possible incipient tuberculosis in such a case and put the patient on a plan to bring about a cure, and quit giving these quasi-consumptive cures, cod liver extract, cod liver o, etc. Samples of such preparations are left on our desks for trial, and in my experience they are absolutely useless. I have abandoned cod liver oil entirely. I do not give any of the hog fat or any of the oil products.

Again, we are prone to rely too much on the microscope. A specimen of sputum is examined and the report comes back that it is not tuberculosis. The tubercle bacilli have not been found in the sputum. We are consequently told that the patient has not tuberculosis. The patient is satisfied. In two months or more, however, the disease has progressed to such an extent that very little can be done for the patient. The mere fact that we fail to find tubercle bacilli in the sputum does not make it clear that we should regard the case as non-tuberculous by any means. The tubercle bacilli may be overlooked or not found on account of lack of proper technique; or the tubercular mass or process may not have broken down, and the tubercle bacilli may not be thrown off; and one of the most fruitful sources of error is that nine-tenths of the sputum we get for examination is taken from the. upper air or nasal passages.

Dr. H. McHatton, of Macon: I am very glad indeed to have heard these papers, and that this subject has been brought before the Association. The early diagnosis of tuberculosis is one of the most important things before the profession to-day, because so many of us see cases constantly, yes, daily, where the diagnosis has been neglected. In the majority of cases there is neglect in making a diagnosis simply because the mass of general practitioners do not take sufficient care to examine patients. The diagnosis of early tuberculosis is one of the most

intricate things in the profession. We do not find tubercle bacilli to amount to anything in many instances; consequently we have to rely upon the physical signs, which are not very pronounced-fluctuations in temperature, white scales, etc. By following these up we may be able to make a diagnosis; but we can not expect to make it in one cursory examination. It will often take several weeks and repeated examinations to make a diagnosis.

Speaking of thermometers, there are slight variations of temperature registered by different instruments. If you tell a patient to get a thermometer and take his temperature and bring the record, have him bring also his thermometer with him, because the variations in thermometers bought by patients are sometimes extreme. So much for the early diagnosis of tuberculosis.

Personally, my experience with tuberculosis goes back a good many years. I was sent to Georgia over twentyfive years ago with tuberculosis, so naturally my attention was attracted to this disease. For over twenty years I have not made the slightest change in my treatment of tuberculous patients. I have cases that have been under observation for over twenty years, and my experience has been that there is nothing in the world comparable with the absolute open air treatment. The more these patients get into the open air the better it is for them. They get better. If they can not go into the country, see to it that they are kept out in the open air.

Drugs are practically of no benefit in this condition.

There is one thing to which I wish to direct your attention, which has not been spoken of before, and that is, as a rule, it is better not to send patients with tuberculosis out of the State of Georgia, for several reasons. In the first place, you send a poor man out West, with probably

a small amount of money, and his condition is simply horrible. In his own State he can get practically any climate and any altitude he wants, from five thousand feet down to the level of the sea. Keep the patient with his people, and not send him off to die, to be isolated from his family and friends. Such patients can go up to North Georgia in the summer; to Middle Georgia in the spring and fall, and then go down to the coast for the winter.

Gentlemen, it is not a question of climate, or a question of altitude, but it is a question of open air, and it does not make any difference to the patient whether he is in Georgia, Kalamazoo, Colorado, or anywhere else, so long as he can live out in the open air. He can get any temperature he wants, and he can be within reach of the members of his family, and, as a rule, he will live better, get better surroundings in this State than any other place of reputation for tubercular patients that I know of. When I came to Georgia I did not know but one human being here, and as I had the pick of the whole world and had to take care of myself, I picked out the State of Georgia, and I have never had any reason to regret it. (Applause.)

Dr. E. B. Block, of Atlanta: These papers have interested me very much, and I can not refrain from giving my experience in some cases, such as have been mentioned.

I regard the use of tuberculin as an extremely valuable test. However, a great amount of precaution is necessary in the selection of cases in which it is used. In no case in which there is much elevation of temperature, or where the physical signs are decided and marked, is the tuberculin test warrantable, because it unquestionably accelerates the inflammatory condition, and we always hear of an increase in the rales around the tuberculous focus after the injection of tuberculin. However, in cases where

there is no marked rise of temperature, not over a fraction of a degree in the afternoons, where the physical signs are slight, this test is of value, as well as the search for tubercle bacilli in the sputum. I do not mean, if we find tubercle bacilli, there is no more indication than if we get a tuberculin reaction; I mean it gives about the same percentage of diagnostic result. In some cases of tuberculosis the tubercle bacillus may be absent. If absent, it does not necessarily prove that it is not tuberculosis; also the tuberculin reaction may be present, and, if present, it does not necessarily mean absence of tuberculosis. It is necessary, however, to know the dose which is given, and the reaction, when present, does indicate tuberculosis in some part of the body. It has been my custom to give one injection of five milligrams as the first dose. I have not found this too large, and there are a great many others who are of the same opinion. It is necessary in getting this reaction to keep the patient at rest. The temperature is taken at regular intervals every three days before injection to know exactly how the temperature runs without tuberculin. Then the tuberculin is given, and the patient kept in bed for three days, taking the temperature at regular intervals. If you start with small doses of tuberculin you must keep the patient in bed for six or eight weeks while giving gradually increasing doses of tuberculin, and I may state that repeated injections have made the reaction in my cases more remote; that is, they have delayed reaction. So much for that point.

With reference to fresh air, it may be interesting to mention the fact that if you take the air from the room in which a consumptive has been confined, in which there has been no ventilation, condense this air and incorporate it in culture media used for growing tubercle bacilli, the bacilli will grow more prolifically in this tube containing

the condensed air than they do upon media where this air is not so used. This in itself shows the importance of fresh air in the treatment of this disease, preferably dry air, because practically the discharges are less in a dry climate than in one in which there is much moisture present in the atmosphere.

I must say a word or two in reference to the treatment of tuberculosis by drugs. While I consider fresh air, rest in bed during the fever, and a liberal diet very essential factors in the treatment of this disease, I can not and will not accept the idea that drugs are of no benefit in this disease. I do not say that drugs have a direct curative effect upon the disease, but I believe their judicious use will prevent infection of the lungs and the development of other foci of infection. My meaning can be more easily understood if you will regard my fingers as bronchial tubes. (Illustrating.) Let us suppose that a patient has a very free bronchial discharge, a bronchorrhea, composed partly of the breaking down of the tissues in the lung from tuberculosis, and partly of the toxines of tuberculosis, causing a bronchial discharge of mucus; and supposing you have a focus of tuberculosis here (indicating), with tubercle bacilli appearing in the sputum, this bronchial tube reaches a point where it coalesces with the other bronchial tubes, and as deep inspiration is essential to vigorous coughing, the patient may suck tuberculous sputum into the other bronchial tubes. Therefore, the suppression of coughing by the use of drugs is of value in preventing the dissemination of tuberculosis in the lungs.

Dr. Louis H. Jones, of Atlanta: There are three points in connection with the treatment of tuberculosis which I think can not be too frequently and too forcibly emphasized, because I have so often seen them disregarded by members of the profession.