material is to keep it off the ground; keep it dry; and keep the flies away from it, and these are not very difficult problems. If we have our privy houses constructed with a proper box, so that the material does not reach the ground until it can be carried to a safe distance and there disposed of, we have removed a menace to the health of the community. Another danger is in the kitchen, but even if flies get into the kitchen, we know that almost all the flies in a farmhouse are bred right on the place, and do not usually come from a distance. Even if we cannot keep them out of the kitchen, they will not be infected if the infectious material is properly protected. So that the problem of the farm to-day is the problem of building proper privies.

DR. L. L. LUMSDEN, Washington, D. C., concluding the discussion:-I am very glad to receive from Dr. Tompkins, the word of caution in regard to the administration of urotropin. The results of his experiments are certainly very interesting and should be given all due consideration. He has just told me that his results have not yet been published. I think they should be published as soon as possible, because the use of urotropin as a routine measure in typhoid fever convalescence is becoming quite general throughout the country. It is recommended without reservation by many distinguished clinicians, both in private and in hospital practice. It is important to determine if there is any irritation of consequence caused by urotropin properly administered. A number of cases are reported in which urotropin was given in quite large doses without evident bad results. "Typhoid Mary," Soper's now famous bacillus carrier, was given 150 grains a day for some days without any apparent untoward effects. It may be that she was peculiarly resistant. In drawing conclusions from the observed effects of giving ten grains of urotropin three times a day to a dog, I think we should consider the size of the dog as compared with that of a man. Furthermore, it should be determined whether the irritation produced is serious and permanent or slight and transitory. I have recently had under observation in Washington a case of chronic typhoid bacilluria, in which urotropin was used with happy results. The typhoid bacilli disappeared from the urine, and the urine, which had contained albumen, became clear. No apparent untoward effects followed the use of urotropin in this case. I appreciate very much the discussion of my paper by Dr. Freeman. I was pleased to hear him lay emphasis on the gravity of typhoid fever as a rural disease. Rural typhoid is a great problem confronting us to-day; and the way to attack it is to endeavor by every means to secure proper disposal of the excreta of human beings.

SOME PRACTICAL OBSERVATIONS CONCERNING THE EARLY DIAGNOSIS OF CHRONIC PULMONARY TUBERCULOSIS.

By TRUMAN A. PARKER, A. B., M. D., Richmond, Va.

Chief of Richmond Board of Health Tuberculosis Dispensary; Visiting Physician to the Virginia Hospital; Instructor in Medicine, University College of Medicine, etc.

Foreword: By "early diagnosis" the writer refers not only to those cases which are showing prodromal symptoms for the first time, but also to those which, by reason of a relatively good resistance, are remaining in a still curable stage of the disease, despite the fact that they have been harboring a tubercular focus for months or years.

Notwithstanding the agitation of the tuberculosis question during the past few years, workers in this line are still confronted with the woeful infrequency

of an early diagnosis. Men of unquestioned ability are constantly allowing those whose health is in their keeping, to slip on into advanced consumption and its direful sequels.

Why this is so, is a question upon which I have frequently pondered, and it seems to me that it is not due to a lack of ability so much as to a failure to make practical use of the diagnostic means we all command. I mean those powers of observation, of discerning questioning, of deductive reasoning, which are necessarily developed by the nature of our work.

My argument is, first; that the average practitioner can diagnose pulmonary tuberculosis in the early stages, by a careful consideration of past and present clinical manifestations, especially when fortified by a realization of its ubiquit

ousness.

Second; That recognizable physical signs are not necessary to a diagnosis and that failure to detect these signs never warrants a negative diagnosis. Third; That we are not justified in refraining from making a diagnosis because one or two sputum specimens have been reported negative, yet the profession, as a whole, is remiss in not earlier and more persistently making use of this diagnostic test, especially since the establishment of free bacteriological stations.

While in an abstract, text-book sort of way, we know that tuberculosis is an insidious disease, in concrete cases we wait for some startling symptom to rise up and defy us longer to ignore its cause.

Slight loss of weight, of appetite, slight weariness, accelerated pulse, increased temperature, slight cough we know the whole gamut of them, but do we make practical use of the knowledge? Rather do we hark back to the days when consumption was regarded as incurable, and demand the presence of heredity, racking cough and profuse expectoration, night-sweats, emaciation, hemorrhage, or else auscultatory and percussion changes that assail the ears and frequently are sought through a shirt or two.

Several of these radical symptoms, backed up by the report of our good friend, the microscopist, usually make our diagnosis for us, and sometimes not until our patient has preceded us to the same baneful conclusion. In the meantime the duration of necessary treatment has increased in geometrical progression, the hope of recovery has correspondingly decreased, and the patient's family and friends have been exposed to the infection.

The importance placed upon a family history of tuberculosis is over-estimated by many physicians in a negative way. While such a history should lead us to suspect the tubercle bacillus as the cause of any train of slight symptoms, its absence should have no diagnostic weight.

Not one patient in five, in a large series of cases, will give a family history of consumption in answer to a direct question. In my experience it has been most exceptional for the patient to recall, under fairly close questioning, any source whatever, for his infection.

Let us forget, once and for all, that a family history is essential for a diagnosis.

Regarding sputum examination it is interesting to note the construction put upon the phrase "absence of tubercle bacilli" by our accepted American authority, The National Association for the Study and Prevention of Tuberculosis, which says: "Each monthly examination (if the sputum be negative) to consist of a careful microscopic examination of the sputum on each of three successive days.*"

*

*

*

Moreover, it must not be forgotten that the causative germ frequently is not found until the disease is far advanced; in fact it may never be found. The finding of the bacilli is merely confirmatory of a diagnosis that often should have been made previously, from clinical symptoms and history.

The futility of demanding striking physical signs for an early diagnosis is apparent when we remember that "large central lesions can exist without discoverable physical signs." (Lawrason Brown, in Osler's Mod. Med.)

None of us are justified in saying to the patient, "your lungs are all right," merely because we can detect no physical signs of the disease.

The National Asociation for the Study and Prevention of Tuberculosis speaks of the physical signs of Incipient Tuberculosis (infiltration) as follows:

*Italics author's.

"Slight prominence of the clavicle, lessened movement of the chest, narrowing of the apical resonance with lessened movement of the lung; slight or no change of resonance, distant or loud and harsh breathing, with or without some change in rhythm (i. e. prolonged expiration), vocal resonance possibly slightly increased, or fine or moderately coarse rales present or absent. If diagnosis be positive,* any one of these."

Physical signs, I say again, are merely confirmatory, and I believe many a good man has been led astray by his failure to detect physical changes which he considers commensurate with the clinical symptoms.

Far be it from me to decry the diagnostic importance of a positive history of exposure, of the search for the causative germ in the sputum (which may be found even when the patient is unconscious that he is sick), or of a physical examination. It should be an inviolable rule with every practitioner to examine the chest for physical signs whenever there is any suspicion of intra-thoracic disease. When the lung involvement is superficially located, or only moderately deep, a careful chest examination, depending on the skill and thoroughness of the examiner, often determines the diagnosis.

What I do mean is that, first and last, the diagnosis of tuberculosis is dependent upon a recognition of the clinical manifestations and the history. And these the veriest tyro can elicit with a little patience and pertinacity. If in doubt he is not to be criticized for calling in a consultant, especially if the diagnosis be unsuspected by the patient and his family, for the responsibility is heavy and the bearer of ill-tidings is as unwelcome now as in the days when he received a sword-thrust for his fee.

Night sweats and hemorrhages, classical indications that they are, can be dismissed with a few words. The former sometimes appear early in the disease, and may be localized, but are seldom noticed until the advanced stages. Being more frequent in tuberculosis than in any other malady, they indicate the necessity for a careful search for other symptoms.

Hemorrhage may result from other conditions. Suffice it to say that he who dismisses a complaint of blood-spitting or blood-streaked spittle with a consoling guess that it came from the nose, the gums, the throat, vicarious menstruation, even gastric ulcer, carcinoma, or circulatory disturbance, because he can detect no physical signs of phthisis, is apt to have a damaged reputation and an ailing conscience.

Two glaring examples of this have recently come to my attention, one from the country, one from my own city.

An old gentleman of sixty-seven years, who had not, until three weeks previously, been under a physician's care since leaving the army in 1865, stopped his neighborhood doctor in the road with the complaint of spitting blood almost nightly for the past fortnight. Withdrawing into the roadside, a chest examination was made through two shirts after which the doctor pronounced his lungs free from disease, but told him that an old Gettysburg wound through the right clavicle had reopened, and gave him some "strong medicine" to check the bleeding. This wound had previously given no trouble since it first healed, half a century ago. On chest examination a large cavity with gurgling rales, was unmistakably evident in the opposite sub-clavicular space, and diffuse areas of consolidation and softening were easily located throughout both lungs.

The other case was that of a tailor, forty-seven years old, who was taken with a hemorrhage seven weeks ago while sleeping quietly in the early morning (quite a characteristic of tubercular hemorrhages). Recurrences occurred throughout the following week. Subsequently a slight cough and anorexia developed; the latter, progressing to irritable stomach, grew worse under medication until the gastric symptoms overshadowed all others. The cough, however, had become productive and with fever and occasional sweats the patient steadily declined. A consultant was brought in and the two doctors, both of wide experience, made a physical examination and assured the patient that he had no trouble in his lungs, but was suffering from catarrhal gastritis. Under this diagnosis he was admitted to a general hospital where I saw him the next day. Moderately pronounced physical signs of pulmonary tuberculosis were then apparent and the first sputum specimen sent to the city bacteriologist was positive. Under rest in bed and a milk diet the stomach symptoms disappeared in twenty-four hours.

*Italics author's.

I think not.

Do we really appreciate the frequency of tubercular infection? Otherwise we would suspect, and frequently diagnose the disease in those patients who are constantly complaining of being "a little run down" even though we can trace no history of exposure nor find any classical symptom.

Sometime ago a well nourished and well-to-do farmer, over forty years of age, came to me with a note requesting that I incidentally look him over, but especially get a throat specialist to advise him as to his "catarrh." This man presented no outward evidence of tuberculosis. Subsequent close questioning gave no history of family or other exposure. He denied having a cough or expectoration.

A pulse of ninety-six first aroused my suspicion, then his temperature of 99.5, then he acknowledged that his catarrh showed itself by the presence, nearly every morning, of a collection of phlegm in his throat, and by a chronic feeling of being "run down." Chest and sputum examination both confirmed the diagnosis of pulmonary tuberculosis, while the throat specialist reported his nose and throat as practically normal.

I recently saw a police officer, forty-two years old, five feet eleven inches tall, and weighing 185 pounds, leave his beat with a slight chill. For two weeks he underwent treatment for "cold," and four weeks later went to his grave with acute pneumonic and intestinal tuberculosis. These men certainly lived an outdoor life, and neither could recall ever having been exposed to the infection.

How often have we had the mortification of seeing a patient with a "little malaria," a "little bronchitis," a "little grip," a "little throat" or "stomach trouble,” a “little nervousness" and, with shame I say it, a "little catarrh," fail to recover under those remedial measures which with nature's all-powerful assistance, are usually sufficient, and finally present startling evidences of tuberculosis?

If we could only remember that tuberculosis is insidious, we would be spared the humiliation of explaining to some magazine reading patient how the malarial plasmodium can metamorphose into the tubercle bacillus and how catarrh and stomach trouble can suddenly become consumption.

What shall guide us in making a diagnosis?

First, a full appreciation of the prevalence and ubiquitousness of the disease. Though more frequent in the crowded pauper districts of the cities, it is distressingly common in the country.

Second, The knowledge that it is one of the most chronic of communicable diseases, many of its victims never learning the true nature of their ailment or the frequency with which they infect others. And that with a relatively good resistance, the symptoms of active disease are all mild, slight, little; and that these little symptoms, though showing a strong tendency to improve, regardless of the treatment instituted, never disappear permanently, nor do they for a variable length of time, perhaps months, perhaps years, grow materially worse.

The cough, for example, is not distressing and constant; on the contrary, it is often so mild as to become an unconscious habit; frequently it disappears for weeks or months, to return under the guise of a "fresh cold." So with the malaise, the anorexia, the malarial-like temperature and all the others.

Third. We must bear in mind the frequency of tuberculosis after acute infectious diseases, especially grippe and typhoid, and regard with watchful care, those patients who fail to rapidly recover their former health after an average period of convalescence.

With all the cunning of a human foe the tubercle bacillus often cloaks its presence in the symptomatology of those ailments with which we are most familiar, giving modes of onset of which the following are the most frequent.

The Catarhal or Grippal. How often we have called early tuberculosis, "grip" or "bronchitis," is a secret buried in the bosom of each of us, and which none cares to disclose. It is enough to say that all the usual symptoms of grippe; the chill, the pains, the cough, the fever, frequently mark an acute exacerbation of a hidden pulmonary tuberculosis, and still more frequently, some of these symptoms, though not all are present. Grippal tendencies and prolonged bronchitis, as well as the recurrent "winter cough," always demand a careful investigation with a view to determining whether the tubercle bacillus be not the real cause of the symptoms.

The Malarial Onset. This, too, may present all the symptoms of the infection which it simulates, the chill, fever, and sweat, all being present. Usually though we have the anaemia, the febrile movement (generally quotidian), the lack of appetitie and the lassitude. Medication has no permanent effect. however, while relapses are frequent and slightly more marked. This is a very

common type.

The Gastric and the Nervous types of onset. Gastric irritability, intestinal indigestion, or mild neurasthenic symptoms, are often the first complaints. “In some cases the disease is marked by dyspeptic symptoms; anorexia that may amount to actual repugnance for food, distress after eating and sometimes vomiting. These cases may closely resemble gastric ulcer and are very apt to be treated for weeks or even months as cases of nervous dyspepsia, if not ulcer.* Prolonged Functional Indigestion, whether gastric or intestinal, should always bring to mind the anorexia and irritable stomach, the distension and acid eructations, so frequently concomitant with a mild tubercular infection.

"Neurasthenia is more common in tuberculosis than in any other disease," says Lawrason Brown; and a better treatment for tuberculosis can scarcely be found than the "rest cure" for neurasthenia.

The Pleuritic onset. Like a faithful scout, warning us of approaching disaster, pleurisy can usually be depended upon to bring us accurate advance information. Dry apical pleurisy or a double pleurisy, with scarce an exception, mean tuberculosis. Hardly less reliable is pleurisy with effusion, while the dry pleuritic pains so often complained of as rheumatism and neuralgia, have a strong diagnostic import. Empyema is often the ultimate result of an old tubercular infection.

Among other surgical indications of pulmonary tuberculosis it is also well to remember that ischio-rectal abscess and fistula-in-ano often indicate a more or less latent lung involvement.

The Laryngeal and the Anemic types. Recurring hoarseness, with or without actual laryngeal involvement is a not unusual early symptom, and may be the patient's only complaint when seeking his physician.

The same may be said of persistent anemia. It may closely resemble chlorosis, and the latter diagnosis should never be made without carefully weighing the possibility of a disguised tuberculosis.

But after all is said, the chief thing to remember is, that in by far the greater number of cases, the onset is insidious, the disease appearing every now and then, in some person in whom we would least expect it, or else in some one who had been "complaining" for some time and whom we had come to regard as a mere hypochondriac.

Unfortunately our patients never come to us with a carefully prepared list of symptoms and a temperature and pulse record. On the contrary they "only want a tonic," and sometimes resent being quizzed as to symptoms of a disease so universally dreaded.

Questioning may elicit come subjective indications of a slight fever, but the only way to definitely ascertain its presence is by giving the patient a thermometer and have him take and record its readings. He should use it every two hours from the time he wakes in the morning till he retires at night, leaving the thermometer in his mouth from five to ten minutes, and continue to do so for at least a week. A subnormal temperature in the early morning followed by a rise to 99, 99.5, or 100 degrees later in the day, is strong evidence of tuberculosis.

Considering the verge of excitement upon which most tubercular patients are bordering, the pulse rate in the doctor's presence is not reliable. Better have some member of the family take and record the pulse three times daily, and if the result shows a rate frequently over eighty-six, especially when taken after rest, we have added evidence of the toxemia of tuberculosis. It is no unusual thing, however, to find a pulse constantly below eighty, in a tubercular patient, nor is their temperature always above 98.6 at its maximum.

If the patient does not know his usual or his present weight, he may recall the fact that his waist bands are looser than formerly; and when no history of actual loss of weight can be obtained, it behooves us to remember that evident lack of weight has a strong bearing on the diagnosis. The actual loss having

*Babcock, Diseases of the Lungs,