I am led to find an explanation for the presence of the tubercle bacilli.

Through the courtesy of Henry G. Graham, M.D., I quote from his paper published in THE LANCET-CLINIC, November 18, 1905, and entitled "The Micrococcus Tetragenus the Immediate Predecessor of the Tubercle Bacillus," the following: "It has been proved by the specimen exhibited in connection with this paper that the acid-fast tetrad forms the tubercle bacillus, but the question arises, from what source is the micrococcus tetragenus derived? It has been stated that this is a protozoon. But now proof of this assertion is demanded."

Time forbids the quotation of his experiment in full, hence I give only the result of it in general terms, asking those in the audience to read his able article in full. Dr. Graham proves beyond a doubt that the tubercle bacillus can be derived from infusoria in water. Such being a fact, the question arises-a question of vast interest to the medical professioncan tuberculosis be derived from impure water used in the household? It is not difficult for the laity to see that water previously contaminated with the sputum or feces of a tubercular patient might prove infectious, but how water apparently pure could be a source of so deadly a disease is beyond their understanding.

In order to prevent tuberculosis we must get at the fountain-head of its cause. We must also make an early diagnosismuch earlier than we are usually able to do, from the fact that patients seldom consult a physician in the incipiency of the disease; and probably from a fact of greater importance, that of depending upon physical diagnosis to confirm our opinion before expressing it.

ISOLATION.

Having made our diagnosis the patient should be informed that isolation in his home should be carefully observed. Not necessarily a shot gun quarantine, but he should have a room to himself, sleep alone and use private drinking cups and eatingutensils. The nurse should be instructed how to care for the patient in regard to ventilation, care of sputum, soiled clothes and in all minor details.

If the patient is able to walk out he should take care not to expectorate upon walks or elsewhere where the sputum can

dry and be raised up with the dust and inhaled. Cuspidors should be used in all public places, and in street-cars, vehicles and railway trains.

The laity are ripe for such instruction. It has recently been my pleasure to see a tubercular case advised to quit school by the patrons upon the complaint of pupils. While I regret very much to ask these tubercular cases to quit school-for among them are found many of the brightest intellects-it is best that they should do so. Their hope of recovery is better out of school, in the open air, taking needed exercise. State boards of health are doing much toward educating the people by sending out circulars calling their attention to the infectious nature of tuberculosis, and to ways and means of prevention.

SPECIAL TREATMENT.

Reasoning from cause to effect, it is logical to assume that a germicide is required to remove the cause. My alma mater had taught me to first find the cause and then prescribe. I graduated from college and began the practice of medicine just at the time Prof. Koch gave to the world his tuberculin cure, and I had great ambition to build up a reputation in medicine. I have seen the "rise and fall" of tuberculin, and its advocates first praise and then condemn it. But I have never lost faith in Prof. Koch's theory; I have lost faith in his tuberculin. If tuberculin has not been successful in the cure of tuberculosis, it has done much toward developing the "germicide theory" of disease by keeping the theory before us.

I have nothing new or untried to give you along the line of special treatment. At present I am using para-meta and ortho-cresols, called for convenience trikresol. This combination of cresols has three times the efficiency of carbolic acid and only one-third its toxicity. You can, therefore, get nine times the germicidal effect from trikresol that you can from carbolic acid. Ethylene-diamine can be added to trikesol as a solvent to albumin and pus corpuscle, thus making the trikresol more effective. Trikresol being acid in reaction and ethylene-diamine alkaline, their solution of equal parts in water will be neutral and freed of the irritating action of trikresol alone.

Kresamine, a watery solution contain

I have used the above prescription with success in early cases, and derived more benefit from it in advanced cases than I have from any other remedy.

Whatever germicide is used should be administered early in the case, and faithfully. Don't wait until you can confirm your diagnosis by auscultation, percussion and inspection, but commence your treatment upon the presentation of symptoms whose ensemble has taught us in the past to look for the development of pathognomonic indications. Cavities and nodules show us the ravages the disease has made, and adds nothing toward prevention or cure. It is like the chieftain of the fire company arriving at the scene of fire when the building is almost consumed. Could the chieftain have been there on time with a pail of water he alone could have extinguished the flame that afterwards defied his united force.

We should make a blood test for the presence of the bacilli or their protozoa, and also examine the sputum for bacilli. Absence of bacilli in the sputum does not exclude tuberculosis, but confirms it if they are present. These examinations should be made upon the presentation of early symptoms.

HYGIENIC TREATMENT.

Physicians in recent years have devoted much study to this subject. Private sana. toria and tuberculosis hospitals have been established in different States. Possibly we may have become too much enthused along this line. I am not saying anything about the quack institutes, only that they should be closed by law. But the institutions which are run for the protection of the homeless consumptive and to give proper care to those who have no homes and are able and willing to pay, should be encouraged. Isolation and good hygiene should be enforced in these institutions.

The laity are somewhat prone to wander to these institutions, thinking they give more hope of recovery than their private homes. I want to emphasize this: No

greater fallacy ever entered the mind of man than that of taking a poor consumptive away from a good comfortable home, away from old friends, and placing him in a tuberculosis hospital with the hope of bettering his condition.

Change of climate as a cure can be relegated as a thing of the past. Let physicians stop sending patients away to die, and teach the laity the laws of good hygiene, and meet the enemy where it is, with scientific measures. Nor is it all the fault of the physicians that people seek a change of climate. They often insist upon the doctor telling them where to go. They often censure him for keeping them at home to die.

GENERAL CONSTITUTIONAL TREAT

MENT.

It is true that we have never received the anticipated results from general therapeutics. The power of absorption and assimilation being poor, we can effect results in the same ratio. Forced feeding has had its day with me. It is necessary

to encourage these cases to take what food we think they can digest and assimilate, but to force it down them in quantities that would make a well man sick is showing lack of judgment. The constitutional treatment should embrace such measures as each individual case may require. Bitter tonics will probably give the best results therapeutically; milk and eggs being the type of perfect combination, will suggest a different diet when these fail. I admit my own inability to meet the requirements with any line of diet that will prove a "ration" for all cases.

TUBERCULOSIS A SPECIAL STUDY.

In years past tuberculosis and scrofula were classed as very closely associated, if not identical in nature. But since the advent of the germ theory tuberculosis stands alone as the only condition caused by the tubercle bacilli. This failure of differentiation was due to want of knowledge of bacteria. Dr. Graham tells us that it takes three or four months to develop bacilli from water. Our failure to differentiate tuberculosis to-day is probably due to not recognizing the tubercle bacilli in their protozoan form of life in the blood. This recognition is difficult, for it seems a fully matured bacillus is only identified by his actions. Tubercu

losis is like the eruptive fevers in regard to periods of incubation, invasion, stages of development and duration, and, like them, is said to be self-limited in many cases. Rohe's "Text-Book of Hygiene, third edition, page 553, contains a circular issued by the Board of Health of New York City for popular instruction, in which it is said: "In a majority of cases it (consumption) is not a fatal disease." I hope the medical profession can hasten the day when this assertion can be and will be accepted without doubt.

In closing, I wish to say that I believe

it is the duty of every physician and surgeon in this broad land to make tuberculosis his special study; not make it a specialty as the public understands a specialty, but in whatever line he is engaged, give tuberculosis its full share of attention commensurate with its gravity. The physician and surgeon alike meet this deadly foe along each of the varied lines of special medicine and surgery. It enters into many cases of "mixed infection," being interwoven with general medicine so closely that it cannot be classed in any special line.

Through all the weird period in the history of the healing art, we see our subject of to-day as a well defined practice in many strange and changing systems of medicine. About 1860 there appeared in medical literature varied and numerous statements of the modus operandi of counterirritation, as well as of its therapeutic value.

Many of the prominent medical men of those days seem to have been divided in their opinions. In a very elaborate paper written at this time, Dr. Anstie expresses freely his opinion about counter irritation, or, as he prefers to call it, counter stimulation. According to his theory, no good can come from counter-irritation, unless there is a direct communication between the diseased parts and the irritated parts, and even if there is that connection a blister may do positive harm by being placed too near the inflamed parts. He also argues that the principle of action is misunderstood, and therefore erroneous ideas and practice are entailed upon it.

Contrary to these hypotheses, Dr. R. B. Plainte comes forth in a long and eloquent discourse on this interesting subject, and he puts in a plea in favor of the timehonored practice; the doctor's opinion. was that great good may be effected in several ways by counter-irritation.

First, in all internal inflammation or congestion from deficient nerve force and consequent dilatation of the capillaries from partial palsy of vasomotor nerves, the stimulus of the peripheral nerves may be so reflected by the efferent branches as

to cause contraction of the dilated capillaries, and in this way resolution.

Second, the vicarious action of an inflammation that is artificially set up may cause the internal inflammation or morbid condition to cease in another part.

Third, the impression of a new action set up by the irritant may break the continuity of the morbid nutrition, just as a bad habit may be broken by a sudden shock or necessity.

In conclusion, he makes the following illuminating statement: "Who of us have not noticed the fact that a draught of wind blowing, we will say, on the legs, produces immediate sneezing, or the circumstance that putting the feet into mustard and water will so act on the nerves and blood-vessels of the uterus as to produce a delayed catamenia? Or who has not seen a mustard poultice or blister on the chest give immediate relief in bronchitis, from pain, dyspnea and difficulty of expectoration? Yet, in these instances, there is no direct nerve communication. In all these cases a certain impression must have been conveyed to the nerve centre, with the result of an altered discharge of nerve force or a change in chemical action."

How, in a given case, counter-irritation may do good, I shall not attempt dogmatically to affirm; it may be by stimulation of the nerves, the capillaries or the absorbents. Suddenly a thought, a habit, a rhythm or a secretion may be altered by a new impression. And if it be true that a mental or other habit can be changed by an idea or new impression, a change as in

fear, anger or joy influencing the whole body and its functions for good or ill, is it not analogous and perfectly sound reasoning to suppose an external impression on a spinal or sympathetic nerve may also influence the whole system for good or ill? In one case the nerve functions are affected from within outward, while in the other the reverse would be true.

The body is one great whole in which functions and sympathies are so closely bound together that we know not where consciousness ceases. Notwithstanding the fact that an entirely satisfactory explanation as to the physiological action of counter-irritation is still wanting, we find that this ancient practice is gaining in favor with our medical men of to day.

The methods of application are, of course, modified to some extent, but the principles ever remain identical. It would be difficult to suggest an ideal counterirritant, but in my opinion a scientific substitute for the crude but useful domestic poultice in its varied forms and compounds would make the nearest approach. Heat and moisture stand out pre-eminently. The virtues embodied in hot fomentations and other forms of domestic poultices, and through their properties, we receive the great therapeutic benefits which are always followed by their application, while without these two requisites any compound used for the purpose of counter-irritation has little, if any, therapeutic value.

If we view the action of counter-irritation from a theoretical standpoint, we can trace the reflex path over which it may travel with more accuracy than the pioneer physician who used the same applications, but we have made little, if any, progress in the methods of its application.

Embryology teaches us the development of the sympathetic nervous system; how in the anterior horn of the spinal cord between the second dorsal and second lumbar vertebræ there appear in the very early stage, the neural cells, which have for their functions the maintenance and preservation of a condition of partial contraction of the muscle cells in the walls of the arteries. These cells maintain the amount of contraction which is absolutely necessary for the proper distribution of the blood to the various parts of the organism, and this maintenance is what we call arterial tone.

During the progress of development there appears another group of cells, particularly located in the sacral, cervical and medulla regions. These cells can bring about a comparatively complete relaxation of the muscle cells of the blood-vessels, and their activities very markedly increase the circulation to any given part. The first-mentioned group of cells are the vasoconstrictors, and the second group the vaso-dilators. This constitutes the control of the blood supply to all parts of the body as a whole, or to any given part in particular. If counter-irritation acts through these paths of reflex constrictors and reflex dilators, we have some idea of its course.

Lest this paper be burdensome by its length, I will conclude by emphasizing one fact, viz., counter-irritation must not be continued too long a period of time over the same location. A natural equilibrium of motions or functions constitutes health, while a disturbance of motions or functions-in other words, a marked want of equilibrium-constitutes disease. Disease is, therefore, a marked diminution of the so-called vital motions which animate the organism. This disturbed vital motion is at first dynamic or functional, without a material substratum, but later, if not corrected, becomes material or organic. A prolonged counter-irritation over the same surface will for this reason produce material or organic changes, when it becomes no longer a curative measure, but an exciting cause of disease. When vital vibrations are increased to a large extent the excess is immediately transformed into mechanical, chemical or physical motion, and the equilibrium is usually quickly restored.

It may be well here to make clear the difference between incitability and excitability. Incitability is a normal increase of functional impulse in a permanent manner, an increase of vitality. It is alimentation produced by gentle hygienic therapeutic means. Excitability is a production of increased motion at some points, while there is diminution or increase at other places in the organism. Excitability is taking away of motions, power or functions from one place in order to add motion, power or function at another. The final result is always detrimental, and is an impoverishment of vitality, though useful and necessary in emergency measure.