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It should not be forgotten that in early cases it may be necessary to make repeated and very careful examinations before the bacillus is found, and that the patient must be instructed to preserve that material which he raises from the lungs, preferably during the early morning, and to avoid as far as possible contamination of this by saliva or nasal secretion. Above all, should the examination of the sputum fail to show the tubercle bacillus, the physician must not rest in fanciful security. It is in the closed stage, when the tubercle bacilli are not in the sputum, that it is of the utmost importance to make certain the diagnosis, and it is in such a condition that the utmost skill of the physician is called into play.

If tubercle bacilli have been found in the sputum, it remains only to determine the location and extent of the lesion; if they be not found, we must determine by other means whether there be a tubercular focus present. The use of tuberculin as a diagnostic measure is often, in selected cases, of great value. It should, however, never be employed except with the greatest care, and usually is not necessary.

In arriving at a diagnosis in a case in the incipient, closed stage one must consider every detail; for only by systematic and careful methods is it possible to attain proficiency and accuracy. We must never lose sight of the fact that a correct diagnosis is of vital and momentous importance to the patient, and our failure to detect tuberculosis in its early stage may cost him his life. On the other hand, a diagnosis of tuberculosis when it does not exist is a serious thing, as it may alter the whole course and future conduct of our patient and debar him from some chosen pursuit, in fact change the entire course of his existence. We must diligently enquire into his family history. If this shows the frequent occurrence of tuber

culosis in near relations, it furnishes valuable evidence of predisposition to the disease. Age and sex are to be considered, tuberculosis being pre-eminently a disease of youth and occurring particularly in young males. Fifty per cent. of all cases occur between the ages of 18 and 25. Loss of weight may be the first symptom noticed by the patient. He is easily tired and has indigestion and appetite is poor.

The character of the pulse is valuable. In nearly all cases there is either tachycardia or an irritability of the heart, due to toxemia and resulting in a rapid pulse upon slight exertion or excitement so that it may even reach 120 or more, while the temperature is either normal or slightly elevated.

Afternoon rise of temperature, even though slight, 99.5, is of the utmost significance. Often exercise will increase the temperature to or beyond the above degree. In women it has been shown that at the menstrual period there is often a characteristic afternoon rise of temperature, increased pulse rate, and the presence of physical signs otherwise absent.

Hemoptysis is often the first symptom observed by the patient, and may usher in an open tuberculosis which in the closed stage had caused no temperature of especial


Cough may and usually does exist early, even before the open stage, and is normally of the hacking variety when dry, which becomes a mere clearing of the throat when expectoration is established.

The signs revealed by physical examination are, of course, of the utmost consequence, but beyond the scope of this paper.

For definite information relative to them I must refer you to the text-books on the subject. The recent work

of Turban is an excellent manual that you will find of great service.

The purpose of this paper is not to present anything new, and it is manifestly impossible and foolish to endeavor in so limited a space to thoroughly review the methods of diagnosis and treatment of tuberculosis. My only purpose is to call attention to the distressing frequency with which cases of pulmonary tuberculosis pass unrecognized until they have become almost hopeless, and to urge the necessity for more careful methods of diagnosis.

We all make mistakes, but it is our duty to make as few mistakes as possible. Some mistakes are excusable, but when human life and happiness is the prize for which we play we can not afford to make even excusable mistakes.



The medical profession has been so often disappointed in the treatment of pulmonary tuberculosis with the ordinary remedies has witnessed the rise, decline and fall of so many vaunted new specifics for this terrible disease, that it has reached a condition where failure is expected, and the whole subject of the therapy of this malady is regarded with apathetic indifference. To such an extent is this true, that I find we have almost as a whole disregarded and overlooked the really wonderful advances in more recent times that have been made in the treatment of this affection.

The combat against this terrible foe that has placed us in a measurable degree of victory has not been carried on in the pseudo-scientific journals of "bio-chemistry," the morning gazettes of "the newer remedies," or the evening telegrams of the "alkaloidal specifics," nor yet in the daily lay newspapers, one of the special prerogatives which the vast majority of them exercise being the dissemination of misinformation generally, and more particularly on medical subjects. In our own land this seemingly hopeless combat was begun nearly three decades ago in the lonely and, at that time, uninhabited wilderness of the Adirondack mountains of northern New York, a combat to which no admiring onlookers lent applause, as

silent and grim as the icy peaks of the surrounding hills. Here, all alone, a weak and emaciated invalid, himself a sufferer from this frightful malady, struck the first blow in the great fight which has resulted in such unparalleled good to mankind, and which is destined in the future to be of infinitely more benefit to suffering humanity. All honor to Trudeau, one of the greatest philanthropist and physicians of this, or any other time. To him has fallen. the happy lot of knowing that thousands are now strong and well, who, but for him, would have long since passed away the victims of one of the most terrible and loathsome of all diseases.

With this great example before us it is our duty to let the world know what can be done to combat the great scourge of tuberculosis, and it behooves us as true physicians to do all in our power to further the great ends that have been already so nobly striven for.

In order that this may be done nothing is so essential as for us to inform ourselves as to all that is requisite in the recognition of tuberculosis in the earliest stages, and then impress upon our patients the necessity of prompt and energetic action. I think, then, that nothing could be more timely than for us to take up this subject, and with renewed ardor never to allow it to rest for a moment so long as this great scourge continues its ravages among us.

Incipient tuberculosis is the form in which the disease is pre-eminently amenable to treatment, and it is therefore particularly to this period of the affection that our endeavors should be most directed in our attempts at its recognition. This incipient tuberculosis was defined at the last meeting of the National Association for the Study and Prevention of Tuberculosis, as follows:

"Slight initial lesion in the form of infiltration limited to the apex or a small part of one lobe."

"No tuberculous complications. Slight or no constitu

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