cism to temper the earlier enthusiasm is always best, provided that one, while having a reasonable hesitation in accepting new ideas immediately, does not fall into an attitude of conservatism which may blind him to the merits of what is new and possibly useful.

I have been long enough in practice to witness the rise and fall of many a vaunted remedy for tuberculosis. Most of them have had their day, only to be put, rightly, into oblivion. Some of them have had a certain amount of merit, "the grain of wheat in a bushel of chaff," and may be utilized as such. While still holding to the hope that we shall yet discover some specific remedy for this disease as in others, that may lessen its ravages, I find that thus far what we call the hygienic care of the patients is the chief factor in all treatment, such as is now made use of in all properly regulated sanatoria: fresh air pushed to its limit, the judicious use of rest and exercise, proper diet, and close observation of the patient during the active stage of the disease.

Serums, inhalations, injections (both rectal and subcutaneous), even drugs, have been tried many times, only to fall into disuse, though a few of them have proved useful as adjuncts to other treatment. After a long-extended conservatism, however, as to the wisdom of its use, I have come, after careful observation of patients who had seemed to resist the ordinary methods of treatment, to the position held by Trudeau: that in selected cases the cautious use of tuberculin is not only beneficial and lessens the liability to relapse, but that it is often followed by complete arrest of the disease, as shown by subsequent histories. That it should not be used indiscriminately and should always be under close supervision, is my firm opinion. I cannot recall any case in which I could trace harm to the patient from its careful use, although in some it has been discontinued because of some possible discomfort or failure to note special improvement after several weeks of trial. The forms employed at Sharon are either those of the old tuberculin or the "bouillon filtré" of Dénys.

As to the use of artificial pneumothorax, our experience at Sharon would seem to show quite marked improvement, occasionally surprising, in certain cases of fairly well advanced disease when ordinary measures had failed to produce marked results. This has not been always the case, however, and as to whether this method of treatment will be as frequently resorted to in the future as some of its advocates prophesy we feel to be in the present stage of its development a matter of doubt.

Let me now give you something of my own personal experience in determining the presence of tubercular disease in its pulmonary form. The day of hasty diagnosis in any suspected case is past, and there can be no excuse for lack of proper and thorough examination of the patient when suspicious symptoms are present. paramount importance is the previous personal history of the patient, which often throws a flood of light upon conditions which may be shrouded in doubt. Civen a history of malaise for several

Of

weeks or months, loss of flesh, possibly slight feverishness accompanied or not by cough, watch your patient carefully and examine his chest from time to time and note if there are any departures from the normal there. Cough is, of course, a suspicious symptom, and if sputum appears it should be examined immediately, keeping the established fact in mind: that repeated negative examinations do not prove the absence of tuberculosis. If, upon percussion of the chest, you find a difference in pitch in the apices, or even slight dulness, note the fact and watch your patient, while keeping in mind the normal difference often found in healthy individuals in the apices of the lungs. If there is a difference in the character of the respiration in the two lungs or a single râle at one or the other of the apices, be still more suspicious of incipient trouble. Modern science and observation have taught us that pathological conditions other than tuberculosis can cause possibly apical changes, but the weight of evidence is in favor of regarding such conditions as danger signals which must not be disregarded. Personally, in accordance with my earliest teaching, I have found that such signs coupled with systemic symptoms of fairly long duration are in the majority of cases significant of early pulmonary tuberculosis as proved by subsequent histories.

As to haemoptysis, the weight of evidence by most observers seems to show that in the great majority of cases it is a signal of incipient tubercular disease even when physical signs are lacking; to which opinion I agree, but from long observation I regard the appearance of blood as less grave, as far as prognosis is concerned, than other symptoms more significant of active systemic disturbance. To determine the exact causes of abnormalities in the lungs with an accompanying enfeebled condition of the patient often taxes the power of the observer to the utmost, and even the most skilled clinician may in some cases be unable to make a definite diagnosis. To lay down absolute laws, moreover, in teaching others how we have reached our own conclusions in a difficult case may be next to impossible.

I shrink from making excursions into the realm of mysticism, but I believe that there often comes after long experience an intuition or instinct, by whatever term we may call that sense of conviction which we cannot put into words or possibly explain to others, but which helps us reach our conclusions: a dangerous faculty to depend upon too much, but which I think we must confess exists to a greater or less extent in every physician of long experience in his dealings with disease.

The use of the X-ray has of late years come markedly to the fore in examinations of the chest. With all the enthusiasm that is natural to a new and fascinating study, there is no one method which should be treated, in my opinion, with more conservatism than this. It is gratifying to notice this spirit among those who are experts in Roentgenology; for, while thinking it to be a valuable adjunct in the diagnosis of diseases of the chest, I believe the errors arising from its use by one of slight experience are too

great to warrant its being resorted to by tyros as a certain means of diagnosis. That further developments may show it to be of even greater value than now, is quite possible, but on no condition should it be considered the one determining factor as to the presence or absence of pulmonary tuberculosis. More than one striking example of hasty diagnosis on the X-ray alone involving serious mental distress to patients who have presented no general symptoms of pulmonary disease have been brought to my attention: a fact which makes me emphatic in my disapproval of conclusions based on this method alone.

Notwithstanding the fact that we have made a marked advance in the past few years as far as the successful treatment of tuberculosis is concerned, we have even a greater work before us in the field of Preventive Medicine. We are coming more and more to the belief that tuberculosis is a disease of childhood, which often lies latent, unsuspected until adult life and then bursts into activity because of some acute exciting cause. It behooves us, therefore, to begin early to fortify children against disease by increasing their powers of resistance in every way possible. Pure milk, the adoption more and more widely of open-air schools even for well children, are among the most important factors in guarding against the development of tuberculosis. Proper housing as a contrast to conditions often found not alone in our poorer districts, thorough ventilation, and cleanliness in all workshops and factories, are equally essential and must be insisted upon if we wish to eradicate this disease.

As a concrete instance of the value of sanatorium instruction in the line of preventive medicine let me cite one case which bears directly upon this point. Not many weeks ago a woman who graduated from the Sharon Sanatorium thirteen years ago, and has been a most loyal friend ever since to the institution, came to my office to tell me of her subsequent history of good health and active work as a public school teacher in one of the largest manufacturing cities in Massachusetts. Sixteen years previously she had come to Sharon to remain as a patient for three years, frequently a source of despair to us because of repeated appearances of tuberculosis in varied forms. By persistent effort she finally regained her health and left with the disease completely arrested, and began again her duties as teacher, anu has continued them with scarcely an interruption since. Not long ago she wrote me "I am better than ever

before, and I lose no opportunity of teaching my children what I learned while at Sharon, the value of fresh air. During the past winter I have had the windows of my school-room almost continually open, and I have not had one child away from school during the season on account of illness, as against epidemics of 'colds' among the children or most of the other public schools in this town."

This is but one of many striking examples of what can be done in the way of missionary work by those who have fought the disease themselves. Such testimony as this should give us hope and courage for the future.

In conclusion I linger over memories of him whose name this School bears, and I obey the strong impulse to tell you the thoughts which come to me whenever I recall the life and work of the beloved leader, master and friend now gone. We are passing through a terrible crisis in the history of the world. Every day brings to us some horrible tale of blood and carnage. Thousands of gallant young lives are daily being sacrificed; tales of noble unselfish heroism are told over and over again, and emphasis is laid upon the wonderful latent attributes of human nature that are brought out in the midst of the horrors of war. All honor to those who thus give their lives to an ideal! But let us not forget the great army of those who, with no thought of personal glory, go bravely forth each day through months and years of patient, strong endurance, facing death by disease with cheer in their hearts and a smile on their lips. There are thousands of moral heroes, too who brave the harsh criticism of the world while suffering mental anguish unknown to most of their fellow-men, and who cheerfully endure for the sake of their ideal. Greatly as I honor the "heroes of war," my sense of reverence for the "heroes of peace" is even greater. Of such was Edward Livingston Trudeau. Always to be associated with the memory of him come vividly to my mind the beautiful lines of a modern poet who, had he written nothing else, would yet be entitled to high rank among makers of verse.

"A picket frozen on duty,

A mother starved for her brood,
Socrates drinking the hemlock,
And Jesus on the rood;

And millions who, humble and nameless,
The straight, hard pathway plod-
Some call it Consecration

And others call it God."

A

The announcement was made in the September issue of this JOURNAL of a gift to the Tuberculosis Sanatorium of Fayette County, Kentucky, of a Children's Building by Miss Magdalen Harvey McDowell of Lexington, in memory of her father, Dr. William Adair McDowell. The gift calls to mind one of those not infrequent instances in the history of medicine of an important discovery, the value of which has for many years been lost to mankind by the scepticism and hostility of the members of the medical profession.

Dr. McDowell was the nephew of Dr. Ephraim McDowell, who, without the aid of anesthetics, did the first ovariotomy in Danville, Kentucky, in 1809. It was at the instance of his nephew that Dr. Ephraim McDowell finally prepared a report of the first three cases in which he had performed this operation, one copy of which was sent to Dr. John Bell, his old instructor in Edinburgh, and another to Dr. P. S. Physic of Philadelphia. The former fell into the wrong hands, and when finally given out was met in Europe with incredulity. The one sent to Dr. Physic was likewise pigeonholed. The young McDowell, then a student of medicine in Philadelphia, who realized the importance of the facts concerning this epoch-making operation being given to the profession and the public, then turned to Dr. Thomas C. James of the University of Pennsylvania, and it is related that "Professor James, who placed confidence in McDowell and his nephew, took the time to study and then communicate the report to his pupils amid their applause, and later published it in the Eclectic Repertory." This was some seven years after the performance of the first operation.

Dr. W. A. McDowell, later a graduate in medicine of the University of Pennsylvania, lived a number of years in his uncle's family and was a student in his office. There is a tradition in Kentucky that when Dr. Ephraim McDowell was about to perform his celebrated operation a mob had gathered about his office in the little country town, determined to wreak vengeance in case the life of the patient was sacrificed. But that Dr. McDowell, having offered up a prayer, as became a good Scotch Presbyterian, proceeded to bring to a successful issue what had never before been attempted in the history of

surgery.

His nephew, besides a considerable skill in surgery, seems to have possessed many of the qualities of Dr. Ephraim McDowell, especially those of simple and unassuming courage, originality and entire faith in conclusions arrived at by his own experience and investigation, however radically they differed from those of all the rest of the medical profession.

In the year 1843 Dr. W. A. McDowell pub

lished a book on "The Curability of Pulmonary Consumption in All Its Stages," based on the results of his own experiments and investigations in twenty-five years of practice in Virginia and Kentucky.

Laennec and some few pathologists of that day had arrived at the conclusion that pulmonary consumption was sometimes curable in the last stages, but curable then only. "Whilst I admit,' says Laennec, "the incurability of consumption in the early stages, I am convinced from a great number of facts, that in some cases, the disease is curable in the latter stages; that is, after the softening of the tubercles and the formation of an ulcerous excavation." Chapman, in a volume published in 1844, says of the disease: “Being fully established, I doubt whether a cure was ever effected of it. Not an instance, at least, have I seen, and I believe that those who report to the contrary deceive themselves, or the truth is not in them."

To the mass of the profession the disease was incurable. The methods generally employed for curing it were according to modern conceptions, and according to Dr. McDowell's notions, almost sufficient for rendering it incurable. They were blood letting, on the authority of no less a person than Benjamin Rush, purging, an invalid diet of weak broth and its like, and protection from the air.

The chief corner-stone of Dr. McDowell's treatment, on the contrary, was a rich and nourishing diet of which milk and red meat formed the essentials. His first and last care always was for the digestion: he insisted that "dieting and starvation" were not "one and the same thing"; that dieting did not consist in depriving the patient of whatever he naturally inclined to, but often in encouraging and stimulating appetite.

In his chapter on Prevention he says: "We have reason to believe that most consumptions are susceptible of spontaneous removal [of the tubercles: he believed them to be cast out as from the lung or absorbed], especially cases that occur early in life. Or, in other words, are cured by regimen intuitively adopted." The italics are his own. He approved four meals a day, and to these he added iron-tonics, outdoor air and graduated exercise.

Of exercise he says: Exercise has been in all ages considered essential to health, and has been especially recommended to the consumptive. That it is essential I presume there can be no question; but that most authorities recommend excessive measures of this description, I am as well satisfied as I am of the inestimable importance of sufficient and appropriate exercise, in all periods of the disease. Exercise should be moderate and regular, and proportionate to the

strength of the patient"; . . . but is . . . "to be prosecuted in every instance to a degree short of fatigue."

"The well-known benefit which is derived from long voyages should admonish us that violent or harsh exercise is not demanded: no exercise is more gentle than that of sailing."

"Excessive exercise, I am disposed to believe, is one of the most injurious and most common errors in the treatment of phthisis."

Dr. McDowell dissented from the prevailing belief that the disease was hereditary. "Hereditary tendency," he says, "is generally reckoned the principal predisposing cause of consumption." Certain family characteristics, he admits, indicate "constitutional predisposition" to consumption. Of such family resemblances, he says: "And so far as regards phthisis, my observations and investigations induce me to believe that this is all of hereditary descent which at all times tends to the production of this disease, with the exception, perhaps, of the estate and the hereditary or family mode of living." And he adds that the disease may be developed independently of constitutional predisposition by a combination of exciting causes such as "deficient and innutritious food, bad air, want of exercise, exposure to cold and moisture."

Dr. McDowell believed the disease to be a degeneration of the blood. His daughter remembers the interest excited in her as a child by the guinea-pigs which he kept during the years of his practice in Virginia for purposes of experimentation. That to the end of his medical career he continued his efforts through painstaking investigations, and post-mortems where possible, to seek further knowledge of the cause and cure of the disease, there can be no doubt. He did not arrive at the germ theory-his book was published nearly forty years before Koch's discovery and many of his surmises as to treatment were doubtless valueless. But the fact remains that he demonstrated to his own satisfaction and that of his patients that the disease was curable, and that as to essential methods employed, we are now nearly a hundred years after he began the practice of medicine still limited to the method of curing by fresh air, rest, graduated exercise and good food, which he employed and advocated.

Dr. McDowell's interest in the disease began as a child when he was thrown into contact with a victim of it. It was increased when as a student he developed the disease himself and cured it by the methods which he afterwards applied to others. During his practice in Virginia he acquired a considerable reputation for success with cases of consumption, white swelling and other forms of tuberculous trouble, the details of some of which he reports in his book.

"From June, 1838, the commencement of my practice in Louisville," he records, “to January, 1843, 120 cases of tubercular disease were treated, 66 of which presented the diagnostics of the last stage of consumption: of which 25 died, 70 have been cured, and 25 are still under treatment, 12 of whom are convalescent." Of the

25 that died, he ascribes the loss of several to failure to obey directions and of the large majority to the fact that on first examination the lungs proved to be so extensively affected as to preclude all hope.

"Of the above," he records, "36 cases were attended jointly, or in consultation with one or more of my brethren in the profession. To 39 others, my attendance succeeded to that of other discriminating and reputable physicians, with whom I co-incided in the diagnosis. The tubercular identity of the remainder rests (professionally) on my individual diagnostic discrimination."

But to the student of human nature perhaps the most interesting portion of the book is contained in the Appendix, in which Dr. McDowell replies to the bitter attacks made upon his theories in the Western Journal of Medicine and Surgery. He gives detailed reports of a number of cases treated both in Kentucky and Virginia, with corroborating statements from those who had assisted him in the post-mortems, and from the relatives of patients. It is interesting to note that two of these patients were members of prominent Massachusetts families who had come under his care in the course of following the prescriptions of their home physicians to “travel in the South."

The medical profession in Louisville, refusing to admit his theory of curability, took refuge in their solution of incorrect diagnosis, even those physicians who had turned over to him cases which they themselves had diagnosed as consumption or which they had with him jointly, so diagnosed, differing with Dr. McDowell only in the opinion that the case was curable. He states that he has generally selected for report cases in which he was supported by the concurrent opinions of other physicians that they were "genuine cases of consumption." Admonished," he says, "of the necessity of this, by knowledge of the fact, that incurability of consumption is so grounded an impression, that the very fact of the cure of a case, however characteristic and strongly marked it may have been, is in the minds of many medical, as well as unmedical men, taken to be conclusive evidence of mistake in the diagnosis of the disease. Thus, as it were, assuming the position that no evidence is conclusive of the existence of consumption, short of the death of the patient. To satisfy these of curability," he concludes, "is of course impossible. My evidences are dedicated to the more rational." The opposition and jealousy of some of the medical fraternity of Louisville amounted, his daughter relates, to a real persecution that seriously cut into his income and his practice. Some years later he was appointed to a chair in a medical school in Indiana and later was appointed by the Secretary of the Navy surgeon in charge of the Marine Hospital in Evansville, Indiana. He died, however, of heart disease at the age of fiftyeight before the hospital was completed.

It is true that Dr. McDowell's methods were followed by some physicians who had become convinced of their value; true, that one of his Continued on page 356