from the section. From that time on I have continued to

watch the results in such cases. Four years ago I read a paper before the American Gynecological Society on the subject of using ether by preference for surgical anesthesia, in cases of bronchial disease. Because of my experience along this line, I have tried inhalations of ether vapor as a remedy in cases of subacute bronchitis with excellent results, and others who have tried this remedy in such cases have reported to me their results, cures taking place in some instances as if by magic.

Since that time I have seen over and over again the good results of this practice. That if you have a case of bronchial disease and are somewhat skeptical as to the effect of the ether, and think you should use chloroform, these are the cases in which to select ether. Let your patient inhale it very cautiously at the start, so that the cough spoken of by the last speaker may be avoided. Even remove the cone momentarily for fresh air should cough annoy. The ether vapor coming into contact with the inflamed mucous membrane has exactly the same influence as applied by Dr Thompson. I want to commend to you this treatment, and if you have a case upon which you hesitate to operate for the reason spoken of above, if you give them ether you will be perfectly safe, and in the bargain the bronchial trouble will probably be cured. In these cases, especially those of chronic character, I am of the opinion that my method of administration is important. My cone, made of paper and muslin, into which abundance of absorbant cotton is placed, receives such abundance of ether at the start that unless the operation exceeds 45 minutes in duration, no ether is added; the cone in the meantime is not removed from face. during the last 20 minutes of the operation the patient inhales considerable quantities of carbonic-dioxid more soothing to the bronchi and the alveoli than would be unmixed ether. The over saturation of the tissues of the body by ether is also thus avoided.

Thus

Dr Wm. W. Glenn, Hillsboro: I would like to ask the writer of the paper, if the camphor and menthol solution acts as an antiseptic sufficiently strong to kill the streptococcus and staphylococcus germs which produce the bronchitis, especially in tuberculosis, tuberculosis being a general infection and the bronchitis resulting from the infection caused by the germs above mentioned? I am very much interested

in these marvelous results. Does this injection of 5 grains to the ounce of menthol and camphor cure the bronchitis, and does it destroy the tubercle bacillus? Does it also destroy the other germs mentioned? What is the marvelous effect of the injection?

Dr John A. Thompson, Cincinnati, closing Discussion: Intratracheal injections can be given without the use of the laryngoscope, but I use it because I like to see the condition of the membranes of the larynx and upper part of the trachea at the time of giving the injections. The condition in these parts is a guide as to what is going on lower down in the bronchi, and thus I am enabled to make a choice of the solution which is best to be used in the treatment of the condition found.

As to the action of the drugs on the bacilli in the lungs, I made no claim for any destructive action on the bacilli of tuberculosis by these drugs. If you will recall the pathology of the tubercular process you will know that the bacilli are found deep in the connective tissue, and not superficially, so that no injection will have any direct action on the tubercle bacillus. In pulmonary tuberculosis the chief benefit of the injection is on the secondary infection, and in curing the bronchitis which is present in these cases. I think none of the writers on this subject claim any direct action on the tubercle bacillus in the lungs. The effect of the injections on the pneumococci and on other germs found in connection with diseased conditions of the lungs and bronchi has been demonstrated time and time again to me by microscopic examinations of the sputum. As soon as the injections are given the number and virulence of the germs in the expectoration diminish as if by magic.

The Relative Value of Diagnosis

BY F. C. GRAY, M. D., DAYTON

That a diagnosis in a given case is always a matter of importance, having immeasurable value in a relative sense, is accepted without cavil. The only excuse for this paper is to accentuate its importance. Intelligent therapeusis and likely prognosis are its dependents. By likely prognosis is meant a result most likely to obtain. It should not be for

gotten that not infrequently physicians prescribe the limit of life, only to learn that their unqualified pronunciation of doom has proven a discredit to them and their profession, while charlatans and charlatanism have profited by an unqualified decision. It is certainly satisfactory to be able to make a diagnosis, and just as unsatisfactory not to be able to do it.

While diagnosis is of relative value there cannot be a relative diagnosis, it is or it is not made. In the realm of pathology the period of the guesser is fast disappearing. In proportion to the guessing will be the disaster. Fallibility is omnipresent, all men are fallible. Were this not true no appeal need be made, no desire need exist for greater ability to diagnose disease. A failure to diagnose should be a matter of regret, if not a matter of humility. It is not to be presumed that a physician will be at all times and in all instances right in his discrimination and conclusion. All men make mistakes, and if they did not they would not be men; yet a physician's success as a physician cannot be said to be due to inexcusable mistakes.

The relative value of diagnosis depends on the fewest mistakes possible, and while it is true that a physician has not at all times and under all circumstances the same acuity of vision, intellectual might, power of recall of symptomgroup, ability to compare and contrast, yet his purpose should be to perfect himself in these things so far as it is within his power.

Again, a man is not alike capable cach day; if he were it would imply such perfect human balance that perturbation and disturbed equilibration would be unknown. All nature has its undulations. Why should man be exempt and stand for constancy? Yet the more inconstant he is as a diagnostician, the more lamentable becomes the fact when applied to him as a physician. Our German brethren have been accused of being sticklers for diagnosis and of being indifferent to therapeutics, their interest in their patients terminating with diagnosis. Whether true or not,

their remarked attitude concerning diagnosis deserves as strong commendation as their accused interest in therapeusis merits condemnation. Certainly all our efforts should be for the making of good for our patients.

Second only to prevention of disease is its early recognition. It is agreeable to note that there is especially manifest in the medical literature of the last few years a disposition to accord to diagnosis its proper value. A plea touching almost all diseases is made for their early recognition on which so often depends success in treatment.

As evidence of the accepted relative importance of diagnosis it is pretty generally believed, "That in the realm of practical clinical medicine there is no one feature that gives strength to the art and science like that of making a diagnosis. As a general proposition it may be said that prompt, accurate diagnosis is the most difficult and, at the same time, the most important thing in medicine or surgery."

The result of applied means in diagnosis is scarcely less than wonderful, and certainly of undeterminable value. For instance, we will consider tuberculosis; the hectic flush, recurrent chills, pronounced emaciation, quantities of pus and cadaveric anemia, are no longer necessary to diagnosis. Thanks to science, a physician has the resources by which he can diagnose tuberculosis even previous to one of the mothers of Israel.

Tissue disorganization, as demonstrable by physical examination, the presence of bacilli-bearing expectoration, are not essential to diagnosis, as it may and ought to be recognized in their absence by the no doubt harmless tuberculin injection. It is believed by most physicians that promptness of diagnosis in tuberculosis very largely determines the prognosis.

Dr W. J. Brooks, who believes in the Virchow distinction of phthisis and tuberculosis, viz., that phthisis is tuberculosis plus septicemia due to pyogenic superinfection, writes: "While tuberculosis, as well as many cases of

phthisis, is eminently curable, early diagnosis is of vital importance. Successful treatment must depend upon measures taken before the lungs are extensively involved, and it goes without saying that if tuberculosis was generally diagnosticated there would be practically no mortality."

We are aware that what promise of cure there is in malignant diseases depends on early diagnosis, and it is deplorable that still many cases are not recognized until it is too late for relief.

Surely rapid strides have been made in diagnosis in medicine and are largely due to the development of the microscope, as a result of which development "almost every disease has been made to come forth and stand in the brilliant sun-light of scientific research." It has enabled investigators to develop anatomy, physiology, pathology and bacteriology, a working knowledge of which furnish us aids in diagnosis which range from absolute to less than absolute aids touching most all diseases.

Besides the many pathognomonic bacteria, how invaluable is the plasmodium of Laveran in determining the presence of malaria, and how much less excuse there is for the existence of low fevers and how less a scape-goat for unrecognized conditions in malaria. Thus another idol is broken, and its idolized companions, neurasthenia, and the lithemic or the uric-acid group, as causes of the not wellunderstood maladies of the human family, are but awaiting the same oblivious fling.

Of decided value are the Widal reaction in typhoid fever and a high-count leukocytosis in the process of pus development.

Surgical diagnosis has not been as rapidly developed as medical, yet it is being constantly improved, and surgeons are pleading for early recognition of cases that are to be relieved by surgery. They demand of the physician early diagnosis in appendicitis, peritonitis, ectopic pregnancy, intestinal obstruction and perforation, malignant conditions, pelvic suppurative inflammations, etc., claiming