after a hæmoptysis. Another author states: "Johnson's observations were made on patients in the advanced stage of the disease, with cavities and at times hæmoptysis. The observations were made before meals, and no attacks of hæmoptysis occurred between the first and second examinations. Of the 33 cases, 25 were found to have leucocytosis-i. e., the white cells ranged above 7,500 per cubic millimeter. The 25 having leucocytosis also had cavities. Nine of the 33 showed a red-cell count of 5,000,000 or above, which, according to Cabot, was a normal basis. The remaining 24 showed a red-cell count in many instances far below 5,000,000, and in no case was the hæmoglobin up to normal. In only one case did it reach 75 per cent."

In the American Journal of Medical Science, June, 1898, the signifi cance of eosinophile cells in tuberculous sputum, is set forth in the following interesting note:

Teichmüller (Centralblatt für inn. Med., 1898, No. 13) calls attention to this as the result of the examination of 153 patients. In all of these eosinophile cells were easy to find in the sputum months before bacilli could be found, according to the author. The occurrence of these cells points to an attempt at defense on the part of the organism, most evident in fairly strong individuals, and not so certain in anæmics and cachectics. In recovery, the gradual increase of eosinophile cells is always notable, and a diminution in their number at any time indicates relapse or, if the fall is rapid, quick consumption.

If there is any doubt in my mind about the diagnosis of a case I have no hesitation in giving test doses of tuberculin. I believe it to be a positive diagnostic agent, practically free from danger, and a perfectly justifiable procedure.

Only the early cases have been mentioned so far-the class of patients rarely seen by us-for these men usually do not come for treatment until there is a cough and expectoration and when the disease is quite well advanced. But even when there is profuse expectoration the case is often not clearly made out at the time, and is put down as "acute" or "chronic" bronchitis.

THE BACILLUS SHOULD BE CAREFULLY SEARCHED FOR.

I think that these mistakes sometimes made in the beginning of the treatment (but of course eventually discovered) are due to the fact that the bacillus is not properly looked for or correctly stained, and therefore not found under the microscope. If we will assume the position that ninety-nine chronic coughs out of every hundred are due to tuberculosis, then we will search for the bacillus until it is found. Even a chronic bronchitis should be cured in a comparatively short time, and if one of these cases persists we should by all means keep such a patient away from our hospitals, where he will not be exposed to tubercular infection. All patients with cough and expectoration are surely better outside our hospitals than in them.

STAINING THE BACILLUS.

I think the text-books pass too lightly over the methods and difficulties in finding this bacillus. Even in the laboratories only the typical bacillus is shown to students. The bacillus of the early stage is quite a different looking bacillus to that of the chronic, partially arrested case. In the former stage the bacilli are larger and longer, of various shapes and sizes, including the branching forms; while in the latter stage they are uniformly small, of a given shape, and fade out and stain uniformly. One can differentiate the chronic from the acute case by means of the microscope alone. As most of the microscopical work falls to the lot of the younger officers, I feel that it will not be out of place to refer specifically to some of the points and difficulties that I have found in dealing with the bacillus and sputum, for it is the little things that bother us most. Taking, therefore, a given specimen of sputum, it is not always an easy matter to demonstrate the presence of the bacillus positively. Especially is this true of the early infection, where we find the bacilli in varied shapes and sizes, some not stained, others taking the counter stain only, or, as is often the case, taking the stain poorly, if at all. It requires considerable practice and experience to always positively demonstrate the organism in the early cases. Any one should be able to show the bacillus in a typical case in the chronic stage.

SPREADING THE SPUTUM.

In dealing with the sputum it is well to discard the use of the cover glass entirely, for much annoyance will be saved by staining the sputum on the slide. To work rapidly and without irritation, I would advise one to discard the oese and cover glass and take instead a stiff probe and the slide. Out of a mass of thick tenacious sputum it is very difficult to extricate the desired portion of sputum with the oese because of the flexibility of the platinum wire, but it is not so difficult with a stiff probe. After placing the sputum on the under slide, take another slide and place it down upon the sputum, holding it in the opposite hand. Press the two slides gently together and draw the top slide slowly over the surface of the under one. More or less of the sputum

will adhere to each slide, and the maneuver can be gone through a number of times, making a beautiful, thin, uniform spread, which is easily dried in the flame, and which will not wash out. At the same time we make two specimens for staining. This is a very desirable thing to do, for I have often failed to find a single bacillus on one of the slides made in this way, while the other was loaded with beautifully stained bacilli, though both specimens were treated alike.

Sputum that is very frothy can be fixed by this method easily. I have found colonies of bacilli in clear, frothy fluid, in which it was impossible to detect, with the unaided eye, any sign of thickened sputum or pus.

STAINING METHODS.

I have been working more or less with the bacillus for a number of years, with constantly increasing interest. During this time I have tried every method of staining I have seen in medical publications. I used Friedlander's method a long time, and to the exclusion of other methods, as I got better results with it; but I now think the most satisfactory stain is Gabbets', modified to suit different cases. It is equally effective in the early and the chronic stages, though the bacillus in the early stage is never satisfactorily stained with any method, as the contrast color of the large bacilli will be modified by the counter stain no matter how careful one may be. It is well to use less acid in the Gabbets' in examining the sputum in an early case. I use as contrast stains both the Gibbes and the Friedlander methods. Both of these are good and rapid in action, but they require more care and practice than Gabbets'. Do not depend on Gibbes' method in the early stage or doubtful case; do not expect to find typical red-stained bacilli in the early stage, as they are partly decolorized and look purplish.

MANAGEMENT OF THE CONSUMPTIVE.

This leads us to the consideration of problems for the improvement of our methods of treatment and management of the consumptive, if we must have him in our hospitals, together with the benefit to the patient to be derived along the lines of proposed climatic isolation.

Now, if it be necessary to have the consumptive in our hospitals, let us do the very best possible by him, and at least prevent him from infecting others. For over twenty years we have figures which show that the percentage of deaths is as great now as at any time in the seventies or early eighties. The mortality for the years from 1873 to 1877 (the only data at hand) was 21.5 per cent; from 1880 to 1890 it was 21.9 per cent, and from 1890 to 1895, 23 per cent.

Conclusions based upon statistics are not always weighty, but these figures, to me at least, are humiliating. The mortality by districts in the early eighties is no greater than in the nineties. What have we of the creosote habit to show as improvement over the results of older officers? Probably nothing more than the attenuation of our cases-a prolonging of life with the possible greater dissemination of the disease. That the virulence of the tubercle bacillus can be attenuated is undoubtedly true; that some persons are more subject to infection, while others have greater resistance, is also true. Let us of the junior officers be not puffed up with pride over the suppositional outcome of our cases, over the percentage of our cures, over our advanced knowledge in the diagnosis, treatment, and management of these cases, until we can show better figures to prove that it is really so and that we are curing more cases.

Notwithstanding the personal efforts of the Surgeon-General, the sanitary spit cup purveyed by the Bureau has not been generally used

in our hospitals. Some hospitals have not used them at all, and some only for consumptives. If a patient must expectorate, give him a cup or the sanitary sputum bottle when on the grounds. When these men must have mosquito bars around their beds, some special provision should be made for frequent changing. Can one conceive a better disseminator of dried sputum than the mosquito bar? The pillows and mattresses should be made sterile by steam quite often. These articles get foul with sputum, in spite of all care, and the making up of such a bed certainly sets free enough dried sputum to infect a whole ward. It is next to impossible to have bedding free from danger unless we have the apparatus to properly sterilize it. Some patients are allowed to wear the mustache and beard, which soon become foul with dried sputum, infecting others and reinfecting themselves. A little persuasion and explanation will be successful in getting men with beards to remove them. Patients should not be allowed to use handkerchiefs, but instead pieces of sterile or clean gauze. These, after using, should be placed in a receptacle for the purpose, and must be destroyed daily. No consumptive should be allowed to chew tobacco, for such a patient will surely expectorate at random. The consumptive patient should be compelled to carry his spit cup or sputum bottle with him whenever he goes to sit out of doors. Many of our hospitals and grounds in the service are undoubtedly infected by dried sputum, and the possibility of infection from these foci is constant and probable. That our hospitals are responsible for the infection of some of our officers and men, to say nothing of patients treated for other diseases, can not well be denied

The tabulation and statistics of the consumptive should be properly made. There are many experiments that might be made in the study of the disease. For example, the advanced workers in consumption have almost positively worked out the nonheredity of the disease. We could study the blood changes in different stages of the disease and under the action of different serum treatments. Each hospital could make a special annual report covering many points of interest in diagnosis, administration, and treatment. It is a disease that must be studied from many standpoints, in different climates, and under varied treatments. If the study of the disease were taken up seriously by a number of officers and a definite plan of action adopted, the Bureau could afford to be most liberal for special scientific apparatus for investigation, and would allow great latitude in the therapy with the multitudinous treatments now known. What body of men can possibly have such great opportunities in working out the many problems of this disease as the officers of the Service?

SANITARIUMS.

Now, then, we must consider the subject from a still more practical point of view, and that is the study, management, and isolation of these cases in sanitariums in proper climates.

Three officers of the Service have written articles advocating the removal of tuberculous patients to sanitariums in the South. Other officers have from time to time made comments and suggestions in regard to these cases. With all the discussion that has gone on, I believe no one has seriously considered the great difficulties in the way of establishing colonies, farms, or sanitariums for tuberculous patients. The first and foremost difficulty will be in obtaining favorable Congressional action. I fear that this will be the hardest part to overcome, for such legislation is rarely obtained unless it can be shown that it is in the line of economy. As an immediate economy in dollars, it will be hard to show that money can be saved. The eventual saving of life will hardly be a factor in such consideration.

We shall always have trouble with the sailor and his friends and relatives in sending him far away for treatment. He would probably procrastinate until he had become an incurable case before submitting to removal. All who have had any experience in treating the negro race know that the negro will refuse to go to any place away from his relatives and friends. He prefers to die at home, out of the hospital, where he feels certain no post-mortem will be made upon his remains. Comparatively few consumptive negroes die in our hospitals.

The only other serious difficulty will be the expense of transportation, as pointed out by the Surgeon-General in his annual report of 1895, page 143.

To get Congress to pass the necessary legislation for the establishment of sanitariums for this purpose it will be necessary to show that the difficulties, after all, deserve no consideration in comparison with the eventual good to the public at large and to these suffering patients. It is not to be doubted that if necessary the Government would send a whole fleet to foreign lands to save the life of one citizen when matters of state were concerned. And yet I doubt if Congress can be brought to see that hundreds of lives can be saved merely by placing these men in favorable climates, possibly saving in actual annual outlay, or, at any rate, costing only a comparatively small amount more for their transportation and care in these sanitariums.

Laying aside, then, all hope that Congress may look at the matter merely from humanitarian motives, let us see how good a showing we can make with figures in saving money in the treatment and care of these cases. It is from this standpoint alone that we need expect help.

During 1895 there were 531 cases of "tubercle" treated in hospitals. The actual number of persons would probably be something more than half this number, and the average period of treatment would surely be 150 days for each person. For the same period, out of the above-mentioned 531 cases treated, there were 283 discharged improved, a percentage of 53.3; or, to put it in another and more probably correct way, 53.3 per cent of patients previously discharged had returned for treatment. The average cost of the hospital ration is close to $7.50 a month.