utes. So, also, a cup of hot coffee or tea will elevate the temperature of the mouth for a time, The mere chilling of the cheeks from being out-of-doors on a cold day will reduce the mouth temperature for a considerable time. The thermometer should be left in the closed mouth not less than seven minutes. We should remember that brisk exercise will raise the temperature of a healthy person.

Loss of strength is perhaps more common than loss of weight in the early stages, but they may go together.

Inspiration and percussion give us but little aid in the very early stages. Ausculation may find little amiss. Generally there is some slight change in the breath sounds. We may find rather feeble inspiration with slightly prolonged and perhaps roughened expiration. The fine rales at the end of inspiration, often only brought out after a forcible cough, are highly characteristic if found at the apex.

Many errors are made by not insisting upon having the chest bared in all cases. This will seldom be objected to when the matter is fully understood.

Sputum examination is of course important and the finding of the bacilli gives positive evidence of tuberculosis. Too much weight has been given to negative results. The bacilli are not found in some cases of undoubted pulmonary tuberculosis, and not infrequently are found only after repeated examination.

The State Board of Health is now examining many samples of sputum. It should be impressed upon physicians that a negative examination by no means excludes pulmonary tuberculosis.

There are two reports that should be made when a physician finds a case of tuberculosis; one to the patient and family, and the other to the health authorities. The first is by far the most important. No good reason can be given why the diag. nosis should be withheld from the patient and his friends, unless the patient is found in a hopeless, dying condition.

The report to the health authorities will often aid in the prevention or spread of the disease. In very few places where such reports are required are they actually being made. The reason probably is that boards of health have no adequate

machinery for following up such reports and using efficient measures in the prevention of this disease.

Where a case of tuberculosis is found in a family the health of the other members of the family ought to be inquired into. Not infrequently an incipient, unsuspected case will be found.

There are probably in the neighborhood of half a million people in the United States with pulmonary tuberculosis, and all but a few thousand of these must be treated in their homes. This shows how important it is that physicians should have a proper understanding of the modern treatment of this disease. It is believed that the application in the home of the methods used in the best sanatoria, as nearly as it is possible to follow these, will give the best results in the great majority of cases.

It is not an easy matter to determine in any particular case of pulmonary tuberculosis what is the best thing for the patient to do. There are a great many things that should be carefully inquired into in determining this very important point. We may send the patient to a sanatorium, or send him to another climate, or treat him at home; and it is about as difficult to determine what is best as it is to recognize the disease in its early stages.

Time does not permit considering the other part of the subject, "the duty of the physician as a citizen and teacher." This must be left for some other time.

THE OPERATING ROOM AND THE PATIENT. By Russell S. Fowler, M. D., Surgeon to the German Hospital, Brooklyn, N. Y. Fully illustrated. W. B. Saunders Company, Philadelphia and London, 1906.

While dedicated to internes and nurses whom the author has helped to train and to those who are yet under training, this volume has a broad field beyond its local dedication.

The first chapter is on The Operating Room and Its Personnel. The second and third chapters, The Instrument and Supply Room; Chapter four, Anesthesia; Chapter five, The Patient; Chapter six, General Considerations in the AfterTreatment.

Nurses and internes will find this a very valuable guide to their work.

REMARKS UPON THE INTERNATIONAL

GRESS OF TUBERCULOSIS, PARIS, 1905.*

BY HENRY BARTON JACOBS, M. D., BALTIMORE, MD.

CON

The International Congress of Tuberculosis held in Paris, October, 1905, was attended by three or four thousand people interested in the work of the Congress. To realize why such a large number of people should have been brought together, consider for a moment the importance of the work; tuberculosis is by far the greatest scourge of the human race. Wars, smallpox, yellow fever, plague, railway disaster, these cause momentary outbursts of great excitement and fear, even heavy mortality, but this mortality is small as compared to this silent, ever-present foe, tuberculosis, which so stealthily and yet so unceasingly lies in wait for its victims.

The statistics of our own city may be taken as a fairly accurate expression of the statistics of the whole civilized world; notice them week by week, always the same thing; deaths from tuberculosis leading the list, except perhaps now and then in the winter months when pneumonia may run ahead, but season in and season out it is tuberculosis which is killing the greater number of people. This fact alone would seem sufficient to incite men and women to an interest in its study, but when we consider that it has been completely demonstrated that this disease is dependent upon an agency which can be destroyed and can be avoided so that the disease need not exist, then we realize more fully the interest called forth the world over in all efforts to comprehend the nature of the disease and the best methods of suppressing it.

The three thousand or more enthusiasts in Paris were by no means disappointed in the results of this last meeting; they came from the nations encircling the globe; all brought some tribute to the cause, not the least of which was an eagerness to see and know what others were doing, thus to receive stim

*Read at a meeting of the Laennec Society, March 19, 1906, and republished from the Johns Hopkins Bulletin.

ulation for better work at home. Such inspiration is not necessarily to be gathered wholly from papers read; it comes from intermingling and conversing, with even looking upon the great leaders in the cause and so breathing in enthusiasm by the mere contemplation of the life and work of such men. It is also to be derived from exhibitions, not only of the practical results of labor, but also of the scientific attainments recorded from many sources, and again from actual visits to the institutions where work is being done, noting conditions, how far they agree, how better and how far inferior to those at home. So it is that the Congress in Paris may be said to have been interesting, instructive and stimulating by the papers presented, the exhibits of many things relative to the subject, the entertainments in which the members met together, learned to know each other and informally derived new ideas and enthusiasm; and excursions to existing institutions where methods and plans were seen and discussed.

At 3 o'clock on the afternoon of October 2, 1905, the opening session was held under the direct auspices of the President of the Republic and the officers of Government with such military and other formal surroundings as accompany full state functions. The ambassadors of various countries in official dress and delegates in full uniform all tended to give picturesqueness and dignity to the first meeting and to emphasize the importance of the movement which the Congress represented. At this session there was little but formal words. of welcome and salutations of respect for France and her President. The United States was represented by Dr. Beyer, of the Navy, who in full uniform as Surgeon and Commandant, in a few well chosen words spoken in French brought greetings from America.

The real scientific work of the Congress began the next day, papers being read simultaneously in four sections: Section 1 being devoted to the medical aspects of tubercu

losis;

Section 2 to its surgical aspects;

Section 3 to the protection and aid of children;

And Section 4 to the protection and aid of adults, including social hygiene in its broadest aspects.

To the papers and discussions of these sections I will refer briefly, especially to those representing at this time thoughts which are uppermost in the minds of those working for the prevention and relief of tuberculosis.

Each Congress marks, as it were, a stage of progress in the work. We have the period in which Bremer, Detweiler and others demonstrated the efficacy of the open air treatment of early tuberculosis in specially constructed sanatoria. Then the period following Koch's discovery of the specific cause of the disease. At another Congress Koch advocated tuberculin as a curative agent, and in the period following, this substance was the all absorbing subject of investigation and discussion.

In 1901 Koch made the assertion that the tuberculosis of cattle was to be considered of little or no importance as a factor in the production of the disease in the human race. In the period since, this question largely has occupied the minds of investigators.

In all these periods progress has been making in many correlative branches, and at the various Congresses there has been a form of "rounding up," and a "taking of stock," so to say, of our knowledge as to the whole range of subjects embraced in the study of the disease, its physical and bacteriological nature, its sources and means of transmission, prevention and cure.

That this last Congress will take its place with those preceding it in marking a similar distinct epoch in the work I have no doubt. There are old questions which seem to have been settled and laid aside and others have been brought forward which are new and will need the test of time and much investigation to ascertain their truthfulness and value.

It seems safe to say that one of the most far reaching conclusions arrived at in Paris is that it must be assumed that tuberculosis in cattle may be a source of tuberculosis in man.

We, therefore, start in this new period following this last International Congress with the conviction that the fullest attention must be paid to our milk supply, especially if fed to young children, lest it become a source of infection. Renewed activity should be exercised by our State veterinarians