tractable under treatment and may precede phthisis for a year or more, Chlorotic anaemia with indigestion and emaciation should always suggests the strong possibility of tuberculosis. Thyroidine and thyroid extract will increase the chlorohydric acid in a stomach in which it is lacking. Whether the thyroid gland has any participation in consumption or not is undertermined. Turbin first noted the tumefaction of the thyroid gland in early phthisis and atrophy of the gland later. The observations of Charrin show that animals deprived of their thyroids are more susceptible to tuberculosis. One can imagine a disthyroidism which may bring about failure of the secretion even if there is no apparent enlargement of the gland. Tachycardia has long been regarded as an early sign of tuberculosis. Long before physical signs or fever show themselves. According to Besancon this is due to the pressure on the vagus by the peribronchial glands, and is in reality an irritation of the vagus. The pulse is weak, rapid, and the heart asystolic. There is a condition of cardiac erethism and when the pressure is low the pulse has the characteristics of a Corrigan pulse. It does not increase on the change of position of the patient and will suddenly augment without apparent cause. This symptom may precede by many months the local out-break. With tachycardia there is also a very low arterial tension. A persistent low arterial pressure is a very significant symptom and is dobutless due to the influence of the toxins on the vasomoter center. This relief of obstruction to the out-flowing blood current is sometimes given as the cause of the tachycardia. The heart finding no resistance to its efforts runs away. We have too many examples in influenza and typhoid fever of low pressure and slow pulse to accept this explanation. It is more reasonable to call in the vagus and explain the rapid pulse as due to a neuritis of the pneumogastric caused by pressure of intrathoracic glands or by direct effect of the toxins. A constant low tension is strongly suspicious of tuberculosis and when associated with a rapid pulse the suspicion is emphasized. The susceptibility of the patient to changes of temperature is very marked in tuberculosis. Daremberg demonstrated that a walk of one hour will frequently cause a rise of one degree. A change of one degree is often noticed during the catamenia notwithstanding repose during that time. Incontestably the thermometer is an invaluable aid in diagnosis and systematic observation should be made after exercise in all suspected cases. Its value during convalescence when the patient commences to take up his exercise is undoubted and need not be discussed here. Landouzy described a group of pretubercular fevers that resemble typhoid fever. It is not rare to meet incipient cases of pulmonary tuberculosis that give a history of having had typhoid or malarial fever. In fact it is sometimes exceedingly difficult without unusual and exact scientific methods to make a differential diagnosis. The rapid pulse, dyspnoea and rapid respiration, the relation of pulse and respiration, the diminished respiratory murmur and the fever curve must all be taken very carefully into consideration in approaching a conclusion. There has been an attempt to show that the fever in tuberculosis is easily provoked by the injections subcutaneously of small quantities of physiological serum. Those who have made the experiments find a rise more frequently in anaemic cases, and in pernicious anaemia a sharp rise, that continued for several hours, has been several times. observed. But as far as tuberculosis is concerned the experiment must be considered as of no value. The consumptive does not necessarily have fever. When continuous it denotes progress of the process or a mixed infection, and when occasional some accident or strain. The patient with a fever should recline. There are but few exceptions to this rule. In tuberculosis one observes amypotrophy localized in the muscles most near to the tuberculous focus. It is important not to confound simple muscular atrophy or weakness and flaccidity with it. When amyotrophy is present the muscle diminishes in volume considerably and shows the peculiar quantitative and qualitative reactions. Cecconi claims to have seen there changes often preceding an explosion of tubercular symptoms. Their seat is varied, they may be general or diffuse but usually strike certain groups of muscles. Sometimes symmetrical, sometimes unilateral one group of muscles after another will be invaded insidiously, progressively, slowly and continuously. The alteration of the muscles shows itself by deformities, functional disorders, modifications of their mechanical and electric excitability. The evolution of this atrophy is coincident with the subjacent lesions and is more manifest usually when the lesion is most advanced. The pathogenesis of amyotrophy rests in the alteration of the nerve filaments of the pleura which makes itself felt in the spinal cord, either by a reflex action or by retrograde degeneration. One was impressed by the effort to get back of the commonly received signs of disease. *The increasing pessimism as to the ultimate cure of phthisis has forced the physician to examine the dynamic as well as the static conditions of the organs. He is not content to study the modifications of their anatomy but to make this exploration more penetrating, to make certain operative procedures if necessary to interrogate the function and to act often after the manner of an experimenter. In order to establish the diagnosis he calls to his aid chemistry, physics, physiology, bacteriology and each one of these sciences furnishes him with new armaments. It is the unanimous opinion of practitioners that the externai manifestations of tuberculosis are much more easily and surely cured the earlier they are discovered, moreover their early destruction has the double advantage of reducing to the minimum the dangers of generalization for the individuals and of contamination for his fellows. As to pulmonary tuberculosis, which surpasses all others in importance and extent, the early diagnosis brings great advantages for treatment and individual prognosis but especially for social prophylaxis. To make an early diagnosis of tuberculosis is in theory to recognize the lesions at their start. But the reality is far from this ideal. How too often to make an early diagnosis (for varied and perfect are many of the means now employed) is simply to unveil the lesions still limited in extent but relatively advanced in their evolution. In reality tuberculosis is a disease which proceeds by many stages. Its germ is wide spread. On many occasions in his existence man has met and combatted it, and when he has allowed it to gain the advantage and he has become really an invalid it is only after having been subjected to many offences, of which the various organs retain more or less marked traces. To unmask these earlier attacks-that is the true object of the diagnosis praecox. Only too often tuberculosis is recognized in its last and decisive advance and a diagnosis made even at the beginning of this final attack is already relatively late. At this moment when the practitioner cannot afford to commit the slightest error or lose an instant it is more important than ever to establish quickly the true nature of the illness. Among the probable signs the leucocytosis often seen in tuberculosis has proven disappointing. The leucocytic equilibrium is so easily disturbed that accidents of all kinds can influence it. As an early sign it cannot be relied upon. The presence of lym *ACHARD; EARLY DIAGNOSIS. phocytes in the pleural sacks is often associated with tubercular pleurisy and has for sometime been accepted generally as of diagnostic value. These cells will however preponderate from other causes, but because tuberculosis is by far the most frequent excitant of the transudate the coincidence of the lymphocites in the fluid and tuberculosis has been very frequent. Thus while an excess of these cells in the fluid may be strongly suggestive it is not by any means positive. The diazo reaction of Ehrlich gives very often a positive reaction in tuberculosis. But this is usually in the acute advances or in the later or chronic stages and has but little value in the prepulmonary state as a factor in early diagnosis. Moreover, it it found so often in other conditions that its advantage as a positive diagnostic sign is much compromised. Tessier of Lyons declares that albuminuria is at times a revelation of the presence of tuberculosis. Such an albuminuria is inconstant, irregularly cyclic, more abundant in the morning and accompanied with phosphaturia. Tessier would not imply that the evolution of tuberculosis is a necessity for in a hundred cases he has seen tuberculosis follow only in twenty instances. It is probably a light interstitial irritation of the kidney due to poison independent of the bacillus but the fact is none the less important and should attract the attention of clinicians. A minute analysisof the urine, the state of the arterial tension and the heart, the urea elimination enables one to differentiate these albuminurias from those due to a lesion of the kidney. We may mention alsothe excess of salts in the urine of the tuberculous. This deminiralization is inconstant but frequent and can serve as one of the suspicious signs. Many investigators have studied the chemistry of the expired air. According to them the activity of the exchanges of gases is a general fact in cases of tuberculosis. While the respiratory capactiy of the lungs may be diminished the compensatory suractivity developes an excess of gases. Many claim that the respiratory quotient is always high. That is the carbonic acid in excess and that this indicates an active internal combustion. Charrin however, demonstrated that the respiratory quotient was normal in stationary cases, and high only in advancing or advanced cases. It is a procedure most assuredly full of interest and doubtless when carefully studied may furnish much information that may profit even general pathology. The technique is somewhat complicated and demands many precautions and is beset with many difficulties. It is claimed however, that even in the pretubercular the results are significant; but at the best it can only be considered now as a premature and not an early sign. The examination of the chest has always been the adopted method of determining the diagnosis and Brouardel has attempted to supplement the known methods by what he calls pneumography. In the normal chest the pneumographic tracing consists of four lines which correspond to the inspiratory rise, the line of the full chest, the expiratory descent and the horizontal line of rest. In tuberculosis the fourth line corresponding to the emptied lung is lacking and the line of expiration is prolonged in a manner that takes its place. Letulle has contradicted these tracings and says that the respiratory rhythm is too irregular to draw any conclusion from and that the tracing presents nothing especially characteristic. At the tuberculosis dispensary of the Beaujon Hospital, an apparatus devised by Grehant, is employed to estimate the pulmonary capacity. The instrument is sensitive and the technique of its operations delicate, but when operated with accuracy is very useful. It aims to establish the fact that bacillosis diminishes the capacity, that is the interior volume of the lungs, by the development of tubercle, the coincident congestion and the changes which invade the territory attacked. Let a very progressive diminution of the respiratory capacity of the lungs constitute a good diagnostic sign at the commencement and a good prognostic sign later. Careful records of patients are kept at the dispensary, which is the most scientific one in Paris, and the claim is reiterated that a diagnosis is possible before definite physical signs appear. They repeatedly make the diagnosis by the Grehant instrument and think that they can depend on their conclusions. The exact method of diagnosis is the demonstration of the presence of Koch's bacillus. There are but few chances of error in this method, though some times the bacillus lives as a saprophyte in the upper air passages of sound individuals. Another source of error is the smegma bacillus which is acid resistent and resembles the tubercle bacillus morphologically. There have been many improvements in the culture of the bacillus which in the biginning troubled Koch and his immediate followers, so that now the bacillus is occasionally found in the blood but this is rare and never at the commencement of chronic tuberculosis. Joasset has perfected the methods of detecting bacillaemia by testing the blood clots and thus gathering and concentrating the bacilli. He |