doing so it is the universal observation of those who work with me that our results have improved. In early cases of tuberculosis, I have no hesitancy in saying that practically all can get well. We have just finished a term of eleven years, during which time we have not failed to bring about an arrestment of the process in a single early stage case that remained under treatment for a minimum period of six months; and we believe that our application of rest and exercise according to the stage of the disease and the patient's powers of reaction has been a large factor in producing such results.

In advanced cases the patient should be kept at rest until in the physician's opinion he can meet the extra demands that are made upon his energy without showing symptoms of toxemia, such as malaise, tiring and shortness of breath. When such a time has arrived the patient's general appearance changes as a rule. I do not refer to fatness, for the patient will usually put on weight during the early period of rest treatment; but I refer to a general appearance of good health. The patient loses his sick appearance; no longer appears toxic; does not show circulatory embarrassment; his skin becomes clearer; his expression becomes one of ease and comfort; he becomes less nervous; does not manifest the urge which is brought on by slight toxemia, and consequently assumes a more placid state. This condition will usually come about before the patient should be put on exercise.

THE TECHNIQUE OF APPLYING REST AND EXERCISE

Technique is just as important in using such simple measures as rest and

exercise in the treatment of tuberculosis as it is in performing surgical operations; in fact, the success depends upon the technique employed. It is not sufficient in dealing with measures of this type to tell the patient to rest or to exercise. He must be told how to rest; how much to rest; when to exercise and how much exercise to take.

The bed-rest as employed in early tuberculosis consists in lying flat in bed for the greater part of the day. Patients whose disease is not very severe may be permitted to sit up during their meals and to take care of their toilet. They may also lie supported with pillows for a short portion of the time each day. They may read or write, or sew or knit, or do little things requiring a small amount of strength for a short period each day; but all such work should be carried out in such a way as to avoid tiring. I usually tell my patients to do these various things for ten or fifteen minutes, and then rest for ten or fifteen minutes, during a period of an hour or two, but never permit themselves to become tired. If the disease is more active and the tax upon the patient is greater, then he should not be permitted to get up even for his meals or for his toilet.

I have never employed as a general routine the extreme rest where a patient is not permitted to move his limbs or his body in bed. I have always felt that a little liberty made the routine easier and produced a psychical effect of great importance. As activity disappears and quiescence approaches, then the liberties allowed the patient can be gradually increased.

When the time for exercise has come, it should be begun very cautiously.

I

I always have my patients measure their sitting up by time, but when it comes to walking I employ distance instead of time as the measure. have never felt that the method of telling a patient to exercise so many minutes was as good as telling him to walk so far. One patient will walk a mile or more in fifteen minutes, while another one will walk only a few hundred feet.

The method which I employ is at first to let the patient sit up ten minutes a day and allow him to increase the time ten minutes each day until he sits up with perfect comfort for three hours. Patients who have been in bed a long time may not be able to increase ten minutes every day without tiring, so when they arrive at a half hour, an hour, and two hours, they hold this time for a number of days until they do it with ease. During this period the patient is reëstablishing the correlation between his nervous

and muscular systems, which has been disturbed more or less as may be judged by the degree of loss of efficiency. A definite program should be prescribed so that he does not push on too fast. After sitting up three hours with comfort, exercise is begun. At first the patient is allowed to increase his walking 100 feet each day. After he has attained one or two miles, this can be increased to 200 feet or even more, but the important point is to always keep the patient within the amount of exercise that he can do without fatigue. If the patient comes back from his walk tired and does not rest within an hour, this should be taken as an indication that he is overdoing. overdoing. A healthy tire is all right, but if it requires much more than a half hour's rest to restore the normal, it is a sign that the exercise is too much. Loss of weight should also be considered as a probable indication of overdoing.

I

COME to you this afternoon

with the problem of focal infection, a subject which has been discussed a great deal during the last ten or fifteen years by many members of the profession, including Billings, Rosenow, Anderson, and hosts of others. Many papers have been written on the subject but altogether our ideas are rather hazy in regard to this important question.

Focal infection is used by many as a sort of diagnostic blanket to cover up a lot of loose thinking and diagnostic sins. A patient comes in and unless there is some outstanding sign or symptom upon which to base a diagnosis, the attending physicians immediately turn to focal infection. This results in the ruthless destruction of tonsils and the extraction of teeth that do not need to come out, the boring out of sinuses, the removal of gall-bladders and so forth. I wish it understood that I believe in focal infection, I think it has a big field in medicine, but I believe we have been over-zealous; I have been, but I have learned some caution. Some months ago I met a doctor and he talked peculiarly. I asked him what was the matter and he said, "I have some new teeth. I thought I had some trouble

'Read before the American Congress on Internal Medicine, St. Louis, Mo., February 18 to 23, 1924.

there and the teeth were taken out but they found the trouble in my prostate." These mistakes often occur and I warn you that we should be conservative in our interpretation of what we consider focal infection, All the diseases in the category have been attributed to focal infection, rheumatism, heart and lung diseases, appendicitis and what not, no distinction being made, or no effort being made to distinguish what results from a general infection and its consequent train of symptoms and what might result from what we speak of as focal infection.

What is the meaning of focal infection? It means an infection in some cavity of the body, such as a sinus, the teeth, the tonsils, the gall-bladder, the appendix, the tubes in women, and the prostate. What are the results or effects of this so-called chronic focal infection in the cavity as we now understand it? First and foremost is the secondary metastatic effect that we get, the absorption of toxins or something of that sort. It is a difficult matter in some of these cases to attribute a given disease to a focal infection. In addition to this we assume a certain resistance, or a reduced resistance. I know of no way in which a man can measure a decreased resistance. We speak of an allergic condition. No man can measure that

and be sure that it is so. Disturbance in the function of an organ is not a striking feature in this as we understand the term.

We have another type of focal infection which we call acute, such as acute sinusitis, acute tonsillitis, with a rather definite symptomatology, fever, chills, and frequently a marked disturbance in the function of the organ, and so on down the list. This set of symptoms is definite enough for the average physician to arrive at a diagnosis on the basis of the definite symptomatology, but when we come to a focal infection we have no definite symptomatology. We may have a conjectural idea but nothing definite. There is no definite symptomatology on which to make a diagnosis of chronic focal infection in the way in which we now understand the thing. The diagnosis is based on its effects. We only have conjectural ideas in regard to the relation, and I maintain that the symptomatology of chronic focal infection is usually based on the secondary effect.

The next point is some work I have been doing in my office on the prostate. I used to palpate the prostate, but not often did I massage it and examine the fluid. I have done so in the last year or two and I have tabulated 200 cases of men whose prostates I have examined, obtained the secretion and studied it in the following manner.

First, with all due care for outside infection, I examine a drop under the microscope. A smear is made of this same drop and sent to a laboratory, by number; the laboratory worker knows nothing of the patient or of the case. He reports on the presence or absence of bacteria and then we check them up.

The startling fact that confronts me is this: Out of 200 men whose cases I report this afternoon in 85 of them I have found an infected prostate. When you consider the incidence of other focal infections, the tonsils, the teeth and sinuses and what not, this is by far a larger element than that in other fields. Perhaps I am wrongI have tried to be conservative.

There are certain difficulties in this observation. The first is that no one knows what a normal prostatic secretion is. I do not. I have asked my laboratory man what proportion of pus cells he would allow to a field and he has said one or two or none. All laboratory men disagree, as do the urologists. Personally, I feel that it may run five to the field with a perfectly normal prostate but when I get ten to the field I get suspicious. I have arrived at this beyond any question. In some we find large numbers of bacteria, and a few pus cells, while in others the reverse is true. If I get a large number of bacteria and ten pus cells to the field I feel that it is infected. I am going to revise this, I am working on those lines.

It is a striking thing if it be true that such a large percentage as 85 out of 200 men who come in for a general physical examination (I am not an urologist) should show infection in the prostate. I want you to think about it.

A tabulation of these cases is somewhat as follows: All the patients were seen for a general examination and I simply happened on the diagnosis. Of these 85 cases 18 were the so-called sacroiliac or lumbago cases; 12 were spondylitis of the sacrolumbar and lower dorsal region; 15 were some

form of arthritis. One case resembled an acute arthritis and the others were chronic arthritis, with one or two of the type of arthritis deformans; 3 were gastric ulcer; 3 were duodenal ulcer; 15 were neurasthenics-whatever that term means; 10 were heart disturbances that we find so frequently. A number were tuberculous and one had an iritis. This man had been to an oculist and he had hunted for some focal infection. He had his tonsils taken out, some teeth had been extracted, his sinuses had been examined and operated upon; but no one had examined his prostate. I examined it and it was saccular and full of pus. Did it have anything to do with his iritis? If it is what we assume it to be, if a diseased tooth will do it, if tonsils or sinuses will do it, the prostate will do it. It is a closed cavity, and absorption may take place from it.

Out of these 85 cases 58 of the patients had had gonorrhea from fifty to twenty years before. Of the others I do not know they denied it. I question, gentlemen, whether a man who has ever had a case of really bad gonorrhea ever escapes trouble with his prostate.

Of these 85 patients some 6 of them, ranging from thirty-eight to forty-three years of age, came to me complaining of loss of sexual vigor.

All had badly involved prostates, both from infection and hypertrophy. Many of them had received endocrine treatment and so on with no results. I cannot say so much for my results as yet-perhaps two had fair results.

This brings up the question of hypertrophied prostates as due to focal infection. The Mayos say that 10 per cent are due to prostatic infection. I think it much higher. I believe it is much higher if it is studied carefully. Is there any relation between these diseases I enumerated and the prostate? I do not know. I only assume it, as I assume it in the case of the teeth or the tonsils. You have all had good results where the teeth and tonsils have been taken out and so I have had with a few prostates where they were properly treated.

The results of my observations force me to say:

1. That the prostate is probably one of the most frequent sites of focal infection in man.

2. That a great many physicians and internists neglect a study of this field.

There is an old saying that disease of the prostate, enlargement of the prostate, is an old man's disease. I am not so sure, gentlemen, but that it is the young man's disease-not the old man's disease.