a knowledge of anatomy-at least of the eye-of physiology, enough to recognize the relation between the eye and other parts of the body that he should have a considerable knowledge of medicine and certainly a thorough knowledge of urinary analysis."

All this is granted, but are there not a few things that the physician and surgeon should also know which he does not know in order to qualify him properly for the practice of his profession?

For instance, we quote the following from the "London Letter" in the April Therapeutic Gazette. The writer is giving an account of the proceedings of the Medical Society of London and says that "a case was mentioned in which removal of the ovaries had been proposed for the cure of severe dysmenorrhoea, but the symptoms subsided with the simple provision of spectacles for an error of re. fraction in the patient."

Does it not appear from this that the surgeon who proposed the operation did not know that eye-stain is the cause of many serious reflex troubles, of which one is dysmenorrheoa? And in view of this and many similar instances that might be given does there seem to be any question but that any one who attempts to practice medicine and surgery should also have considerable knowledge of the effect of ocular reflexes?

Now, is not ignorance on the part of the surgeon just as bad as on the part of the optician, and are not his mistakes on account of his ignorance of refraction troubles just as liable or even a little more so, to be serious than those of the optician from his lack of knowledge of medicine?

From my acquaintance with physicians and surgeons in general in this country I think it would be safe to say that not one in ten in the Medical Society of London could correct an error of refraction or determine its character or effects.

There is much that all of us would be the better for knowing and should know, and the recognition by each one of his own shortcomings would contribute more to our improvement than the disparagement of others.

The truth is that a correct diagnosis cannot be made in many cases by either physician or optician without each possessing much more than he ordinarily does of the knowledge of the other. But as the capacity of the human mind is limited and all knowledge is not possible to any man, the remedy is this, that each should at least know when to call to his assistance the knowledge of the other.

Pleasanton, Kansas.

R. J. PEARE.

CLIMATIC TREATMENT OF PULMONARY DISEASES *

J. N. HALL, M. D.,

Professor of Medicine, Denver and Gross Medical College: Visiting Physician to Denver City and County Hospital, etc., etc.

I should not bring this subject before you were it not for my firm belief in the great urgency of the need of a wider knowledge concerning it. It is no exaggeration to say that the average practitioner can probably save more lives by early diagnosis and prompt action in cases of pulmonary tuberculosis alone than in any other * single ailment. The subject receives but scant attention in the ordinary curriculum of the medical school, and is not one that forces itself upon the attention of the physician after graduation. The general practitioner must know what to do with a fracture, an acute attack of appendicitis or a case of typhoid fever, but in too many cases the poor fellow with a chronic cough must wait until all these have taken the best attention that the doctor can give, and then it is too late.

Those of us who practice in the larger cities of Colorado see so many lamentable illustrations of the danger of delay that I feel sure you will gladly listen to our side of the story. Only today I sent back to Virginia a poor fellow with one lung solidified, with advanced laryngeal phthisis, hectic fever, night sweats, hemorrhages, and the whole ominous troop of tuberculous manifestations, who had spent his all to reach Colorado. After seventeen days he was himself convinced that he had come too late, a fact obvious enough at a glance to a physician. I have seen scores of similar or even worse cases. Yet most of these patients might be saved by prompt recognition and treatment.

First in importance as in frequency amongst the pulmonary diseases demanding our attention comes tuberculosis. All that we have to say might well be condensed into "make the earliest possible diagnosis." But this needs amplification. It is not that the diagnosis of consumption is so difficult; it is that we are not sufficiently alive to the early manifestations of the disease.

My own explanation of the manner in which such a mistake is made as that of sending to Colorado the patient just mentioned is as follows: A man complains to his physician of a cough. Without

*Read before the Golden Belt Society, April 7, 1904.

inquiry as to loss of weight, night sweats, lack of appetite, or special exposure to tuberculosis infection, and without even so much. as listening to the chest with the naked ear through the clothing, prescription for a cough mixture is given, with the ready assurance that it is "only a cold," although I am persuaded that no member of this society would be thus guilty. Relieved of any fears he may have had the patient returns to work and losses another ten pounds. before again seeing the physician. Even then he is too often put off with the statement that the cough will be "better when the weather becomes settled." At this time the finding of the bacillus in the sputum, or of fine rales and perhaps a shade of dullness in one apex might save the day, but the poor patient returns again to work in a deleterious atmosphere when he ought to be at absolute rest in the open air. Finally it is so manifest that the patient is seriously ill that a change in diagnosis or in climate becomes imperative. The chest is at last, months too late, stripped for examination, and, as a result, the patient is sent away for the change of climate, even then oftentimes with a diagnosis of bronchitis. Evidently certain physicians lack the moral courage to state to a patient that he has consumption; it is so much less disagreeable to agree with the family idea that it is "only a cold."

How different the result when one's suspicions are more easily aroused! I have long believed that proportionately more physicians recover from pulmonary tuberculosis in Colorado than men of any other occupation. They realize in their own cases the significance of the early signs, seek expert aid at once and frequently present themselves at our offices within ten days of the first slight hemoptysis, or of the finding of a few crackles in the apex, or a stray bacillus or two in the sputum. It is strange that we do not all lay down a more rigorous course for our patients with the same symptoms!

Any patient who has had a cough lasting over two weeks, with loss of weight beyond a few pounds, ought to be regarded as suspicious. His temperature should be taken daily, his pulse watched for increase in frequency, his chest examined for the ominous fine. crackling in one apex, and his sputum for bacilli. It is so easy to send sputum by mail for expert examination that the mere fact that one does not do this work himself is no excuse. There is scarcely a place in the United States so remote that one could not receive expert help within a few days along this line.

The early diagnosis being granted, what must one do to be saved? Climatic treatment does not necessarily mean the sending of a patient to a distance. Much may be done in any reasonable climate,

and certainly in one such as you have here,-really a Colorado climate on a smaller scale. One of your number, familiar with the treatment of tuberculosis in my own state, has just told me of the wonderful improvement, with a gain of thirty pounds in weight, which has resulted, in a city near you, in a consumptive so poor that he could not be sent away. I may say that any fair climate, with judicious treatment, in the incipiency of tuberculosis, is better than the best climate in a later stage.

When the diagnosis is established the next step is not really treatment, but an honest statement to the patient. If you convince a man that he has consumption, and that you can offer him a fair chance for his life if he will follow your guidance, he will ordinarily co-operate cordially. Without full conviction as to the diagnosis such co-operation is generally impossible.

The first step in the treatment should be absolute rest. So long as there is rise of temperature each afternoon there is no other safe procedure. The patient should sleep in a room so well ventilated as to be practically out-of-doors, or, in suitable season, in a tent or upon a porch. If dressed during the day it should be simply that he may lie upon a lounge or cot, and not that he may walk about. So long as there is fever, rest in the recumbent posture is imperative if one is to hope for recovery.

The feeding must be along such a line as to force a gain in weight if possible. The two strongest features in a favorable prognosis are subsidence of fever and gain in weight, and they commonly go together in favorable cases. The patient should drink several pints of milk or buttermilk daily, and as much cream as he can digest, from four to a dozen or even more raw eggs, with beefsteak or other fresh meat where possible, or beef juice if the meats cannot

Other foods may be admissible but not to the exclusion of the ones mentioned. The patient's recovery perhaps depends more upon his ability to take and digest food in spite of his infection than upon any other single factor.

Many pa

But, you ask, what about his medicinal treatment? tients recover without medicines; few without some such line of climatic and dietetic treatment as we have outlined.

I believe these patients should take strychnine as a tonic, creosotal or guaicol in moderate dosage if the stomach is not disturbed by their use, cod liver oil in cold weather or extract of malt, syrup of hypophosphites and other roborants as may suit the individual

case.

If the average doctor would think less about drugs and more

about air and food for his consumptives it would be a distinct gain. If the weather be severe, or the patient live in a region where dampness, fog, coal soot, dust, impure air and lack of sunshine combine against him he had better be sent at once to a higher and dryer climate. Probably no region of the world offers better chance for these patients than the great eastern plateau of the Rocky mountains, upon the approaches to which we now are. A pure atmosphere, freedom from exposure to the bacilli of tuberculosis, abundant sunshine, cool nights even in hot weather, dryness and rarity of the air, all combine to give the patient a chance to better resist the advance of the bacillary infection. Ninety per cent of these cases may probably be saved if the diagnosis only be made early and the treatment instituted at once.

I know of no serum treatment of this disease that deserves to be mentioned in comparison with the measures outlined.

The cases that recover most certainly and completely are those seen while the pathological basis of the disease is as yet only a capillary bronchitis in one apex, with dullness so little marked as to be difficult of detection. Such cases should be treated as if they were tuberculous, even in the absence of microscopic confirmation. The finding of the bacilli in the sputum is a great thing; the cure of a patient with an apical catarrh and a loss of ten pounds of weight, but without the finding of the bacilli is a greater one. Let us take to heart the lesson that when one sees much smoke it is best to call the fire department first and hunt for the exact source afterwards; that when one hears a bad cough it is best to act as if it were of tuberculous origin, and cure the patient, even without a microscopic verification of the probable diagnosis, than to obtain the latter at the expense of the patient's lung tissue.

*"The predominance of the fibroid element in the tuberculous process is certainly favorable as to slowness of advance, but cases with this characteristic rarely attain the complete arrest so often seen in the early catarrhal cases. I see many of these cases following pleurisy with effusion which go on for many years, always coughing and expectorating a little, with very gradual loss of weight, with bronchiectasis, and perhaps finally, apical cavity formation. These cases have many years of useful life here, beyond what they would have enjoyed in a less favorable climate.

"Persons with a bad family history of tuberculosis may well consider the advantage of moving permanently to a high, dry region

* Quoted from a paper presented by the author at the American Therapeutic Society, Washington, May, 1903, and published in the Medical News, November 21, 1903.