up from the street or on the floors of dwellings. It is equally certain that the next step in most cases would be to introduce the dirty hand with its disease-producing germs into the mouth, and thus initiate every condition that is favorable to the setting up of infection of greater or slighter degree. Under these conditions "hand-to-mouth infection" becomes a hygienic problem of the first rank. Prevention then means to a large extent the thorough policing of our streets with the most stringent ban on public spitting in effective practice. If Flügge's theory is correct we can practically disregard promiscuous expectoration as a danger, disgusting though it may be. If Cornet is right the danger from it is relatively slight, for in practice Cornet himself limited the menace from sputum to conditions that obtain indoors.

Finally, we have been at some length to prove by the citation of examples that manifest disease in later life, in many cases perhaps, undoubtedly does develop on the basis of a primary infection that occurred many years before-perhaps in childhood. But without a more searching inquiry we are far from

accepting even as a working hypothesis the sweeping generalization, which has become almost a dogma, that adult disease is typically the expression of childhood infection. We have seen that such a point of view at once leads us to a consideration of the question as to whether a human being or any animal can be infected more than once with tubercle bacilli as well as of the persistence of tuberculous lesions.

This brings us logically to the second stage of our discussion of infection. The first stage that dealing with sources, portals of entry and modes of infection-has been mainly an analysis of what we know in regard to Ahead primary infection; and is behind us. of us lie matters that are much more intricate and complex-reinfection, resistance, the transmutation of bacilli, the effects of the bacillus on animal tissues, etc. And it is perfectly impossible for us to understand tuberclous infection without having some information about all these varied phenomena.

(To be continued in the May number)

In

There are among you those whom I regard as "good patients.' You obey rules, observe rest hours and comply with general regulations. You are advocates of a personal patriotism. You are patriotic to the extent that you will protect what is your own. the warfare against tuberculosis, you are like those in the world war who declare that they would fight to defend America if we were invaded; but would not take up arms to make the "world safe for democracy." The times

demand more than this. Real manhood and real womanhood require that you enlist, not only in the protection of yourselves, but that you give all that there is in you to that warfare against tuberculosis which will make the world safe for men and women and children. If we, who have remained at home, on account of our physical unfitness, have really felt deeply the spirit of this war, it should bring us to a new spirit of bravery, a new spirit of heroism, a new patience, a new submission to discipline, a new spirit of the brotherhood of men, a new interest in the safety of the people of the world-factors essential to victory in the brief war against the Huns and even more essential in the greater and longer war against the tremendous forces of tuberculosis.

II. Uniform Records by Other Units.

(As listed data would serve by fitting in with central method. Medical history cards or sheets and nurse's card will probably be approved by central authority.)

III. Field Records of State, Local and Intermediary Agencies:

(Detailed investigation cards (see 1-10) will be submitted by State, local and intermediary agencies, or information to record on

cards, and during intervals of six months the patients should be looked up by the central authority directly or through the cooperating agencies, for the purpose of noting progress toward recovery or death. It will not be necessary to make out a new card, but it is essential to have a supplementary card with a few questions to be jotted down as one goes over the original report, and have these questions answered by a field worker and add the information to the set-card. The first supplementary information may be put on in red ink, after which a plain white card may be attached to the detailed card with dates written in to the right with memoranda in brief form in regard to the condition of the patient, etc. There will probably not be more than one white card used in most cases since the patient will die, get well or remove from the State. (See again 1-10.)

Dispensary statistics asked for during periods of six months, including number of examinations, number under supervision, with classification, will help to show the growth and usefulness of dispensaries as clearing houses.

IV. County Institution Records:

(See above under II.)

Remarks:

When it is learned that a case has died from tuberculosis, the date of death should be recorded on the State record card, and the card transferred to a death section of the file which should be kept in the same manner as cases, viz., by cities and towns and alphabetically. Many times a detailed card will not have been received. When, as a result of special field or survey work, brown detailed death cards are used, they become set-cards in the death file centralizing all information thereon. Care should be taken to note the date of report as a case if ever reported.

Likewise, when it is absolutely certain that patients have left the State, the card should be transferred to a section "Left the State," and following should be guides designating the State where the person went, which ultimately may result in reciprocal notification. Again, the same may be said in regard to the "Cured." These sections however, will have a close relation to the rest of the file, since those leaving the State may return and those "Cured" may have relapses, and families where deaths have occurred may be studied.

Realizing that each State has a problem of its own, it nevertheless would seem that, generally speaking, it would be well, after starting the uniform method, to go back over the records to the time of "first legal reporting of tuberculosis" or, at any rate, for a three or four year period, checking off the deaths, and then through actual field investigation or

through conferring with local workers, go over the situation throughout the State and account for each case. By doing so and grasping the situation as it comes up daily, the central file would be vital, and a picture of the real situation would be seen. Local governments are constantly changing and after a certain community has been analyzed, certain misunderstandings may be righted and interpretation of statistics clarified, and narrative reports also kept by the communities will enhance the situation.

Until we have gone back to the beginning er within such a period as to include data in connection with that submitted from various sources and have analyzed back cases, the different colored cards representing the various sources will appear to represent many cases, as not having been reported, which really have been. But, again, as one looks ahead and these different colored cards persist in being in evidence, or, on the other hand, are eliminated through analysis and filing of detailed investigation reports, then the problem bids fair to be solved; and correctly we can state the per cent. of cases never reported and go to sources for explanation and remedial measures.

It would seem feasible to suppose that the year of starting such a system might reveal a higher death-rate than just previously, because of the elimination of so many duplicate cases. And, too, if new activities have just been organized, such as dispensary supervision of patients, is it not reasonable to suppose that intensive efforts on the part of the nurses have prevented many cases? Another point of view in connection with the establishment of new activities, such as dispensary organization, would be that people would flock to the dispensary and many new cases be reported. But when this is analyzed, it may be noted that old cases are appearing or people are coming from other places. Including the maiden name of a married woman on the legal report of case, considered with the death report which contains such information, would help toward eliminating duplicates as a uniform method progresses. We need, too, to understand how to read the old death statistics uniformly and take into consideration the possibility of increased death rates where hospitals are located, or where people have moved about and lived where the climate was conducive to recovery from tuberculosis.

A Sanatorium Sunday School

SUNDAY SCHOOL AT TEXAS STATE SANATORIUM

TO THE EDITOR:

I am sending you a picture of the State Sanatorium Sunday School, located at Carlsbad, Texas, together with a short letter, trusting it will find a space in your valuable Journal of which I am an admirer. My object in sending this is with the hope that other Sunday Schools may be organized at sanatoriums where there are none.

We have about one hundred and eighty patients here and have about eighty members enrolled in our Sunday School. On account of members continually leaving, we have teachers and assistant teachers so when one leaves, the assistant can take his place. We also have every member that reads a chapter in the Bible during the week report to our secretary as many as they have read and the secretary also makes a report on the minutes. We often have over a thousand chapters read by the members during the week.

We also contribute to foreign missions on the first Sunday of each month. There is always a liberal amount given. We also have a few moments of secret prayer, especially, for the unsaved, the sick and afflicted.

We have our Chapel-a modern two-story building with library and reading rooms down-stairs and Chapel above.

The management of the Sanatorium is excellent, the Superintendent, his Assistant Physicians and Nurses, and all of the employees are all kind and considerate in everything; they are so attentive to their duties and to the interest of the patients that one feels like being entertained by lifelong friends, instead of being here for treatment.

In conclusion my dear reader, let me say, "Let us not be weary in well doing for in due season we shall reap, if we faint not." (Galatians, 6:9). And "we know that all things work together for good to them that love God." (Romans, 8.28). All that have a troubled heart should read the fourteenth chapter of John's Gospel. If you are impatient, sit down quietly and talk to Job; if you are a little strong-headed go and see Moses; if you are getting weak-kneed, take a good look at Elijah; if there is no song in your heart, listen to David; if you feel chilly, get the Beloved Disciple to put his arm around you; if your faith is below par read Paul; if you are losing sight of the future, climb up the stairs of Revelations and take a glimpse at the Promised Land. Let us all pray more and worry less, and life will be sweeter in every respect.

Yours with a Christian love,
Supt. of Sunday School.

TO THE EDITOR:

1. Could you give me the name and address of a physician's good supply house in Philadelphia or New York?

2. Does a person who has had T. B. glands removed from the neck have to lead as careful a life as one who has recovered from pulmonary tuberculosis?

3. Is Calcirose (cough) Compound of any benefit to a T. B. patient? Do you know if it has been tried much?

4. If a patient's highest temperature in the day at 4 p. m. is 99°, is it harmful to exercise if it goes to 99 2/5° and in a while returns to 99°?

5. If a patient is out of doors all the time and comes in the house once a week for four hours and temperature rises from 99 1/5° to

100°, is that what is known as "reaction"? Was the reaction harmful if temperature returns to 99 1/5° after a few hours?

6. Is it best to hear large bubbling noises or small bubbling noises in the chest? 7. Is Cod Liver Oil of any benefit to a T. B. patient?

8. Has treatment of T. B. throat with 5% Formalin and glycerine found to be of benefit? Has 10% Formalin and glycerine ever been tried?

9. Does a person with T. B. throat ever have a hemorrhage from the throat?

10. Does vinegar have any chemical action on a raw egg and would it be harmful to take a little vinegar once a day on a raw egg?

11. What causes so many tuberculosis patients to lose their voice? E. G. A.

1. Kny-Scheerer Corp., New York, N. Y.; William V. Willis Co., Phila., Pa.

2. As a general rule no, but so much depends upon the individual case that a definite answer cannot be given.

3. You probably refer to Calcreose. This is of benefit under certain circumstances, but your physician should determine whether or not to prescribe it.

4. A half-hour should be allowed to elapse after exercise before taking temperature and pulse. If fever or rapid pulse persist over that time, the propriety of exercise may be questioned. In health the temperature may go to 99.4 upon vigorous exercise, but should return to normal very soon. Your physician can best determine in your individual case, considering all the factors.

5. Probably. Consult physician.

6. This cannot be definitely answered in individual cases without intimate knowledge of the case.

7. It is valuable only as a food tonic. Ask your physician whether to use it.

8. Both have been tried, and apparently good results obtained in some cases.

9. This can happen, but the chances are that the hemorrhage would be from the lungs.

10. Yes. Ordinarily the effect would not be harmful, but there are conditions under which it would not be wise, and we suggest asking your physician.

11. In laryngeal tuberculosis, patients lose their voice through the destruction or severe inflammation of the vocal cords. Temporary loss of voice may also occur as a reflex spasm in pulmonary tuberculosis when the vocal cords are not definitely involved.

TO THE EDITOR:

Would you kindly give me some information concerning work suitable for a young woman who has had T. B. but is in good condition and has had almost two years' training in the Philadelphia General Training School for Nurses?

Also concerning work at hotel or sanatorium for several girls who have had T. B. but are in good condition to work? L. S.

Suggest that the patient who has had some training as nurse write to superintendents of some of the nurses' training schools at sanatoria. See other inquiry in this issue.

The other girls could write to superintendents of sanatoria and summer hotels at various health resorts, also to boards of trade and bureaus of information at such places.

TO THE EDITOR:

1. The condition of my lungs is improving but there is an excessive amount of sputum. Will the expectoration diminish as the lungs continue to improve? There is no change in the excessive amount of sputum during the past ten months.

2. Are there any books written on T. B.

of the kidneys? If so, who are the authors and where are they published? SARANAC LAKE.

1. Usually the expectoration diminishes as the lungs continue to improve, though in rare cases the reverse may be true temporarily. The physician in attendance can best answer in your own case.

2. Yes, but they are written in technical medical language and would be of little or no value to a layman.

TO THE EDITOR:

Will you please advise me, what progress if any, has been made during the past few years by the use of Pneumo-Thorax (gas) treatment?

I simply wish an idea as to how it is generally regarded and if it is used to any extent except in emergency cases. J. E. D.

Artificial pneumothorax may involve complications and perhaps hazards and is not usually resorted to until after a reasonable length of time the patient shows a disinclination to improve under the rest, fresh air and good food routine. In suitable cases the results from pneumothorax are most gratifying.

TO THE EDITOR:

My physician says I have one good lung and the other almost gone. Is it possible that one lung could be so far gone and the other not infected? If possible is there any chance for recovery after one lung is gone? H. L. T.

It depends upon what is meant by "almost gone." The entire lung on one side may be involved with tuberculosis while the other side remains relatively if not absolutely free. However, in the vast majority of cases tuberculosis of moderate extent is usually bilateral. Recovery naturally depends upon the nature, extent and intensity of the involvement, as well as upon the individual temperament and resistance, and the facilities for taking proper treatment over sufficient length of time. People with an entire lung involved may become quite thoroughly arrested if these factors are favorable.

1. Will a fellow's lung be just as efficient as if he never had tuberculosis, if he is altogether healed? I had pleurisy twice and was affected in the right lung at about the third rib.

2. Have been taking tuberculin for about six months. Do you think it is beneficial? Some say it is and some contradict it.

3. Don't you think I'll have just as much chance for recovery in Missouri as in Colorado? I think the western air is a little drier and better, but I judge the food on the farm will put it on an equal footing.

4. Is there any drug that would help heal the lung? Some say a good "fat dog" is the best meat a fellow could eat and it would heal the lung in no time. What about it?

5. Could you give me the address of a good correspondence school? J. B. F.

P. S.-I certainly love the serial "Well, Sid!" I think it encourages many a poor lunger and also the "Question Box."

1. No. The lung can never be regarded as the same after once becoming involved with tuberculosis, though under favorable circumstances and moderate living its shortcomings may be unnoticed.

2. Refer you to an article on tuberculin which appeared in this JOURNAL for September, 1914. Copies of this number are not available, but you may get access to it in a library.

3. In most instances climate is not the most important factor in treatment. Competent medical care and good advice, with the proper facilities for carrying out the treatment usually are more important than geographical location, though quiet surroundings and clean air free from dust and away from much dampness are of course desirable, and in some cases necessary.

4. There is no drug known which has any definite beneficial effect upon tuberculosis, nor is one meat preferable to another except in point of relative food value.

5. This is somewhat out of our line.

TO THE EDITOR:

In the last edition of your magazine I read an article "The Tuberculosis Nurse," in which I am interested. I am taking the cure at home under the direction of a T. B. doctor and should like when I become an arrested case, to take up nursing. Have consulted my physician and he too thinks it a good idea. Can you tell me where I would obtain the best training or where to obtain information regarding it? W. A. R.

Suggest you write to the superintendent of nurses at some of the sanatoria where there are training schools, among which are:

Trudeau Sanatorium, Trudeau, N. Y. Eudowood Sanatorium, Towson, Md. Catawba Sanatorium, Catawba, Va. Loomis Sanatorium, Loomis, N. Y.

TO THE EDITOR:

I have been a patient in a Sanatorium for one year and nine months. My height is 5 feet, 7 inches. When I first entered a San. I weighed 128 pounds, but at the present I weigh 165 pounds; have run a normal pulse and temperature practically all the time except the first month. I still raise from one to two ounces of sputum; also have the germs. 1. Could I ever become an arrested?

2. How long after sputum is negative, before you are an arrested case?

3. After leaving the San. as an arrested case, how long before you are considered a cured case?

4. Can a T. B. patient ever get married after they become a cured case?

5. Which is considered the most harmful, a rapid pulse or a high temperature? D. J. E.

1. Yes.

2. The sputum may still contain tubercle bacili and the condition be regarded as arrested.

3. A case is not judged apparently cured until two years after leaving the sanatorium, during which time the patient has been working and leading a practically normal life without symptoms or tubercle bacilli in the sputum, the signs within the chest being those of a healed lesion.

4. So many conditions may modify this proposition that it is impossible for us to answer it in the individual case. Your physician can best tell.

5. Both are undesirable, but not harmful in themselves, and are only symptoms of some abnormal condition. The significance of fever and rapid pulse depends upon the gravity of the condition which causes them.

TO THE EDITOR:

1. Age 42; 5 feet, 7 inches; 150 pounds with clothing; T. B. case 12 years ago; typewriter. Improved nicely, still raise about one-half of sputum box every day. I have a pretty good appetite but do not eat more because of my offensive breath from my stomach. When retiring at night I do not fall asleep for some time after, and I begin to think of myself and if I doze off and awake soon after, I will get a scare that almost takes my breath away for the next ten minutes, shortness of breath. Would the nerve cause this? I am very nervous at times.

2. What is asthma and bronchitis and also stomach trouble and how is it acquired, and if a cure for all, and if either one is contagious?

3. Would smoking be harmful if one did not inhale the smoke, whether it be a cigar or cigarette or smoking tobacco and which is