The greatest opposition I meet with daily, in my exclusive line of tuberculosis work, is the downright skepticism of physicians to the specific action of the culture products of the tubercle bacilli and their curative value in early stage cases of circumscribed pulmonary consumption. That many lives have been saved with the old original tuberculin treatment, with all its impurities, the ablest physicians in the world attest. That the impurities contained in crude tuberculin, in fact in all the tuberculins, was just causes for their unpopularity must be admitted; yet, the fact remains, nevertheless, that the bodies of tubercle bacilli contain a toxin capable of marked curative action in tuberculosis.

Looking now to the clinical results coming from the last step made in perfecting a specific toxin for the cure of tuberculosis let it be emphasized that in tuberculosis, as in syphilis, no therapeutic agent is expected to directly influence necrosed tissues; and, in the former, as in the latter disease, curative results can only come of treating vascularized tissues. It is true that in the treatment of pulmonary consumption, where the destructive processes can be arrested, by removal of the more recently proliferated tubercle, with an improved metabolism, reparation is possible in all the destructive areas by the usual induration and fibroid processes.

The isolation of the pure toxins from tubercle bacilli fell to the honor of our distinguished American citizen, Dr. Karl von Ruck. During the last five years, in the course of rather large exclusive tuberculosis work, I have relied solely, as a curative therapeutic agent, upon his "watery extract of tubercle bacilli." That this product has a direct specific action on all live tuberculous processes there is not the shadow of a doubt. It is only of late, however, in the light of recent research, that the philosophy of such cures and the conferring of a stronger relative immunity, has become apparent.

Let it be understood, once for all, that in the treatment of tuberculosis we do not need to introduce into the patient's body an "antitoxin," as has been expressed in the various serums applauded for this purpose; we do not want to neutralize the toxins in cases of this disease; in fact, what we need is more toxins than are found present. The toxins derived from solution of the tuberculosis germ are highly curative, in that they stimulate the production of antibodies. It must be remembered that all infections occur by reason of a

weak blood resistance. Immunity stands in direct ratio to the presence in the body fluids of an "immune body." Without induced affinity of the alexins for the bacteria to be killed, the latter go on proliferating until the wide dissemination of tubercle, with its caseating and toxic impress, destroys the life of the consumptive. By supplementing the toxins in situ, with those from cultures, the immune or antibody is constructed in the blood by certain intricate chemical laws. Recent research demonstrate quite conclusively just how these laws may be utilized for great good. The fact is this line was worked out clinically before the nature of the process was understood. It has frequently been alleged that the specific cure of tuberculosis has never been worked out to practical ends; even Bridge, in his late book on tuberculosis, attempts to discredit this great work, his experience resting, however, largely on the use of "horse serum." Of course, no man of any scientific attainments will attempt to defend the serum treatment in tuberculosis. The writer gave all these serums a fair trial for two years and must say they are absolutely worthless in treating tuberculosis. Some very good physicians still have such serums and the "direct method" of injecting the pure toxins into the patient direct, very much mixed; having failed in the former they condemn the latter on general principles.

The writer has treated about 1000 patients with tuberculosis, for varying periods of time, over 3c0 of whom took the ful course. Most of these patients were rather advanced cases of pulmonary tuberculosis, 90 per cent having fever on reaching the sanitarium, with cough, moderate or severe, loss of weight, night sweats, loss of appetite and strength, shortness of breath on exercise, and 98 per cent softening and excavation as evidenced by the presence of tubercle bacilli in the sputum. The results of this specific treatment in these 300 cases show, after the lapse of years, about 60 per cent of permanent recoveries.

The method of cure is by the production of immunity the rationale of which, together with technic, dosage, management in the fever period, feeding, rest, exercise and general control, must be the subject for a separate paper.

[Sanitarium Place.]

The Baby Incubators on the "Pike."

A Study of the Care of Premature Infants in Incubator Hospitals Erected for Show Purposes.

BY JOHN ZAHORSKY, M.D.,

ST. LOUIS, MO.

(Continued from page 275, May Number).

HYPOTHERMIA.

A rectal temperature below 36°C. (96.8°F.) should be considered an indication for employing warming measures. It is not sufficient to raise the temperature of the incubator only; it is necessary to inquire into the cause of the reduction in temperature. In the first place, there is the post-natal hypothermia which resulted from too great exposure after birth. A fall in temperature will also occur even if the infant is placed at once in the incubator. The observation of Perrett is instructive in this connection:

A premature infant, weight at birth, 950 grams, had a rectal temperature of 36.1°C. It was immediately placed in an incubator at 32°C. The temperature taken every two hours thereafter gave these results-35.6, 34.2, 34, 35.2, 35.9, 36.9°C. In other words, the temperature dropped to 34°C. in spite of the incubator; then, after six hours, it gradually rose to normal. Even Lepine, more than forty years ago, asserted that the temperature of the premature infant at the room temperature may drop to 33°C., but, as Budin remarks, the return to normal is not so easy as he indicated.

Evaporation and radiation from the translucent congested skin, causes a rapid loss of heat, and the incubator is designed to prevent this. It is questionable, however, if the incubator should be used to supply heat to the infant. Warm air is a slow method of heating the infant. For the initial drop in temperature the warm bath should be resorted to. When the infant's temperature is normal it must be thoroughly dried and placed at once in the incubator. These warm baths can be frequently repeated.

Repeated attacks of cyanosis usually result in a fall of the

rectal temperature. Warm baths and careful attention to diet are necessary.

Very serious is the reduction in temperature following attacks of indigestion. When there are symptoms of colic, green, undigested stools, some of which contain mucus, the question of treatment offers many problems. Blair has been very successful in these cases by heating the incubator up to 96 to 98° and keeping the rectal temperature slightly above normal. In addition he employs bathing. Personally, I feel that the bathing and careful dieting witout the incubator being so high will be found equally successful. In private practice it not infrequently happens that after the premature infant is a few days old, and has been overfed, dyspeptic symptoms appear and the infant has hypothermia. The careful treatment of the indigestion and the employment of warm baths are the rational indications and may be absolutely necessary.

Here again I must insist that attention to clothing should be given in just such cases. There is no better way to stop heat loss from a radiating body than to envelop it in nonconducting (woolen) clothing or blankets. Frequently, a reduction in temperature may be checked by enveloping the infant in a soft woolen blanket. Even its head may be thus enveloped and radiation checked.

Our experience shows that infants weighing even less than 1000 grams should be allowed a difference of 4° between their own and the atmospheric temperature. When, even with additional clothing, hypothermia ensues, attention to the food supply and nutrition is necessary.

Finally, a sudden hypothermia may be caused by some infectious process and rapidly end fatally. Altogether, the prompt and careful management of hypothermia is one of the problems of premature infants.

FEVER.

Fever results from an insufficent water supply, an overheated incubator or some infection. Occasionally, constipation seems to be the only cause present. It is remarkable how the temperature of the premature infant fluctuates, being disturbed by sligh causes. An elevation of temperature up to 38°C. (100.4°F.) has no significance. A temperature higher than this demands attention. Fever was a very common condition of the infants of the First Series. As I have incomplete

data, a report of the cases would be unprofitable. In the Second Series the only two infants having a temperature of more than 102° were infected.

The treatment of fever in the premature infant does not differ from that of older infants. As a rule, it is best to remove the infants from the incubator if the temperature rises above 102°. Often this is all that is necessary, besides the treatment directed to the underlying pathological condition.

INDIGESTION.

Under this head may be grouped a class of disturbances which are brought about by functional derangement of digestion. It ranks with cyanosis as one of the disorders which