formation. "Though the pus-producing organisms as a result of their rapid growth may produce pneumonic consolidations in which the tubercle bacillus does not participate at first, the resulting caseation is caused by the presence of the tubercle bacillus." Cornet. In a case examined by A. Fraenke18 of disseminated tuberculosis with high fever as a result of haemoptysis, accurate examination was made at the post mortem for mixed infection, and no diagnostic point was found for it. Schröder,9 Meissen 10 and Kogel1 have shown that chronic mixed infection is comparatively rare, and that no connection exists between the presence of pathogenic microorganisms in the sputum and a certain type of fever. If tubercle formation in pleurisy, peritonitis, meningitis with fever, is often associated with high fever, why should this be otherwise in the lung? Moreover, the fibrous form and the closed incipient cases do not usually course free from fever,12 F. Moeller,13 says that the tubercle bacillus may induce fever without mixed infection, and the caseous tissue degeneration, which is the basis for cavity formation, is, according to him, solely conditioned by the tubercle bacillus and its toxins.

We thus see how very important it is to get an accurate knowledge of the course

of temperature. This is of the greatest value not only in the diagnosis but in the observation of the case.

REFERENCES

1. Brecke-Brauner, Dr. A. G. and Schröder, Handbuch der Tuberkulose, S. 638 Bd I.

2. Spezielle Diagnostik der inneren Krankheiten. 8 Aufl. Bd., I S. 181.

3. Vers. d. Tub. Ärzte, 1908, Bericht S. 10.

4. Über den Einfluss der Korperbewegung auf die Temperatur Gesunder and Kranker. Münch. Med. Wochenschr. 1899 S. 469.

5. Richer u. Dahlmann: Beiträge zur Physiologie des Weibes. Volkmann's Vortrage, 1912 S. 645.

6. Über die Sekundarinfektion bei Tuberkulose. Berl. Klin. Wochenschr. 1902 S. 489. u. 523.

7. Kolle und Wassermann: Handbuch der pathogenetischen Mikro-Organismen, II. Aufl. 1912, Bd. S. 487.

8. Berl. Klin. Wochenschr., 1902, S. 492.

9. Über die Misinfektion bei der chronischen Lungen Tuberkulose.

10. Beitr. z. K. d. Lungentuberkulose. 1904, S. 244. 11. Zur Frage der chronischen Misinfektion bei Lungentuberkulose, Beitr. z. Klin. d. Tub. Bd. xxiii, S. 75.

12. Brecke-Brauer & Schröder, Handb. Bd, I S., 644. 13. In v. Merling Lehrbuch der inneren Medizin, 5 Aufl. 1908, S. 267.

trees,

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'N order to realize what a change has come over all our ideas in regard to the proper treatment of tubercular cervical adenitis, try to imagine with what scorn that man would be treated, who twenty years ago would have the temerity to treat tubercular abscesses without the use of the knife. that time, the wisdom of removing diseased glands was no more questioned than the wisdom of removing a diseased appendix. There might be some difference of opinion as to the proper time to operate; whether it was good judgment to attempt a radical operation with glands already broken down; or whether to merely drain, and do the more complete operation when the discharge had ceased. Other numerous, minor points of controversy there were, to be sure, among the surgeons of that time, but none as to the advisability of some kind of operation.

Although, to-day, we still have our advocates of radical operation, they are in the minority, and are rapidly diminishing, nor do they urge surgical measures with the same insistence as of old. The feeling that the lesion in bone or gland is merely a local manifestation of a constitutional disease, is awakening in the medical consciousness, and with it a realization of the utter futility of attempting a cure by the removal of the most obvious symptoms.

For a great many years the medical world had wondered at the mysterious cures of bone and glandular tuberculosis, that every day were occurring at the French seaside sanatoria, more particularly at Berck. Was it something in the air, or in the water, or perhaps a combination of both? Was it the result of injections into the disease areas, so universally practised by the French surgeons, that caused the swollen glands to return to normal, the running sores to dry and heal, the pain of bone disease to stop, and the motion to return in diseased joints? Or was it because of the more efficient fixation, as practised by Calot, with his nicely moulded plasters so snugly fitting the part involved? What was the important factor and could the same results be attained elsewhere? Perhaps, as some suggested, it was the sun's ravs, whose healing power was intensified by reflection from the ripples on the water and from the sand on the beach.

Rollier then showed that, many miles from the ocean, with snow-clad mountains on all sides, using braces, instead of nicely moulded plasters, and disregarding the injections of the French surgeons, equally good results

* Read at the Medical Session of the New England Tuberculosis Conference at Augusta, Maine, on Thursday, September 28th, 1922.

could be attained. This fact confirmed the belief that sunlight was the most important element in the cure. Rollier made a further important contribution to the study of heliotherapy, when he observed that his patients failed to improve, if the sun treatment was given on glass inclosed porches instead of in the open. Therefore, he attributed the therapeutic benefit to the rays on the ultraviolet end of the spectrum, inasmuch as those are the rays which fail to penetrate ordinary window glass.

Another factor in favor of this belief is the popularity and success of the snow-clad mountains and the seashore in the treatment of surgical tuberculosis. Conditions prevailing in both places favor a comparatively greater amount of the ultraviolet of chemical rays. The direct rays of the sun are no different in those localities than in others, except possibly more intense, because of the greater clearness of the atmosphere. essential difference, however, is in the character of the reflected rays. The longer heat rays are quickly absorbed by the water at the shore and by the melting snow on the mountains; while only the rays lower down in the spectrum are reflected.

The

Along the eastern shore of Long Island Sound is a little bay, fringed by a delightful stretch of sandy beach, and having to the southeast an unobstructed view of the great Atlantic. Here Connecticut has made a profession of faith in heliotherapy. Here, even when the ground is covered with snow and the ponds with ice, naked children, who are winning their uphill fight for health, may be seen romping on the beach or swimming in the ocean. Even the school sessions are held in the open, with an overhanging cliff shutting off the cold north winds. Our children not only wear no clothing, but upon admission, their clothing is taken home, with the exception of shoes, ear caps and sweat

ers.

During the past winter, the sweaters were not even taken out of their closets.

In spite of their outdoor life, and in spite of the fact that they wear no clothing, since the institution was opened in December of 1919, there has not been a single case of pneumonia, a single severe case of spasmodic croup, nor even a severe case of bronchitis. We have not even seen among our children an instance of middle ear disease that was not present on admission. According to our experience, exposure of the entire body to the weather, during both summer and winter, not only does not cause colds, but actually is a most effective means of prevention. It is, I believe, now generally acknowledged that those ailments are the

result of faulty elimination of heat, a condition best brought about by covering the body with a heavy layer of clothing.

In a very short time our little patients learn to enjoy the outdoor life and become as brown as Indians. So intense is the tan that a woman visiting in our vicinity for the first time, and seeing the children playing on the beach, asked if there were any white children in the institution! That same woman, on going home to Massachusetts, told how she saw naked children running on the beach in winter, and a friend of hers thought that a great number must die from exposure. She then remembered that she hadn't asked how many died from the cold and wrote us a letter for the desired information.

Heliotherapy, we have found at the Seaside, increases weight, cures tuberculosis, and in a most remarkable manner stops the suffering from pain. A comparison of the increase in weight among our children, with children of the same age attending school throughout the country, showed a remarkable difference in favor of those whose bodies were exposed to the healing rays of the sun. Weight charts show that the average gain for a normal child, between the ages of two and twelve, is from four to six pounds. Children at the Seaside average gains of eleven and a quarter pounds a

year.

Even more striking than the gain in weight is the astonishing change in the general condition of the patient. Allow me first to recall to your mind the picture of the ordinary case of bone tuberculosis, which is being cared for in the home or in a general hospital. You are all familiar with the pale, undernourished child with the anxious expression, the irritable disposition, the result of long nights of disturbed rest and constant pain. After about ten days of sun treatment, there is noticed a surprising change. The appetite has improved, the skin has taken on the glow of health, the expression is happy and contented, the disposition is no longer irritable and fretful, and the sleep is long and undisturbed.

While the recovery is being brought about, the diseased bones and joints are immobilized by means of plaster of Paris bandages or braces and the crippled children, as well as those suffering from glandular disease, are allowed to indulge in the usual activities of childhood. During the fine weather, even our bed patients are carried to the beach where they attend classes, play in the sand or crawl into the water. One of our patients, who was admitted with both lower limbs completely paralyzed from spinal tuberculosis, actually learned to swim, while the power was coming back into his limbs, even before he was strong enough to walk. Although he still wears a large Calot jacket. during the baseball season, he demonstrated his skill as pitcher. The only boy he has been unable to strike out, is a little fellow who has one limb encased in plaster of Paris, and who, when he comes to bat, is able to

support himself with one crutch and still use both arms for a full swing at the ball.

Although most of our children on entrance are suffering from an active disease and complaining of intense pain, it is most unusual for them to have any pain after they have had the sun treatment for about ten days. One boy of rather unusual intelligence who could give a fairly accurate description of his symptoms before admission, stated that for a year and a half he had been in constant pain day and night. After about ten days of exposure to the sun, his pain completely disappeared and has not since recurred.

In addition to heliotherapy during recent years various other forms of radiant energy have gained more or less popularity in the treatment of surgical tuberculosis. The xray, radium, the Alpine rays and the Quartz Claims lamp are the most commonly used. have been made for these remedies that they accomplish the same thing as heliotherapy in a much shorter time. Even if we are willing to grant that swollen glands subside on the application of those remedies, nevertheless, we must deny any such improvement in the general condition, as is found with heliotherapy. Then, too, I cannot help feeling that the greatly increased metabolism necessary to maintain the body temperature during exposure of the naked body to the cold has much to do with the improvement found.

There is another procedure which, I fear, is too often practised in the hope of relief in tubercular adenitis. I refer to the removal of tonsils and adenoids. The report from the Rochester clinic where about sixteen thousand tonsilectomies were done in one winter showed little if any improvement in glands of the neck after operation. going into the history of our own cases we have found that a large percentage of them have had the tonsils removed without any benefit, that I have been able to observe, and with a decided aggravation of symptoms in many of them.

In

Before closing, there are just a few words I should like to say about the surgical care of tubercular abscesses. For a great many years it has been observed that tuberculosis of the dorsal spine had a much lower mortality than disease in the lumbar region, and this in spite of its proximity to the lungs and heart and the great vessels of the chest. We have now come to believe that this is due to the relative inaccessability of abscesses in this region to the surgeons' knife. scesses in the lumbar region, on the other hand, have a shorter distance to burrow, are usually quickly opened and the discharge continues, all too often, until the death of the patient. If left alone, most of those abscesses would absorb. If they threaten to rupture, aspiration through healthy tissue and as far away from the most prominent part of the abscess, is the most satisfactory

treatment.

Ab

Ding! Ding! Dong!

Ding! Ding! Dong! Hurry up! Let us follow the rule in detail. It is the only way to get better to get rid of that terrible disease-T. B., Tuberculosis, Consumption in plain language.

First the morning shower bath-this reminds me of the Regiment, where, under the eye of the day officer, each soldier had to go through his daily ablutions. I have lost the habit, and I admit that it is with a timid hand that I turn the cold water tap.

Come on! Have courage! It is done this time. Two minutes! Brr!... It was cold. Now a good rub, in order to re-establish promptly the circulation. What a salubrious sensation!

Well, here are the stragglers-those who wait until the last minute to get out of bed, and when they enter the dressing-room I am ready to go out and breathe the fresh air before breakfast. I will certainly do honor to the bill of fare.

Ding! Ding! Dong!

Ding! Ding! Dong! It is the signal for the first meal. In the dining-room (on small tables, as in the King Edward Hotel), the breakfast is ready, and pretty waitresses, well trained, await your order. The one who is in charge of my table has a hard task, believe me, and I can read in her eyes that she is asking herself if she has not before her the ogre of the fable who scares the little ones.

Even yesterday, in Toronto, I could not eat anything. Here I am ready to devour everything. It is a good sign certainly. Let us eat, since it is a part of the program! A part of the "cure!" Listen! A bowl of porridge, two fried eggs, a slice of bacon as large as my hand, accompanied by an incalculable quantity of toast, composes my breakfast.

Bing! Bing! This time it is a gong that gives the signal of the end of the meal.

Everybody rises and each one goes towards his own shack to fill up the second part of the program-get to bed in order to digest slowly and thus give to all the digestive organs the minimum of work to do.

I am hardly at the bottom of the stairs when a gentle nurse stops me and invites me to present myself at eleven o'clock sharp in the examination room. "Very well, nurse, I will be there" and I feel happy in thinking that

in a couple of hours I will know exactly my fate.

Well, I am once more between the sheets, breathing the health-giving, invigorating air of beautiful Muskoka, while building castles in the air to banish my trouble. Ding! Ding! Dong! Ding! Ding! Dong! The bell-the gay sound again. This time it is the end of the compulsory rest. I must have slept! So much the better! The lungs heal while one sleeps.

Quietly I arise and dress briefly, for in a few minutes it will be in Father Adam's costume (or near to it) that I will have to present myself; and with a quick step I direct myself towards the examination room, where another nurse shows me the door of a small place where I have to undress.

In one turn I am ready, and at the doctor's call I step into the next room-like a boxer into the ring-naked to the waist-line.

This room is almost as bare as myself. A table on which there are two inkstands-one for red and the other for black ink, two penholders, a portable sputum cup, and pieces of cheesecloth for patients to cover their mouths when coughing. In the center, a chart with a drawing in red ink representing the lungs back and front, a chair, and a stool complete the furnishing of this room, worthy of a Trappist monk.

The doctor installs himself comfortably in the chair-and I conclude that the stool is for me, and I sit down.

Immediately two eyes are fixed on me and quickly observe all the parts of my anatomy, as does a horse dealer on the market-place before purchasing a horse. It is the taking in of everything at a glance from the head to the waist. Then the stool turns brusquely on its pivot, and this time it is my back that faces the disciple of Hippocrates-my skinny spine that suddenly appears to him.

A turning of the stool puts me again in front of the master. The questioning starts. "How long have you been sick?" "Have any of your family ever had tuberculosis?" etc., etc., etc. It is a real confession that I have to make, and I submit myself to the questioner willingly, understanding well that my duty is to enlighten the man of art and science.

All at once I feel myself muzzled-a cheesecloth covers my mouth. I must coughbreathe deeply-inhale-exhale-in a word, a perfect gymnastic of the chest, which permits the doctor (thanks to his stethoscope) to catch the inside sounds. Then tap! tap! tap! A little everywhere; it is the percussion that follows the auscultation, and when it is all over, the doctor knows all the corners of my chest and is able to establish his diagnosis. (Concluded on page 416)