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conditions is quite essential, or a great deal of energy on the part of the institution and the patient may be wasted.

Bearing in mind the great importance of a careful physical examination, let us assume that signs of a definite tubercular lesion, such as increased tactile fremitus, impaired resonance, increased vocal fremitus, broncho-vesicular, or even bronchial, breathing over a localized area were discovered. This would only mean that the patient is tubercular, but would not necessarily mean that the lesion is a recent one or an active one. A lesion which has become quiescent, arrested, and even cured, will still give physical signs. Of the physical signs, the presence of râles is the only sign which, in a measure, indicates whether the disease is active or not. A healed lesion shows no râles. An arrested lesion may show the presence of a few residual crepitant or subcrepitant râles. The presence, however, of any great quantity of râles, which become increased after the patient is made to cough, is a strong evidence that the disease is active in a greater or lesser degree. The symptoms, however, are of more importance. The following is the order of their importance:

1. Fever.-Any case showing a definite lesion, but whose temperature while the patient is up and about remains normal indicates that the lesion is not very active. The morning temperature is quite important. 95 or 97 in the morning is not normal.

2. Rapid Pulse.-An increase in rate is a very frequent sign of an active lesion, and is frequently present when fever is absent. If a carefully counted pulse, recorded twice daily while patient is up and about, shows no appreciable increase in rate, the lesion is probably an inactive one.

3. Loss of Weight-Loss of weight, though a constant symptom of pulmonary tuberculosis, may appear late in the disease, and non-tubercular patients suffering from any psychosis may show great loss of weight. However, in patients showing physical signs of a tubercular lesion, but whose weight is normal or above normal, it may be considered as an evidence that the disease is not very active.

4. Cough.--Cough is considered by some authorities on tuberculosis as the most constant symptom of this disease, and some go so far as to say, “No cough—no tuberculosis.” Its sig

nificance is, in my opinion, greatly exaggerated. It may be absent while the disease is progressive, and a hacking cough may be present, though the disease is quiescent, arrested or cured.

In the præcox cases, especially the catatonic group, cough is often the very latest symptom to appear. However, a patient who is up and about, and showing a tubercular lesion, but who does not cough, may be considered as showing an inactive lesion.

5. Expectoration.—This is a more important sign than cough, and is often present when there is apparently no cough. Presence of expectoration by itself is of no especial significance, as it may be due to a chronic bronchitis, asthma, etc. However, in the absence of expectoration, the catatonic præcox cases being excepted, the lesion may be considered as an inactive one. Like in all other conditions, the presence or absence of one symptom should be less relied upon than the presence or absence of an entire group of symptoms. Any patient, then, sent to a tubercular cottage, but who after three, four, or more months does not show the above indicated symptoms, or the symptoms disappear, may be properly considered as an inactive or arrested case and sent back to the Preventorium, and if there is no recurrence of symptoms he may be sent back to the general ward. In the presence of the above symptoms, where the proper physical examination cannot be performed because of lack of coöperation on the part of the patient, or his negativism, such a patient should be considered tubercular unless another condition can be definitely established accounting for above symptoms.

Special attention should be paid to the dementia præcox group of cases, especially the catatonic type. My own studies, and those of others, of this group would tend to show that this group of mental cases is especially vulnerable to pulmonary tuberculosis. Many symptoms are absent until late, and their negativism and failure to coöperate render the diagnosis of these cases especially difficult. In their desire to withdraw from reality, they try to perceive of themselves as dead. They, therefore, refuse to speak, to eat, etc. They immobilize their chests, doing as little breathing as possible, thus furnishing a good medium for any tubercle bacilli which may be present. It is, of course, an established fact that the tubercle bacillus thrives best where there is less fresh air. On this basis is the frequency of apical lesions explained. The

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low state of general vitality, that these patients are usually in, accounts for the absence of fever, as the body is not strong enough to put up a fight, and hence there is no reaction.

Such cases should be specially watched and frequently sent to the Preventorium where they could be given more attention. This is especially important, since this very type of cases has a better chance to recover from the psychosis, and, of course, we should try to save them from tuberculosis.

The proper management, however, of the tubercular department alone, no matter how efficiently conducted, will not solve the problem of pulmonary tuberculosis in a large institution. A great deal of attention must be paid to the general ward, and unless the coöperation of the various physicians-in-charge, of the other departments, is enlisted, very little will be accomplished. Like the family physician on the outside, the physicians of the various departments are the ones who come into contact with the patients at a stage when they can be helped most towards curing the disease, when their removal to the tubercular department is specially desirable, since, at that time, they are the greatest source of danger, so far as spreading the disease among the nontubercular population is concerned; and so, from the standpoint of prevention alone, it becomes our duty to diagnose the cases of tuberculosis as early as possible. Any physician in charge of a patient for a period of four or five years, and who transfers that patient to the tubercular department three or four months before his death, has been neglecting his duties, and he lays the institution open to severe criticism. What would a psychiatrist say, if, in a general hospital, patients suffering from paresis were diagnosed three or four months before death?

The early diagnosis of pulmonary tuberculosis by the various physicians in a psychiatric hospital is, of course, not an easy matter. In most of the larger hospitals, each physician must look after such a number of patients that to demand of them careful individual attention to every patient would be unreasonable, and such a performance on their part would be impossible. When we consider that the majority of the patients in each department are usually quiet and are only in need of custodial care, it becomes quite evident that a patient can develop most any chronic disease that may escape the physician's attention. Again, the mental condition of the patient is often such that even when observed, because no subjective symptoms nor a history can be obtained from him and because of his failure to coöperate in the performance of a physical examination of the chest, which is so essential in the case of pulmonary tuberculosis, a proper diagnosis becomes an impossibility.

But while there are many obstacles and difficulties to be met with in attacking this problem, by adopting certain routine measures many cases will be diagnosed which otherwise would have remained unobserved. The following rules should be observed :

1. More attention must be paid in performing the initial physical examination of every patient admitted to the hospital. It is so easy to say, “Respiratory system negative."

2. The weight of every patient upon admission should be carefully noted.

3. It should be the duty of every nurse or attendant to call the physician's attention to any patient who shows any definite loss of flesh. Such patients should be frequently weighed, and a persistent loss of weight should make one suspect pulmonary tuberculosis. This applies especially to the dementia præcox group of

cases.

4. The presence of cough or expectoration, no matter how slight, if continued for a period longer than three or four weeks, should be brought to the special attention of the physician-incharge.

5. Not all patients are inaccessible. Most of them, at some time or other, are able to give a good and dependable history. Special inquiry should be made as to attacks of pleurisy, dry or with effusion, and any patient giving a history of either should be considered tubercular, though, of course, not necessarily suffering from an active or open lesion, and not requiring any special treatment in the absence of any other special indications. A history of atypical attacks of typhoid fever, "touches" as they are called, is important, as they usually prove to be exacerbations of tubercular lesions. Blood-streaked sputum, or any hemorrhage from the lungs, no matter how slight, is always suggestive of pulmonary tuberculosis. A history of anal fistula is another suggestive sign of pulmonary tuberculosis.

6. By observing the points mentioned above, many patients will be brought to the attention of the physician who would otherwise have escaped his particular notice. However, the diagnosis of pulmonary tuberculosis to be definite will have to be made as a result of a physical examination of the patient's chest. While we cannot demand of a physician-in-charge, of mentally ill patients, to have the skill and experience necessary to make a diagnosis of incipient tuberculosis by means of physical signs alone, no well-defined case of moderately advanced tuberculosis should escape his attention, “moderately advanced " meaning a case showing an infiltration of one lobe or part of a lobe, or of both apices, with a moderate amount of moist rales. Most pulmonary tuberculous cases are not diagnosed, not because of “not knowing," but because of “not looking." No one, no matter how expert, can perform an intelligent chest examination in 10 or 15 minutes, unless the patient is in the far advanced stage, when no chest examination is necessary. Unbuttoning the patient's shirt while he has his coat on and placing the stethoscope here and there in front of the patient's chest, or percussing the chest in an unsystematic manner, is worse than useless. The following procedure in performing a physical examination of the chest will be found helpful :

Strip the patient to the waist and perform a complete physical examination, using the following methods : 4

Inspection.—Look for any retractions or depressions, especially above or below clavicles; note any bulging at the bases; watch the patient's breathing; note if one side is lagging. Is the breathing deep? Shallow ? Rhythmical? or interrupted ? Always compare any finding with the opposite side.

Palpation.-Elicit tactile fremitus all over the chest. A definite increase of tactile fremitus over a localized area is suggestive of tuberculosis. A diminution or absence of tactile fremitus would suggest fluid or a thickened pleura.

Percussion.—This is a very important method. Percuss the chest in a systematic way. Start on one side from above downward, or from below upward, as preferred by some. over the other side. Then compare suspicious areas of one side with symmetrical areas on the other side, and with normal areas on the same side. Do this, first, anteriorly, then posteriorly, and,

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