examined but twice a week, a conscientious use of the tuberculin treatment may be seen to be impossible. For it to become possible, our dispensary would have to be provided with a ward in which the progress of the respective patients could be observed several times daily with a view to ascertaining the individual reaction of each to the tuberculin injection. After such period of experimentation the tuberculin treatment could well be continued under the ambulatory system probably with as effective results as those reached in the sanatoria of Trudeau or Brown in Saranac Lake, and in others. Koch's rules for the tuberculin treatment follow:

(1) Afebrile cases only, and those in which the process is in its earlier stages, are adapted to this form of treatment.

(2) Very small doses must be used at the start, and increased so minutely as to give rise to insignificant reactions only, or

to none at all.

(3) Should a reaction set in, the tuberculin injection must not be repeated until the temperature has been normal one or more days.

(4) The application of tuberculin is to be continued until in the course of three or four months the tendency to react has completely disappeared.

Besides the above measures, the patient is advised to consume liberal quantities of milk in every form, and of eggs, meat and vegetables. Milk, and other ample nourishment, is furnished the poorer patients by the hospital.

The use of alcohol is absolutely forbidden. At this point I might mention a case strikingly illustrative of its deteriorating effects. The patient, aged twenty-six, was employed in a brewery, and in spite of his healthy appearance, infiltration of the apex of one lung was found, with a daily temperature of 100-101 degrees and a loss.

within six weeks of five pounds. He acknowledged the daily consumption of two and a half litres of beer. Acting under my advice he abandoned this practice with the result that in the course of the second week his temperature became normal, his appetite increased and coughing grew less. Two months later we had the satisfaction of transferring him to the bi-weekly class of patients whose visits serve the single purpose of allowing us to keep them in condition. As far as fresh air is concerned it would of course be best for every sufferer from pulmonary tuberculosis to live in the country. But as this is hardly ever possible particularly for our class of patients, we caution them to keep their windows open day and night irrespective of the weather. Our nurse sees to it that these prescriptions are adhered to, by visiting the sick in their homes and supervising the carrying out of our orders.

In regard to the treatment of abnormalities of the nose and throat I am strongly opposed to operations of any kind in patients suffering from fever. In my experience they almost always prove unfavorable. And although the treatment of laryngeal tuberculosis is not strictly within my topic, I would nevertheless call attention to the fact that here too absolute rest and, where necessary, refraining from loud talking for several months, has had the best results. Treatment by means of hyperemia has not been attempted at the dispensary.

My observations, on the whole, have led me to the following conclusions:

(1) The ambulatory treatment of pulmonary tuberculosis affords the poorest patient the opportunity of receiving medical attention without the necessity of leaving his family and in many cases without interfering with his vocation.

These advantages of the ambulatory system of treatment are offset by corresponding disadvantages.

(1) Effective treatment is impossible. because the patients are not sufficiently under medical supervision.

(2) It is but seldom that a complete. cure is brought about because the patient is apt to abandon the treatment after some improvement has manifested itself.

(3) Absolute rest, such as is prescribed for instance in cases of typhoid fever, is impossible, because the patient is often. forced to continue in his employment in order to support his family.

The ambulatory system of treatment for pulmonary tuberculosis as practiced at the German Hospital is, in short, as effective and as great a benefit to humanity as it well can be; and it is hoped that in the near future an annex will enable us to put into practice all the methods of treatment which painstaking and unselfish labor in the field of research may put at our command.

221 E. 68th St.

In the treatment of leukoplakia of the tongue the use of strong irritant applications should be avoided, since they rarely do good and may lead to the development of cancer.