of the foot is allowed to sink upon a piece of cheesecloth which covers the plaster and the borders of the newspapers are raised and the plaster is pressed against the foot until it is more than half covered. The foot is held at right-angle with the leg, corresponding to its usual position in the shoe, that is, slightly plantear flexed, and the sole should be in the plane perpendicular to the seat of the chair. As soon as the plaster is hard, another piece of cheesecloth is placed over the foot, and the remainder of the foot is covered with plaster. The two halves are removed when sufficiently hard to be taken up and after being smeared with vaseline are bandaged together. The advantage of using the cheesecloth next to the foot is that the foot does not have to be greased.

After the cast is hardened the shell having been well greased with vaceline is filled with plaster and after the outside shell is removed one has a reproduction of the foot, which when properly made will stand upright without inclination to one side or the other.

In all cases it is best to deepen the inner and outer segments of the arch in the model in order that the arch of the brace may be slightly exaggerated, especially at the heel and so that the depression of the anterior extremity of the oscalcis may be prevented. If the outer border of the cast is flattened by pressure a little plaster should be added to approximate the normal contour.

USE AND ABUSE OF SPECIFIC TREATMENT IN

TUBERCULOSIS

Louis C. Roughlin, M.D., Atlanta, Ga.

There is, at present no disease which holds the attention of the world more than tuberculosis, and the only thing next to it in importance, both to the laity and profession, is tuberculin. Its popularity in our own state may be judged by the fact that in spite of the thousands and thousands of doses sent out free by our State Board of Health, the sale of tuberculin has increased over four hundred per cent. in the last fourteen months, according to information given me by an Eastern representative of a commercial laboratory. Since presenting my article on this subject before the Fifth Congressional Medical District in 1898, I have had over a thousand requests for copies of the reprint, and am in almost daily receipt of letters from the laity and physicians, desiring information on this subject. There is, perhaps, no single therapeutic agent, which had in such a short time, such a varied career. On its introduction in 1890, it was lauded as a postive specific, shortly to be followed by a reaction, and we had an era of "Tuberculin terror." In the last two or three years, began the era of "Tuberculin renaisance," and unless checked we are rapidly approaching an era of "Tuberculin delirium."

WHAT TUBERCULIN IS

Every physician should be impressed with the fact that tuberculin is not a serum. It is not an anti-toxin; it is the very opposite to it. It does not decrease the toxins in the system. It increases it. That no matter what form or preparation used, (I have fully described

the methods of making the different preparations in my former paper. They are practically identical in their physiological effects, and represent the toxins of the Tubercle Bacillus. Tuberculin immunization represents an active, not a passive process. It is a poison, pure and simple, and like all other poisons used in therapeutics, is of value only when administered properly, and under special care and attention; otherwise, it is only productive of harm and disaster. Under ordinary conditions its greatest value lies in its use for diagnostic purpose, for its therapeutic use, especial conditions and environments are required.

DIAGNOSTIC USE OF TUBERCULIN

For diagnostic purposes the Cutaneous, Inunction, Intradermic, Conjunctival and Subcutaneous method may be used. Their value depends upon the sensitiveness of the infected tissues to tuberculin, and manifests itself by an inflammatory response when brought in contact with skin and mucous membrane. Any of the above methods may be used with safety, except the Subcutaneous test, which should be used only, as a last resort, and the same care and caution is necessary as when used for therapeutic purposes. The delicacy of the reaction becomes lessened as the disease undergoes the process of healing. It is greater and more delicate in the very recent as well as the more extensive form of the disease, except in the rapidly progressive and very grave form. The reaction may occur in healthy persons, and when persisted in use may arouse a sensitiveness from a latent or from a former healed infection, therefore its value is equally great in excluding tuberculosis by its absence, and in postive cases it can only be considered as a confirmatory evidence to previous physical findings by other means.

THERAPEUTIC USE OF TUBERCULIN

For therapeutic purposes there are many conditions. which must be carefully considered. They are, first, the patient himself-his physical condition, his environments, and supervision while under treatment. Next must be considered the choice of the preparation-the dosageits indications and counter-indications-reaction, if any occur the kind and its severity, and the interval between dosage, and unless a physician is prepared to be able, at all times, to be reliably informed by a competent scientific observer on all these absolutely necessary conditions, he is not prepared to administer tuberculin.

Before an injection of tuberculin is given, a most thorough physical examination of the patient should be made, the condition of his stomach, bowels, liver, and kidneys, as well as the condition of his nervous system, must be considered, microscopical and chemical examinations of his sputa, urine, and when necessary, of stomach contents, feces and blood should be made, the temperature, pulse and respiration should be taken by a competent observer, at least four times a day, for several days prior to the injection of Tuberculin. Any abnormal conditions found, as far as possible should be corrected. The choice of tuberculin lies chiefly between the soultions and emulsions of vaccine, opinions vary as to the formation of any rule on this subject. The method used at Pine Ridge Sanitarium has proven excellent in our experience with same. The Pine Ridge method is as follows:

PINE RIDGE METHOD OF CHOICE OF TUBERCULIN

The patient's arm and forearm is first thoroughly scrubbed and cleaned with soap and water, dried and the parts washed off with ether, and by means of a special scarifier the patient is inoculated with the different forms of tuberculin; one inoculation is made with the normal saline solution for a control; the choice of tuberculin to

be used is then made by means of the different cutaneous reactions. The predominant type manifests itself by the greater local reaction, the concommitant by the least. Springler and Detri have shown, and their views have been borne out by observations at Pine Ridge, that the injections of the concommitant type causes, in many instances, the disappearance of toxaemia, while the predominant filtrate causes an accentuation of the symptoms, and that the greater number of patients can be more easily immunized with the concommitant toxin, but show great tolerance to the predominant filtrate. These tests are repeated from time to time, and necessary changes made according to indications, by these means we have, in a large measure, been able to determine the choice of tuberculin in a given case, and prevented using a non-suitable and intolerable toxin.

SELECTION OF DOSAGE AND INTERVAL

The crucial point in tuberculin treatment is the selection of dosage and interval between dosage. There is not, and we cannot make any scheme of dosage, which can be blindly followed. Individualiation plays the most important part, the proper rate of increase varies for each individual, and even varies for the same patient at different times during the treatment. We have no rule to follow as to dose, rate of increase, or maximum dose desired to be reached. We must be guided by the degree of toxin tolerance of each patient as manifested by the symptoms, progress of the disease, and general conditions; each patient is a law unto himself. The general symptoms are by far the most important, as they give the first sign of tolerance. Pronuonced symptoms do harm, and when the patient is under constant observation, by day and night, by especially trained nurses, they can be avoided, and should not occur.