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4. Hypertrophied tonsils and adenoids.

5. Tuberculin tests.

6. Sputum examination.

Of these, the pulmonary symptoms and signs and the tuberculin tests appear to be the most valuable and consistent.

The physical signs in children under ten years are not those of the typical apical lesion usually found in adults, but are often signs of a persistent localized bron chitis, usually in the lower anterior chest.

The ophthalmic, the cutaneous, and the hypodermic tuberculin tests were all employed, and the results of the local tests were corroborated in all cases in which the hypodermic test was also given. The cutaneous test was fully as reliable, if not more so, than the ophthalmic test.

Enlarged cervical lymph-nodes and hypertrophied tonsils and adenoids do not seem to be a determining factor in a diagnosis of tuberculosis. Malnutrition is sometimes the only appreciable evidence of tuberculosis in children. The examination of the sputum was of little value.

The results of this investigation lead to the conclusion that pulmonary tuberculosis is very frequent in the children of tuberculous parents.

"Tuberculosis of the Ear."

BY DR. CLARENCE JOHN BLAKE, Boston.

The clinical aspects of tubercular infection, as manifested in the middle ear, and the consequences evidenced in advanced implication of the temporal bone were described by the earlier writers on otology, but it is only within the past ten years that more precise attention has been given to a form of invasion of the middle ear and labyrinth, characterized by considerable and rapid destruction of all tissues, this being coupled with a peculiar lack of preliminary subjective symptoms.

The accessibility of the middle ear cavity to infection, through the medium of the tympano-pharyngeal tube, and the character and location of the soft tissues in the epitympanum explain the more common implication of this cavity, while the peculiarity of the objective symptoms emphasizes the importance of aural examination for purposes of differential diagnosis.

The Comparative Value of Change of Climate and of Treatment in Sana. toria Near at Hand in Cases of Pulmonary Tuberculosis.

BY DR. CARROLL E. EDSON, A. M., Denver.

An outdoor life is one of the essential aids to the cure of pulmonary tuberculosis. Climate is the sum total of the meteorologic conditions prevailing in a given region over considerable periods of time.

The climatic surroundings of the patient have to be considered. Consciously or unconsciously we select a climate for every patient, even when we keep him at home. That climate is most favorable which most readily permits an outdoor life.

A change of climate will be of advantage to a patient, if we can thereby place him under meteorologic conditions which to a greater degree than before, and more constantly, permit him to lead the necessary outdoor life with ease, safety and economy of vital expenditure.

The accompanying change of scene and surroundings may be expected to act advantageously in an individual way.

In making any proposed change of climate, attention must be given to the facili ties in the new region for obtaining suitable food, accommodation, care and medical supervision.

If these conditions can be fulfilled in a better climate as well as at home, the patient should be advised to make the change.

If the patient's financial, social or domestic circumstances are such that he can not, in the new climate, secure proper and sufficient food, accommodation, care and medical attention, or if his mental attitude is such as to make separation from home inadvisable, he should not be sent away.

Tuberculosis of the Nose, Mouth and Pharynx.

BY DR. H. P. MOSHER, Boston.

Owing to the protective power of the nasal mucous membrane, primary tuberculosis of the nose is rare. Primary tuberculosis is characterized by a superficial ulceration situated over the anterior part of the cartilaginous septum. Secondary tuberculosis of the nose is more common than the primary form. It is part of a general or of a pulmonary tuberculosis. The secondary form tends to produce tubercular tumors. Nasal tuberculosis has a slow, painless and progressive course. As a rule, it does not extend to the pharynx.

In making a diagnosis of tuberculosis of the nose the chief disease to exclude is syphilis. The points of difference are as follows:

Tuberculosis attacks the cartilaginous part of the septum; there is little, if any, inflammatory reaction, there is no odor, and its course is painless. Syphilis, on the other hand, attacks by preference the bone of the septum. There is a marked inflammatory reaction, there is odor and there is pain.

Tubercular lesions are found in all parts of the mouth. The most common lesion is an ulceration. The first sign of a tubercular lesion of the mucous membrane of the mouth is the appearance of a circumscribed area, which is pale and slightly edematous. Within this there are small submucous yellow or gray tubercles. These soon break down into a shallow ulcer. On cleaning the bed of the ulcer, numerous tubercles are found scattered over it. The worm-eaten edge of the ulcer is set about with tubercles and granulations. Occasionally a tubercular tumor or a tubercular abscess of the tongue occurs, but the common lesion of the tongue is the common lesion of the rest of the mouth, namely, an ulceration. In most cases ulcerations of the tongue, like other tubercular ulcerations of the mouth, cause little, if any. pain; at times, however, ulcerations of the tongue are very painful. Trauma plays an important part in causing and localizing tubercular lesions of the mouth and tongue.

The final and absolute test of tuberculosis of the nose, mouth and pharynx is the finding of tubercle bacilli. Tubercle bacilli are very hard to detect in tissue removed from the nose, mouth or pharynx, The finding together of giant cells and caseation is very strong proof of tuberculosis. Before making a diagnosis of tuberculosis of the mouth syphilis must be ruled out. In certain cases, where tuberculosis causes an abundant over-growth of nodular tissue, the presence of malignant disease is simulated.

Tuberculosis of the pharynx is not uncommon as a secondary infection from tuberculosis of the lungs. Extensive tuberculosis of the pharynx is a serious complication, because it interferes with the patient's swallowing. Such cases soon end fatally. Tuberculosis of the tonsils often occurs secondary to tuberculosis of the lungs. In most instances it runs a mild course. Sometimes, however, the tonsils

become deeply ulcerated, like the rest of the pharynx. Primary tuberculosis of the faucial and the pharyngeal tonsil occurs in 5% of cases.

The pharyngeal tonsil is infected by the air current, the faucial tonsil by food. In what percentage of cases tonsillar tuberculosis is of the bovine type has not been determined. Wood maintains that 5% of the children have latent primary tuberculosis of the tonsils. At any age there are few diseases which are latent in the body in such a large percentage of individuals. The tonsils are oftenest infected with tuberculosis in childhood during the time when the epithelium lining the crypts is spread apart and thinned by the passage of lymphocytes through it. While the germinal centers are active they shower lymphocytes into the surrounding tonsillar substance, and upon the epithelium of the crypts. Tuberculosis of the tonsils rarely causes pulmonary tuberculosis or general tuberculosis. The great importance of tonsillar tuberculosis lies in the fact that an overwhelming majority of enlarged cervical glands are tubercular, and that these glands are infected from the tonsils. Cervical tuberculosis is limited to, the glands of the neck; it seldom gives rise to tuberculosis of the apex of the pleura or the lungs. The first step in the treatment of enlarged cervical glands is to remove the tonsils by thorough dissection.

The treatment of tuberculosis of the nose, of the mouth and of the pharynx, is the thorough removal of the tubercular tissue with the curette, and the subsequent use of lactic acid. In this way small lesions may be made to heal, large lesions also may be made to heal for a time, but they break down again. In small primary lesions of the nose, of the mouth and of the pharynx, the use of tuberculin would seem to have a special field.

I.

Treatment of Renal Tuberculosis.

BY PROFESSOR THORKILD ROVSING, Copenhagen.

The danger of infection from tuberculous urine is underestimated or neglected. The diagnosis of renal tuberculosis is, as a rule, made only after many years' illness, and then only when the bladder has become affected.

2.

3. Until the bladder symptoms set in, the diagnosis is nephritis, and the treatment, therefore, quite different to the rational therapy.

4. The physician's attention, therefore, ought to be drawn to the early diagnosis through microscopic and bacteriologic examination of the urine in every case of albuminuria.

5. If pus is found, but no bacteria, in stained preparations and by culture, the diagnosis of tuberculosis is nearly sure.

6. The diagnosis made, care must be taken of the linen and the urine, on account of its contagiousness.

7. The patients ought to be sent to a surgeon for cystoscopy and ureteral catheterization, as they always have a chance to be cured, if one kidney is healthy, by nephrectomy of the diseased kidney, and, if the bladder is also affected, this can be treated by injections of 5% to 6% solution of carbolic acid after my method.

Tuberculosis of the Bladder.

BY DR. BRANSFORD LEWIS, M. D., St. Louis.

Tuberculous infection of the bladder is accomplished in five ways: (1) through the blood-channels, (2) through the lymph-channels, (3) by means of the secretions of the semen, urine, etc.), (4) by continuity, and (5) by contiguity.

This infection is almost never primary; is practically always secondary to tuberculous infection of some other organ or organs of the body. This fact is largely

due to two reasons: To the non-absorptive mucous membrane of the bladder, making it resistant to the infection and, therefore, late, or secondary, in its accomplishment, and to the fact that, in the male, it lies in the path of the flow of the two secretions that are commonly carriers of tubercle germs, the semen and the urine.

Early Manifestations.-The location and early manifestations of the disease in the bladder are much influenced by the mode of accomplishing the infection, though the trigone and immediate neighborhood of the ureteral orifices are the seat of most frequent manifestation.

Clinical Evidences.-In the early stages the clinical evidences, as disclosed by the cystoscope, are typical and characteristic; but, later, they are modified by the mixed infection that is prone to occur. The early typical evidences are localized congested areas, then tubercle nodules, with stellate accentuation of the small vessels, the centers breaking down into rounded ulcers that show a tendency to coalesce. The vesical membrane loses its natural luster and becomes roughened or velvety. The bladder becomes reduced in capacity-contracted.

Symptoms-Among the earlier clinical features that should awaken the suspicions of the practitioner are the complaint of apparently causeless frequency of urination (connected more especially with infection of the neighborhood of the neck), the prolonged persistence of blood cells in microscopic quantities in the urine, and, later, the development of marked pain in the bladder or its neighborhood, either spontaneous or excited by urination. This becomes so severe that many sufferers become addicted to the use of morphine or cocaine for its alleviation.

Diagnosis.-The diagnosis may, and often must be, arrived at without detecting tubercle bacilli in the urine, although this is ordinarily the supreme test of the question. Tuberculosis of the bladder, without exposed ulcers, may not shed the germs, hence they could not be expected under such circumstances, unless from another organ higher up. On the other hand, tubercle bacilli in the urine do not necessarily indicate tuberculous infection or ulceration of the bladder. It has been definitely proved that, like typhoid and other organisms, tubercle bacilli may, for indefinite periods, be carried in the urine without being derived from any of the urinary organs; indeed, without any infection of the urinary tract.

If, in connection with the clinical evidences of tuberculous cystitis, it is impossible to detect bacilli in the urine by means of the microscope, it is advisable to accomplish sterile catheterization of the bladder, draw the urine, centrifugalize and inject the sediment into a healthy guinea-pig, which shows tuberculous infection within two or three weeks, if positive.

Treatment.-Comporting with the more hopeful outlook for tuberculous subjects in general, vesical and urinary tuberculosis should no longer excite the pessimistic hopelessness that they formerly did. By the judicious administration of general and local measures, an untold number of sufferers have been reclaimed to either comfortable living or to complete recovery.

The various hygienic influences suitable for tuberculosis in general are indicated, but it is probable that more good can be accomplished by local measures here than in the other instances; and this in the face of the formerly accepted doctrine that it was best to avoid local instrumentation for either diagnosis or treatment, in urinary tuberculosis.

Any local measures adopted should be as little irritating as possible; but this does not indicate the exclusion of the catheter or the cystoscope, when necessary. Obstructive conditions of the urethra should be done away with, securing free transit for the urine; for which dilating is preferable to cutting. Iodoform emulsion, with some bland oil, such as liquid vaselin, as a vehicle, is not only soothing but markedly beneficial in the majority of instances. It is injected daily, either with or without

the aid of a catheter, and is allowed to remain as long as possible. The formaldehyde group of medicaments is contra-indicated (the urine being already acid and sterile, with the exception of tubercle bacilli), but creasote and guaiacol, in full dosage, are often beneficial. The use of air or oxygen in the bladder, injected in connection with air-cystoscopy, seemed, in itself, to have a beneficial influence in certain cases of the author. Tuberculin injections are advisable in this condition, as they are in a similar infection elsewhere.

Surgery has a well-defined position in tuberculous cystitis, but it is chiefly related to the surgery of the contributary factors-of the kidneys, ureters, testes. Experience has proved the justification of removing the original focus, if it be a primarilyinvolved kidney or kidney and ureter; or, occasionally, the worse of two tuberculous kidneys, relieving the sufferer of a suppurating and infected organ that is doing no good, but is undermining the health and inciting infection in the organs below it. Many tuberculous bladders have recovered after such application of surgery. Permanent vesical fistula may become a necessity of the later stages of tuberculous ulceration, draining the bladder through a supra-pubic opening in the male, or through the vagina in the female.

Curetting the vesical membrane, after supra-pubic access, with direct application of strong bichloride solution, is claimed by Guyon to give much assistance.

The Intradermo-Reaction to Tuberculin in Animals.

BY PROFESSOR G. MOUSSU, Veterinary School, Alfort, and DR. CH. MANTOUX, Graduate of the Hospitals of Paris and Medical Consultant at Cannes Le Cannet.

The following are the conclusions which we consider possible to be drawn from this study:

1. The intradermo-reaction to tuberculin, as we have defined it, has shown itself in our investigations quite sensitive enough to reveal tuberculosis in the animals (cattle, hogs, goats).

2. The intradermo-reaction betrays itself by the evolution of a local manifestation, characterized by thickening of the skin, edema (in bovines), and sometimes the appearance of a central red spot (in hogs).

3. This local reaction does not usually cause any general disturbance, little or no fever, no loss of appetite, little or no loss of milk.

It develops without any change in the ordinary conditions of the life of the animals, and without its being necessary to take any measures or special precautions. 4. It has none of the disadvantages of the ocular and cutaneous reactions, and presents all the advantages of the subcutaneous injection of tuberculin.

5. It reduces the obligations of the operator to a minimum, by dispensing with every preparatory or supplementary measure (taking of temperature, denudation of the skin, etc.).

6. It is applicable to every kind of domestic animal.

Tuberculins and the Measure of Their Activity.

BY PROFESSOR A. CALMETTE, Pasteur Institute, Lille.

Since Robert Koch prepared his first tuberculin, now by common consent called old tuberculin (alttuberculine, or tuberculine brute), efforts have been made by means of various processes to obtain a purer and more active substance. Koch's old tuberculin, which consists of a simple glycerinated extract of bouillon cultures,

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