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Pulmonary Tuberculosis.


Synonyms:—Pulmonary phthisis; chronic tuberculosis; chronic pulmonary tuberculosis; chronic ulcerative phthisis.

Definition:—Tuberculous development within the structure of the lungs, characterized by hectic fever, cough, progressive emaciation, night sweats, diarrhea and great prostration.

This disease is probably more widely prevalent than any single disorder. It has developed with advancing civilization and chooses all alike, without distinction of social standing, race or color, except as has been stated. It is more common between the ages of eighteen and thirty, and during middle life, although children, especially after six years of age, are not wholly exempt. Those of advanced age quite readily contract the disease also.

Symptomatology:—In a large proportion of cases the development of this disease extends over quite a period of time. There is a history of impaired health, from causes that seem to be well understood, but the treatment of which has been unsatisfactory.

In other cases there is a history of exposure, with an acute inflammation, most commonly some one of the forms of acute lung involvement, which during a protracted and unsatisfactory convalescence develops a hectic fever, night sweats, greatly increased prostration, emaciation and a return of cough, though perhaps it differs in character from that which previously existed. The cough of severe bronchitis may continue in spite of all treatment, until hectic fever, chills and night sweats appear, and lead to a diagnosis of developing phthisis.

It is observed in the cases of slower development that there is increasing debility, an incapacity for continued labor, or for any persistent active exercise, and an inclination to be chilly on slight exposure or from a draft. There may at first be no cough, but in the larger proportion of cases a persistent cough is present, which varies in character at different times, but is always unyielding to any of the usual methods of treatment. Occasionally there is much improvement at the first, but the condition suddenly increases without known cause and becomes very severe, and the sputum may be streaked with blood, or there may be a slight hemorrhage. This always causes alarm and usually results in a thorough investigation, disclosing the real character of the disease.

With the occurrence of the chilliness, if the temperature be taken, it will be found that there is a slight elevation above the normal all the time, perhaps less than a degree, or even a fraction of a degree, at the lowest point, increasing, with an increase of chilliness, at a given time each day, usually in the evening, to perhaps 101 1/2° F. If the cough is not conspicuous, this is ascribed at once to chronic malaria, and treatment for this condition is instituted, which postpones the discovery of the real cause until the disease may have become thoroughly established. Persistent fever, progressive emaciation and increasing feebleness, with developing cough, ultimately prove an error in the diagnosis and lead to the discovery of tuberculosis.

The fever is seldom persistently high; in fact, 103.5° F. is probably the point of its highest development. It varies from 99.5° F. to 101.5° F. in the milder cases, or in the incipient stage, to from 101.5° F. to 103° F. in the severe cases, or in the stage of complete development. In the later stages of this disease there may be septic or pyemic infection, which will increase the temperature and alter somewhat its previous character. At other times, in the erratic temperature changes, it may become sub-normal for a short time, as low as 96° F. in some cases, for brief periods. The chilliness is more apparent in the developing stage. When the disease has reached its full development and a higher temperature persists, the chilliness disappears, or only occurs on actual exposure. The fever is always more or less irregular in character and may be temporarily influenced by antipyretic remedies, but ultimately increases and persists in spite of the treatment.

The pulse is rapid from the first. It is disproportionally so as compared with the temperature. This is due in part to the profound impression the presence of this disease makes upon the vital centers. The pulse varies, but is always small and easily compressible, and as the disease progresses, becomes feeble, sometimes hard and wiry, at other times slightly irregular.

The tongue varies in appearance in this, as in all febrile diseases, as the conditions within the system vary. At first, while the color and shape may be unchanged, it will be coated white or brown, as in the condition described as "biliousness." This confirms the early erroneous diagnosis of malaria. Later, local irritation and a deficiency of normal acids within the system deepens the color of the membranes. The tongue becomes thin and more pointed and dark red, and a dark fur is persistent. Stomatitis is a common complication; an aphthous ulceration, difficult to relieve, or thrush, or other form of ulceration, may appear.

The cough varies greatly in the time of its appearing, and in its character. It is, of course, the result of the progressive changes. At first, if nervous irritation, or bronchial irritation, with deficient secretion, are present, it will be dry and irritating, perhaps hoarse and barking and almost constant. It is apt to be worse on lying down at night, or on the least exposure to cold. If bronchitis coexists, a distinct thick mucus, or muco-purulent bronchial secretion, will appear shortly, which will materially change the character of the cough. It will occur in paroxysms and will be loose, with a "rattling" respiration. When, in the progress of the disease, softening and disintegration occur in the process of the formation of cavities, the cough is protracted and very "hard" on attempting to rise in the morning, and continues until large quantities of sputum of varying character is expectorated from the tubes and from the cavities, in which it has accumulated during the night. This may induce nausea and vomiting, and result in temporary faintness or exhaustion. The taking of food may induce a paroxysm of cough, which may also result in vomiting. When the cough induces hemorrhage, active efforts for its restraint must be adopted, and it must be controlled also when it induces irritation, sleeplessness and exhaustion.

As has been stated, there may be no expectoration at the onset. This may account for the absence of cough in a few cases, as the cough may be only necessary to clear the air passages. The first sputum is usually composed of mucus alone, and, unless there is a coexisting bronchitis, it will be colorless, in which case it will assume the greenish or yellowish green, thick and tenacious character of the bronchial exudate. Very soon, however, it becomes grayish yellow in character, somewhat watery in appearance, and is distinctly muco-purulent. As the cavities develop and disintegration of tissue progresses, the sputum is thin and filled with very small greenish gray or yellowish gray masses.

Later, pus will be found in the expectoration, and in some cases, from decomposition within the cavities, the sputum is of a sweetish and offensive taste, and fetid and offensive odor.

If, in the development of a cavity, hemorrhage occurs, the blood will not be uniformly intermingled in the sputum, as is the case in pneumonia, but it is thrown out independently. The quantity of the sputum expectorated, during the earlier stages of the disease, increases slowly until the formation of cavities begins, when it increases greatly for a short time, and from that time on will be irregular in quantity, depending upon the course of the breaking down of tissue within the cavity. In some cases only a few drams will be expectorated in twenty-four hours. In the later stages it may amount to from eight to twelve ounces. In childhood and in the aged there may be but little expectoration throughout the entire course of the disease.

Pain:—It is not common for a tubercular patient to suffer pain unless there are rheumatic or neuralgic complications, or unless the pleura is involved. When this appears, the pain occurs on inspiration and is increased by deep breathing and by coughing. In an occasional case there may be a steady pain through the diseased area. Usually h is lateral, or at the base of the lung, or beneath or between the scapulae. These patients are quite subject to muscular rheumatism of the chest walls, or to intercostal neuralgia.

Respiration:—There is increased frequency of Respiration with the onset of this disease, and as the disease progresses, the respirations vary from twenty-four to thirty-six, and the latter point usually continues during the latter stages of the disease. When the tubercular deposits are miliary in character and thus are more general in their involvement of the lung tissues, the respirations become still more frequent, and in the later stages of the disease cyanosis may develop. Dyspnoea is by no means as common as in acute pulmonary troubles. It occurs in the later stages when the respiratory area has been seriously reduced in quantity.

Hemorrhage occurs in a majority of the cases of phthisis, especially in those that are ulcerative in type. It is much more frequent in males than in females. In the majority of cases it occurs at first as a single streak of blood in the sputum, or a tiny red clot, later a small mass of frothy blood will be brought up, bright red in color, to be followed soon by other streaks or small clots. While in a few cases the increase in quantity may be very gradual, there is apt to be soon after the first appearance, quite a free hemorrhage. These continue irregular in quantity and at very irregular intervals throughout the entire course of the disease. As has been stated, in an exceptional case quite a free hemorrhage may occur before the disease has been recognized, and sometimes this may be very severe and prostrating. With all hemorrhages, especially those occurring early, there is a flush of heat over the body, some vertigo or faintness, a sweet or sweetish salty taste in the mouth, and increasedly rapid breathing, with sudden weakness, which in the severe cases amounts to extreme prostration or even collapse. The blood is set free usually during the development of a cavity, but in the first stages it may occur solely from the intense .local congestion. It results from ulceration into the small vessels at first and later into the larger ones. In rare cases the tendency may be increased by a defibrinated condition of the blood—a tendency to hemophilia.

In a very few cases the hemorrhage may occur in large quantity and result in death, either from its immediate influence upon the heart and circulation, or from suffocation. It may escape into the tissues of the lungs, may fill a cavity and induce compression, or it may induce compression and pulmonary apoplexy by escaping in large quantity into the pleural sac. Another peculiar manifestation of hemorrhage is that it may occur in an occasional patient, a number of months or perhaps a year or two, before the occurrence of any symptoms or conditions that will make a diagnosis of tuberculosis possible.

Sweating:—A symptom that occurs early in the disease is sweating. This occurs with the development of the fever, and is commonly nocturnal or occurs only during sleep. From the first it is api to be very profuse in quantity, and later is the immediate cause of weakness, which is very apparent to the patient. The sweats are caused by the conditions that induce the fever—an effort on the part of the system to rid itself of the toxic elements—and occur when the system is in a state of relaxation. When they produce exhaustion they must be controlled, in order that the strength may be preserved, although the treatment is known to be only temporary in its influence.

Anemia:—Anemia may be apparent quite early, and is attributed to pre-existing causes before pulmonary tuberculosis is diagnosed. It undoubtedly results from the vital shock to the system, impaired oxygenation of the blood and malnutrition. It occurs coincidently with loss of appetite, faulty digestion, increasing feebleness and emaciation. With deficient red blood corpuscles there develops later in the disease, occasionally, some leucocytosis.

Emaciation:—Lo$s of flesh and consequently of weight occurs from the onset of this disease, in part from the same causes which I have just named, as those which induce anemia. The patient loses strength because the irritating causes which are present in the disease, such as fever, sleeplessness, loss of appetite and persistent cough, with occasional hemorrhage, all interfere with nutrition and restoration. These contribute equally in the reduction of the weight of the patient. When the disease is established the loss of weight may early be quite rapid, amounting to an average of from eight to twelve ounces per day.

The rapidity of the loss depends somewhat upon the severity of the disease, and if the pathologic processes are arrested there is a stay in the emaciation, and if a gain in flesh can be secured, this is indeed encouraging.

Gastrointestinal Complications:—The importance of nutrition in pulmonary tuberculosis makes it absolutely essential that the closest attention be given to the digestion and appropriation of food, and for that purpose the condition of the stomach, intestinal tract and the larger glandular organs must be closely watched. Loss of appetite occurs very early, and indigestion appears simultaneously. A chronic gastritis may have existed for some time previously, with the train of symptoms that usually accompany this disorder. At first there is apt to be an excess of hydrochloric acid, but, as is common with other protracted fevers, the acids diminish as the fever progresses, until there may be an absence of hydrochloric acid. Thirst is an ever present and often annoying symptom, and the ingestion of large quantities of water may interfere with the already imperfect action of the digestive fluids. All this contributes very materially to defective nutrition and consequent emaciation and debility, but a more important cause of debility is the diarrhea which is apt to develop at an early stage of the disease and persist throughout its entire course, although constipation, obstinate and intractable, is observed in an occasional case.

Cystic Irritation:—A mild form of catarrhal cystitis, albuminuria or actual nephritis are conditions that occur in a few cases when this disease has become fully developed.

Notwithstanding the fact that nervous complications are very common in other infectious or pulmonary disorders they are not likely to occur in this disease. Mental depression or despondency is almost an unknown factor; the patient is cheerful and happy, always hopeful and optimistic concerning the outlook and lays plans for the immediate future within a few days of death. It is rare that the infection is conveyed to the meninges or to other nerve structures which will develop meningitis or paralyses. Peripheral neuritis is a rare complication, and insanity has developed during the progress of the disease, but it is more than possible that a previous tendency to insanity existed, which might have induced that condition if tuberculosis had not occurred.

Treatment of Pulmonary Tuberculosis:—In the treatment of pulmonary tuberculosis a strictly systematic course must be adopted with reference to the following facts, the necessity for which course is now being established by incontrovertible proofs from the united observations of the entire profession:

  • 1. An immediate recognition of the real character of the disease and the prompt adoption of a systematic course and plan of life, for its cure, are of the first and of vital importance.
  • 2. The bacillus tuberculosis must be destroyed.
  • 3. The vital forces of the patient must be sustained and improved by—
    • (a) A care-free, out-of-door life, with a correct climatic adjustment and physical exercise, fitted to each individual patient.
    • (b) The utmost care of the stomach and intestinal apparatus, to secure the ingestion, the digestion, the appropriation and assimilation of the largest possible quantity of highly nutritious foods. A careful watchfulness through the entire course of the disease for this purpose, until health is unquestionably established.
    • (c) Attention to the nervous system to retain its vigor and prevent the continuance of any irritation of any character.
  • 4. Drugs alone will not cure the disease and must not be depended upon for that purpose, but conditions are constantly arising which materially decrease the resisting power of the patient, reduce his vital force and permit and encourage the development and progress of the disease, which can be overcome entirely, or greatly modified, by medicines, which must then be carefully prescribed.

A proper restraint upon all the developing processes of the disease will exercise a controlling, an inhibiting power upon the influence of the bacillus and will retard its destructive operations. This can be accomplished with medicine. With prompt attention to these conditions tuberculosis in its early stages is certainly curable. Statistics now prove that at least 75 per cent of the incipient cases should recover.

Pure Air and Sunlight:—The first essential in the destruction of the bacillus tuberculosis is an abundance of pure air. The attainment of this alone has resulted in the improvement of the case otherwise unfavorably situated. The patient should spend as much as possible of the twenty-four hours in the open air. Those who have discovered the onset of the disease before their physical strength was materially abated and have wandered off into the woods and have roughed it, sleeping in the open air at all reasonable temperatures, and especially in pine woods, have observed a rapid improvement. Others have adopted a cowboy's life, doing at first only such work as the strength would permit, but sleeping always in the open air, riding on horseback and increasing the amount of enjoyable labor as strength improved.

Amelioration of the symptoms is effected at home, by the patient spending the days in the sunlight, and the nights in a large open room, freely ventilated, or upon a veranda, or on the house top, as is done in large cities in an occasional case.

At all resorts for such patients provision is now made for exposed sleeping rooms and for sunbaths in the open air. Much has been said of the benefit of cool air, to properly* protected patients, but the consensus of opinion now is that temperature is of less importance than pure air and sunshine. A temperature which is steady and uniform, devoid of sudden changes or of contrasts between the night and day temperatures is most desirable. Provision is now made for the construction of small portable houses where a patient can have all essential conveiences, with light and constant, perfect, thorough ventilation by day and night, provision also being made for heating and the preservation of a pleasant and equable temperature when desired.

Dryness and Humidity of the Atmosphere and Altitude:—In patients where the secretion is persistently deficient a moist atmosphere, at a comparatively low altitude, and in a warm climate, is desirable. With these the Florida east coast, the gulf coast, and Southern California are desirable locations. The extremes of these climatic conditions are modified at Lookout Mountain, in Southern Georgia, and in North Carolina.

When there is an abundant secretion in the early stage of this disease, a dry climate is to be preferred, and usually higher altitude. New Mexico and Arizona offer exceptional advantages in this particular, as there any elevation that is desired may be obtained, from three thousand to twelve thousand feet or more. Changes of temperature can be thus obtained if it becomes too hot in the lower altitudes, or too cold in the higher. The dryness of this climate is persistent and the sunshine is unfailing. The mountain atmosphere is very invigorating.

In those cases in which bronchial irritation, or irritation of the larynx, is a conspicuous feature of the disease, it is usually best to avoid a hot and dry climate, but as these conditions are accompanied with deficient secretion, this fact has been considered in the reference made to the coast.

Throughout the entire range of the mountains in our extreme west are desirable locations for consumptives, as well also as on the east coast, especially in the Adirondacks. A factor that must be estimated upon in determining altitude is the condition of the heart. Where the heart muscle shows signs of enfeeblement at the start, and where the pulse is persistently rapid, a high altitude must be avoided, as these conditions are increased, as are also certain valvular disorders. Emphysema is increased and the respiration becomes more difficult in high altitudes, which are also undesirable with patients who have previously suffered from neurasthenia, accompanied with persistent nerve irritation, which has influenced the functional operations of other vital organs. Patients with whom hemorrhage has appeared early do not usually do as well at first in high altitudes. These may improve, although perhaps slowly, in a lower altitude, until the hemorrhage is controlled, when they may be taken to a gradually increasing altitude, sometimes with much benefit.

Nutrition:—There is hardly a condition of the system that is of greater importance than the preservation of normal gastric and intestinal action, that the food shall be received pleasurably, quickly appropriated and readily assimilated. With the development of a reasonably high temperature, often quite early in the history of the disease, the secretions become deficient throughout the body, and especially those of the gastro-intestinal tract. Among these a deficiency of the normal acids is conspicuous. The evidence of this is red mucous membranes, red, thin-pointed tongue, often with elongated papillae. Another condition is that in which the tongue is of normal size and thickness, but moist. The papillae, however, are elongated and very red, except upon the tip, which is coated white. I have observed this peculiarity in several cases of achlorhydria.

This condition demands acids, and explains the fact referred to later on, that hydrochloric acid and the tincture of the chloride of iron are acceptable in so large a proportion of these cases. Chronic gastritis in some one of its many forms is very apt to be present with its well-known manifestations. A poor appetite, which is difficult of improvement, is also common. These conditions will receive attention under medical treatment.

In adapting the food to the patient, while the highest nutrition must be preserved, the individual articles must be selected with reference to existing conditions and idiosyncrasies. Because of the rapid progress of the emaciation and because of the demand for nutrition in the reconstructive and restorative processes, the feeding must be generous in the extreme.

The French method of feeding comprehends the introduction of concentrated liquid nourishment into the stomach through a tube, at regular intervals, without regard to the desires of the patient, the appetite or the condition of the stomach, or of the nervous system. This must prove irritating and unacceptable in a large number of cases, as, leaving other conditions out of the consideration, there must be nerve force and power behind the digestive processes, and if these are absent no appropriation can be made of the excess of food.

Exercise and out-of-door air increase nerve force and promote an appetite. These can also be further increased with medicines properly adjusted. The appetite must be satisfied with fresh raw eggs, given in a fixed quantity at stated intervals; milk similarly given, meat juices and rare meat, as raw beef properly prepared and seasoned. These may be made very palatable, and should be given about five times a day at stated intervals. It is well for the patient upon awakening in the morning, before being disturbed, to drink slowly a pint of hot milk, to which has been added a pinch of salt. He should compose himself upon his right side, to sleep again if possible, or to remain perfectly quiet and undisturbed for perhaps half an hour, when this will, in most part, have passed through the pylorus and have been absorbed without actual digestion. He may take a raw egg with this.

In the course of about two hours he should have a cereal breakfast with cream, and perhaps a small juicy steak, and toast, with oranges or other fruit. At midday the patient should have a full strong meal, with roast meat, vegetables or macaroni, a dessert of rice, tapioca, corn starch or Indian pudding. It is often of much advantage to give a simple digestive after each meal, however small, for a time until the exact digestive power of the stomach can be determined. This may be the essence of pepsin, papaw, some diastatic ferment or pancreatin, as shall be indicated. Soups, oysters and fish are all of value and acceptable under proper circumstances.

It is necessary to give the patient a light meal again late in the afternoon, and at suppertime strong food, but that easy of digestion, must be selected. Oysters, raw or stewed, raw eggs, or eggs soft boiled, should be taken at this meal, with creamed toast and perhaps baked potatoes or baked apples.

In the selection of a beverage the patient may be permitted to drink sparingly of either tea, coffee or cocoa, properly prepared. It is well to heat cream or milk, a half teacup full, and then fill the cup with the other beverage and season as is desired. If possible, milk should be adjusted as the most reliable restorative beverage. Buttermilk or matzoon and kumyss all are palatable and nutritious beverages and will be accepted when the acids in the system are deficient and when the stomach is feeble.

The use of fruit juices, or jellies dissolved in water, or cider, are all in place under proper circumstances. The author is not in favor of alcoholic beverages in this disease, believing that but little, if any, good has come from them. He has permitted, occasionally, an egg nog made with port or sherry wine, in the advanced stages of the disease.

As has been suggested, the amount of food at each meal and the character of the food must be adjusted with reference to conditions that then exist and no rule of general and continued application should be laid down, as in no disease do conditions change more readily, or are more easily influenced than in this. In the morning, after having spent a quiet, undisturbed, restful night, a much stronger breakfast can be taken than after broken, disturbed sleep and an unrefreshed awakening. Food in quantity must be avoided immediately after exercise, when the patient is exhausted, or after a fit of anger or worry. A nutritious beverage or a stimulant may be first given and followed by a period of rest, after which food properly selected may be given.

Medical Treatment:—In the adaptation of medicines to this disease it is my custom to begin with a course of tonic treatment, which adds tone to the central nervous system, and to the stomach, without general stimulation.

In quite a large number of cases there is found to be a deficiency of acids in the fluids, as well as a condition of achlorhydria in the digestive fluids.

While hydrochloric acid, in from five to fifteen minim doses, may be administered after each meal, it should be given conjointly with hydrastis. This remedy is best given in the form of the colorless fluid, or where there is unmistakable chronic gastritis, five-grain doses of powdered hydrastis may be given after each meal, with perhaps a fourth of a grain of powdered capsicum. I have frequently prepared a capsule which contains one grain of the yellow alkaloid of hydrastis—hydrastin—one-fourth of a grain of powdered capsicum, one-eighth of a grain of the extract of nux vomica, one grain of the precipitated carbonate of iron. This combination must be often administered to be appreciated. It is certainly of great value in restoring the tone of the stomach and in improving the appetite. Other remedies for this purpose which may be selected are collinsonia, gentian, cornus florida, columbo, glycerine, quassia, ptelia and frasera, which also corrects excessive night sweats and diarrhea.

When these conditions are present with anemia much benefit has been obtained by the use of the tincture of the chlorid of iron in from five to ten minim doses, after meals, instead of hydrochloric acid. There is sufficient free acid in this to assist the digestion, and the conditions are favorable to the appropriation of the iron.

In a large proportion of cases the condition of the nervous system will be restored by those tonics which are adjusted to other existing conditions. However, it is common for all practitioners to administer the hypophosphites or the glycerophosphates, or when spinal irritation or general nervous irritability exists, with a deficiency of acid, the compound syrup of the phosphates, all with excellent results. Nux vomica with me supplies the demand for strychnine, without any irritating influence, but I have found cases where there was persistent oppression of the breathing, with exhaustion, in which the arsenate of strychnin in small doses produced good results.

When nervous irritability exists, with or without cerebral hyperemia, which is sometimes present, gelsemium or the bromides may be given for a short time. Gelsemium tranquilizes the nervous system, soothes the heart's action and conduces to refreshing sleep. For this purpose it may be given to good advantage in conjunction with hyoscyamus, passiflora or Jamaica dogwood.

When the condition of the heart demands attention the specific indications should be carefully studied, but usually speaking, there is an atonic condition, with irregularity, which is satisfactorily met with cactus or lycopus. The latter remedy is especially useful in its influence upon the capillary circulation of the respiratory apparatus, when fever is present, promoting a greater freedom of respiration and more perfect oxidation, while cactus improves the nutrition of the heart organ. When dyspnea is present with these complications, quebracho, whether alone or in conjunction with lycopus, may be given to advantage.

For its constitutional and local antiseptic influence, creosote is accepted as a remedy of much efficacy. This agent must be given, however, with reference in each case to its receptivity by the stomach. With some patients it is readily received and improvement is apparent almost from the first. With others the necessity of first adjusting it to the stomach is apparent, as the remedy is poorly received, except perhaps in very small doses. Sometimes it can be begun in small doses and increased to the desired quantity. With other patients no adjustment is possible, and the use of the remedy induces a general disorder of the digestion, unpleasant eructations and dizziness, with perhaps persistent nausea. When the remedy is properly received, without interfering with the functional operation of other important organs, there can be no doubt of its beneficial influence.

For the fever and for the inflammatory processes existing within the lungs, direct remedies have but little influence, and yet beneficial results accrue sufficiently often to encourage their administration. No special sedative must be given in sufficient dosage to produce depression, but minute doses of aconite, bryonia and belladonna may be continued in small doses for a considerable length of time with pronounced benefit in their staying or retarding influence upon the pathologic processes. Bryonia is of especial benefit and may be given in conjunction with lycopus when that remedy is indicated, as has been suggested. Together they clear the respiratory passages, unload the air cells, equalize the capillary circulation, produce a freedom of respiration and are soothing to respiratory irritation.

Sponge bathing or general bathing for the fever, in consumption, while of value, must be administered with the utmost care and must be always adjusted to the immediately existing conditions and seldom advised in advance.

The cough is a most troublesome feature of this disease and one often quite difficult to control. It is often the case that specific cough remedies are contra indicated and that the sleeplessness, exhaustion, annoyance and worry from the cough result in such debility that relief of the cough is imperative. The inhalation of soothing medicinal substances is advised. Where the cough is very dry the inhalation of steam alone, or steam charged with acetic acid, with a little turpentine, or with the tincture of benzoin, will be all that is necessary. A hot bath taken before retiring, in a warm room, heavily charged with steam vapor, will sometimes secure a quite restful sleep, with freedom from cough during the entire night. The use of the acetated tincture of lobelia, or of lobelia and sanguinuria, or of the stillingia liniment, a few drops on sugar, or of from two to four drops of turpentine on a lump of sugar, held in the mouth, the patient breathing through the mouth, will sometimes sooth a cough for some hours. Small doses of codeine or of cannabis indica will be found necessary when the cough is violent. The latter remedy will, in certain cases, relieve the cough most satisfactorily, with marked improvement of the respiration and circulation, and a sense of general well-being. In the later stages of the disease a cough syrup may be prepared after the usual method, which contains small doses of the deodorized tincture of opium, paregoric, or morphine, but usually these agents are not advised.

Half of an ounce of the syrup of ipecac, with three and one-half ounces of the syrup of wild cherry, to which is added three drams of ammonium chlorid and three drams of the deodorized tincture of opium, is sometimes useful in dram doses every three hours. The old method of treating this disease by the nauseating expectorants has long since been abandoned.

The pain is not usually severe, but mild conter irritation is indicated for this, with bryonia, when the pleura is involved, or fifteen minim doses of asclepias, or very small doses of morphine. The author's favorite formula will control both pain, cough and nervous irritation. This is made of the sulphate of morphin one grain, sodium bromid three drams, tincture of capsicum fifteen minims in two ounces of the syrup of tolu or of wild cherry. This may be taken in dram doses every half hour, hour or two hours, as needed, with no unpleasant results.

Hemorrhage, when appearing early, must have prompt and efficient attention at once. It is best controlled with temgrain doses of gallic acid, but ergot is effectual also, as is thuja, in small doses. The compound tincture of erigeron and cinnamon is probably the most reliable of all these agents, but it disturbs the stomach to such an extent that it is often contraindicated. In sudden and severe hemorrhage medicine does but little good, as the hemorrhage is past before the remedy is absorbed. The benefit from medicine is obtained where there are frequent small hemorrhages occuring at irregular intervals, perhaps several times during a week. An astringent should be given in small doses at intervals of perhaps four, six or eight hours, and continued over quite a length of time. The course is not highly satisfactory even then, as the ulcerative processes from which the hemorrhage occurs are probably steadily advancing.

The sweating, when mild in character, does not need special attention. When the patient is taking tonics, as hydrastis, or the tincture of the chloride of iron, these sometimes keep the sweating in abeyance satisfactorily. When night sweats produce exhaustion they must be checked if possible. A single dose of the one one hundred and twentieth of a grain of atropin at bedtime is sometimes all that is needed, and when first administered this is often not needed more than two or three times each week, later each night. Often a drop of the tincture of belladonna before meals and at bedtime will exercise a good influence upon cough, pain and mild night sweats, influencing the actual pathological conditions. Agaricin is an efficient remedy, a single dose of from one-twelfth to one-eighth of a grain given at bedtime.

Other remedies which may be useful in this condition are duboisine, in one one hundred and twentieth of a grain dose at bedtrme; geranium, muscarine and small doses of pilocarpine. When other conditions would permit, I have dissolved quinine in aromatic sulphuric acid and obtained excellent results from this. Alexander of Berlin advised the use of camphoric acid for this purpose. In the treatment of tuberculosis in general he dissolved one part of camphor in nine parts of olive oil and used this in perhaps five-drop doses, hypodermically, every three hours. It supported the strength, relieved disagreeable sensations and exercised a controlling influence over the night sweats, cough, expectoration and diarrhea.

In the treatment of the diarrhea of this disease attention must be paid to the condition of the stomach and to the diet primarially. Subsequently geranium, epilobium, turpentine, and other mild astringents of this class, may be prescribed as indicated. It is sometimes necessary to give intestinal antiseptics for this purpose and occasionally a colonic flush with the peroxide of hydrogen, as suggested for typhoid fever, will be sufficient.

Where the diarrhea is accompanied with nausea or vomiting, when other conditions are corrected, a powder may be given every two or three hours, which contains ten grains each of the subnitrate of bismuth and ingluvin. This exercises a double influence, which is usually satisfactory. When the indications show that there is a deficiency of acids, or an excess of acids, these conditions must be corrected by appropriate treatment before the diarrhea can be controlled.

In a few cases the patient will suffer from painful swallowing. This will be controlled by some mild pain relieving remedy unless it is neuralgic or spasmodic in character, when it must be treated with gelsemium or small doses of lobelia.

For the debility of consumption, in addition to the adoption of the course or courses that have been suggested, it is frequently important that cod liver oil be administered to the patient. With some individuals an adjustment of this remedy cannot be made; with others it is received with no difficulty; yet, with still others, a little attention to the stomach and digestive processes is all that is necessary for its favorable reception. I am inclined to think that the pancreatic function is interfered with in those cases where the oil is not digested, as it is one of the purest of the fats, and I think the administration of pancreatin or other mild artificial digestive that will assist the digestion of fats, will promote its ready and satisfactory absorption.

Prevention of Pulmonary Tuberculosis:—That this disease can be prevented is now universally acknowledged, and laws looking to the enforcement of proper conditions have been passed by several of the states. In the first place, when it is determined that a patient has a predisposition to this disease, or that from other tubercular conditions within the system there is a tubercular diathesis, the patient should be removed to a climate which is of benefit in the treatment of this disease, and must have an abundance of out-of-door employment, or exercise, and the essential food.

When a patient is suffering from the disease and remains in contact with other individuals, he must sleep alone, in a thoroughly ventilated room, and all of the sputum must be expectorated directly into a proper spit cloth, or into soft cloths that have been treated with some antiseptic solution, and these must be burned before the sputum dries. The floor of the patient's room must be devoid of carpets, and the walls of hangings, and everything that can possibly be dispensed with must be removed.

Most important of all is the complete isolation of the patient. There is now no doubt whatever that the prevalence of this disease at the present time is due not to hereditary transmission, as was once thought, but to the fact that the patient has lived with the family in close and poorly ventilated apartments during the entire progress of the disease.

The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.

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