By DR. A. ROSE, 173 Lexington Avenue,

NEW YORK.

Summing up the exceptionally voluminous literature on ichthyol and considering all that has been said about it, we come to the conclusion that there has been hardly any exaggeration in praising its therapeutic value. I believe that its importance surpasses by far that of cod-liver oil, and it is a positive fact that there exist few medicines which are indicated in so many different diseases, which have been given with such gratifying results, and which at the same time are entirely harmless, whether applied externally or internally, in small or in large doses.

Near the village of Seefeld, in Tyrol, is found a fossiliferous deposit, a kind of asphalt, a bitumen to which for over five centuries have been attributed therapeutic qualities. Under the name Tierschenoel it is mentioned in the documents of the courts of Hærtenberg, near Telfs, as early as the year 1350. Its fame as a remedy in diseases of cattle and in rheumatic affections was widespread among the Tyrolians, and under the name black-stone-oil, oleum petræ nigrum, it became an article of trade, not only throughout the Tyrolean valleys, but even in faraway countries, in Hungaria and the Balkan lands.

By means of a kind of dry distillation, the bitumen of the oil stone was decomposed, the oil which thereby formed collected, and, without further manipulation, applied for therapeutic purposes.

In the year 1882, Rudolf Schroeter, of Hamburg, while traveling in Tyrol, learned of this peculiar oil and its history and had an opportunity to convince himself of its therapeutic action.

By means of a chemical examination he found that the most important of its constituents was sulphur. In order to free the oil from impurities he treated it with concentrated sulphuric acid and thereby succeeded in transforming it into a substance which was soluble in water. By the process it had become more applicable for therapeutic purposes. He named this new preparation, an organic combination with sulphur as the essential constituent, and soluble in water, "Ichthyol"-a fictitious name which has no etymology.

The essential question was now to estab

ble preparation had retained the valuable therapeutic qualities for which the mother substance, the old Tierschenoel, had been praised.

It was Unna who tried it clinically; and, by means of a series of classical tests, demonstrated the therapeutic significance of ichthyol. Based on theories which Unna deducted from therapeutic facts, all the indications which he himself and which others after him, principally Schwenninger and Nussbaum, had found, were formulated. Unna not only gave the basis for therapeutic application, but he also investigated the chemical particularities of ichthyol. At his suggestion, and together with him, Baumann and Schotten made a thorough chemical study of it.

Before Unna introduced ichthyol into therapeutics there was in use an oleum lini sulphuratum, or sulphur balsam, and a solution of it in turpentine, oleum terebinthinæ sulphuratum. This balsam, as it was called, had some resemblance to ichthyol, namely, a similar odor; and, like ichthyol, it has as its essential constituent sulphur, but in reality there is a wide difference between the two: ichthyol is a natural product, containing the organic sulphur combination as it is found in the dolomits of Seefeld, while in the sulphur balsam, the inorganic sulphur has been added artificially. And this difference is yet more or less present in substitutes for ichthyol, even those containing organic sulphur, as compared with the genuine article.

The therapeutic success of ichthyol induced many industrials to manufacture synthetically preparations which resembled ichthyol; some of these preparations are compositions out of stone oil containing organic sulphur, but found in other regions away from Seefeld. (This does not apply to preparations which contain real ichthyol combined with other drugs.)

There is an endless list of substitutes for the genuine ichthyol, the ichthyol prepared from the Seefeld oil stone, that marly chalk found in the nests and layers of the dolomits and trias formation near Seefeld.

The brown, almost black, color as well as the combustibleness of the oil stone are due to the fact that it contains fossil organic substances, principally of animal origin. Such organic substances, which are known as bitumen, comd. ng of hydrocarbon combinations, are berciently found as part of stone formations, and we shall speak of

them later on. The bitumen of Seefeld is distinguished especially by its high percentage of chemically-bound sulphur. In the so-called fish slate and gall-stone layers found near the oil stone, which layers, however, are poor in bitumen, there are frequently seen impressions of ganoid fishes; in the oil stone itself they are missing.

The first day I learned of the internal administration of ichthyol, as noted in a paper I contributed to the Medical Summary, June, 1912, it was about 1885; reading of its successful administration in the case of Prince Bismarck by Schwenniger, all details of which I have given in the paper mentioned, I learned simultaneously that there were in the market, under the name "ichthyol," a number of imitations, preparations of which I have spoken. I remember well the difficulty which I had at that time in seeing to it that my patients should receive the real ichthyol. At present these conditions have improved: the name "ichthyol" is protected by law, and no honest druggist will dispense anything but real ichthyol when ichthyol is prescribed.

How important it is to ascertain that our patients receive the genuine preparation we learn to understand when studying the chemistry of ichthyol. And this chemistry, as stated, has been studied by Unna in association with Baumann and Schotten, and supplemented by the later researches of Passmore, Aufrecht and Helmers.

These investigators have found that ichthyol presents a very complicated composition; that one thing above all is characteristic, the high percentage of sulphur by which the Seefeld oil distinguishes itself from all other bituminous masses, and this high percentage of sulphur in the Seefeld product has a therapeutic effect which cannot be equalled by any of the imitations.

Dr. Otto Helmers, of Hamburg, has given a complete description of the chemistry of ichthyol in the twentieth volume of "Dermatologische Studien❞ (Hamburg, 1910).*

In order to understand the origin of the organic sulphur constituent of the Seefeld oil, it is necessary that we know certain geological facts. The cadavers of those fishes of the antediluvian period which did not strand on the shores accumulated at the bottom of the sea, where they became decomposed by the action of bacteria. Ani

Ein Beitrag zur Geschichte corremie der in Wasser löslichen organishen Schwef parate. Passmore, Chemist & Druggist, Dec. 18, Mediz. Central-Zeit., 1912, No. 69.

Aufrecht: Allgem.

mal matter has a very complex composition, and is made up of three or four component parts, consisting principally of the following simple elements: Carbon, hydrogen, oxygen, nitrogen, sulphur, phosphorus. These component parts, when set free, act in different ways upon the water and the mineral matters with which they come in contact; they, among other actions, impart medicinal properties to the waters, and, in the case of ichthyol, to the mineral matter, as found at Seefeld.

The floating organisms which after their death drop to the bottom of the sea in large quantities, serve as food for the animals of the deep, which under normal conditions act as scavengers and to some extent clear away these deposits. Generally the deep-sea currents carry oxygen with them in quantities sufficient to nourish the bacteria which decompose the cadavers. The products of their fermentation are swept away by the currents. But when, owing to peculiar topographical conditions, there is no current in the deep carrying oxygen in sufficient quantities, the deep-sea animals cannot live, and the floating organisms accumulate in great masses.

There is not enough oxygen in the sea water to suffice for transformation by bacteria into carbon dioxide of the carbon contained in the organic matter. The microorganisms are then obliged to borrow oxygen, of which they are in need, from the salts contained in the sea water, and especially in the sulphates which they transform into sulphides:

RSO,+2 C=2 CO2+RS. Sulphate Carbon Carbon dioxide+ sulphide.

The sulphides of sodium, of potassium, of calcium, of magnesium, thus formed by reduction, are converted on contact with water and carbonic acid into carbonates, with the liberation of hydrogen sulphide: RS+CO2+H2O=H2S+RCO。.

Sulpide+carbon dioxide+water=hydrogen sulphide+carbonate.

When the alkali carbonates are dissolved in sea water, calcium carbonate is precipitated.

It is not only at the expense of the sulphates that the bacteria produce hydrogen sulphide. The albuminous matter of the organisms contain, as we know, a certain quantity of sulphur and there exist bacteria, especially the bacterium hydrosulphuricum, which have the property to abstract the sulphur from the albuminous

substances and to transform it into hydrogen sulphide.

These different phenomena occur as well in the seas as in the lagunes and in the sweet-water lakes which receive a sufficient supply of waters which are called selenitous, which means rich in sulphate of calcium, but it is, above all, in the Black Sea that the conditions of the production of hydrogen sulphide have been studied. Geologists are endeavoring to ascertain if the dolomits of Seefeld and South Tyrol in general have originally been sea reefs.

(To be continued.)

TUBERCULOSIS.

Its Physical Diagnosis, and a Plea for Its Rational Management from a Sanatorium Point of View.

By OSCAR O. MILLER, M.D.,
ASHEVILLE, N. C.

Physical Diagnosis. Dilatation of the pupil or inequality in the same may be mentioned as an early diagnostic sign of tuberculosis, due to infiltration and enlargement of the bronchial lymph nodes, thereby causing pressure upon the sympathetic reflex by dilating the pupil.

Cogwheel respiration may also be cited as another factor that should put the examiner on guard, when not due to nervousness. Expiration is naturally prolonged over inspiration, especially in women and children. Inspiration is to expiration as 6 is to 7, hence it is only in those cases where expiration is markedly or rather appreciably prolonged that it becomes of diagnostic value.

Inspection is not to be ignored, of course; the phthisical chest counts for nothing unless it be to excite our suspicion, as tuberculosis occurs as frequently in the normal thorax.

Depression above or below the clavicles may or may not be noted, but limitation in expansion in either or both should always be noted

The excursion of the chest wall may throw some light on the subject, especially when the examiner applies pressure below the clavicles, thus often inhibiting expansion of the more seriously involved area.

Palpation should always be indulged in for the information it imparts in regard to lungs and pleuræ. Light percussion will often reveal involved areas when they

are superficial, but will fail to elicit any impaired resonance if the spot is situated deeply.

Under the heading of "Ausculation," we probably have our greatest aid for making a diagnosis, both in regard to the amount of information it conveys, and the fact that most physicians are more expert with this diagnostic method than with palpation and percussion.

Ausculation should be conducted carefully, in a quiet room, with a non-magnifying stethoscope. Having auscultated the chest during ordinary inspiration and expiration, go over it again and interrogate forced respiration; by having the patient cough gently and then take a deep inspiration. A fine post tussile crepitant râle is an important diagnostic sign, and can often be elicited where there is roughened breathing with prolonged expiration. This second auscultatory examination completed, let the physician go over the chest for the third time and have the patient whisper "twentyone, twenty-two, twenty-three," each time. the stethoscope is placed upon him. This will bring out any increased or diminished vocal resonance and will confirm the findings of percussion and palpation. When examining in the region of the right bronchus, either back or front, due allowance must be made for its greater volume.

Finally it should be kept in mind that negative findings often convey as much information as positive ones, and should on no account be overlooked. Absence of breathing in an apex or elsewhere is equally as important as harsh breathing.

Sometimes a patient may give a history of recent hemorrhages and yet, on examination, present no pathological physical findings; this, however, does not exclude tuberculosis, but should incite the examiner to make persistent careful re-examinations, three to four weeks apart.

Careful graphic charts should be made each time, and should be compared after each examination, but never before.

Given a patient with a family history of tuberculosis, and with a personal history of repeated pleurisy or a one-time fistula, even with negative findings in the chest, behooves us to be ever on our guard.. Fast pulse, with subjective pulmonary symptoms, irrespective of fever, are points to be well kept in mind.

Tuberculin Tests.

It is a well-known fact that none of the tuberculin tests differentiate a latent tuber

culosis from an active process, except in children under five years, when it should be regarded as active. In the negative findings lies the real value of the test.

It should also be remembered that acute infectious diseases may modify the test, as it has been shown in children, who were positive to the Von Pirquet, and became negative in 100 per cent. of measles cases, 85 per cent. in scarlet fever cases, and 17.5 per cent. of diphtheria cases, 150 cases being tested in all. (A. M. A. Journal,

pp. 1729.) These results may be due to the changes in the skin, which is an accompaniment of the foregoing diseases.

Since the tuberculin test does not differentiate a latent from an active tuberculosis, it is difficult to see how one can decide whether his patient is well or not by this means. The only rational way to decide is by physical examination.

Climate.

To take a patient from an ill ventilated, dark room, and place him on the roof or back porch, may not be a change of climate, as the laity understand it, but it certainly is a vast change in atmosphere, since it has been asserted that "a man out of doors is exposed to 100 times more fresh air than he could get in the best ventilated room in any given period of time." The same applies to patients living in cities, crowded or otherwise, where the conditions are not conducive to taking the treatment. To move such a patient to the outskirts of the city, where there is good room and plenty of good air circulating freely, will constitute more than a theoretical change of climate.

Social Phases.

Another phase of the question that may be discussed to advantage is that unfortunate, indigent class, where the victim is the sole support of the family. Unfortunately, this class of patients rarely seek aid, even when a free dispensary is at hand, until the disease is moderately advanced; but, given such a case, where there is good resistance, and fair nourishment, we may often do much for the patient by having

him seek a change in employment, especially if his former occupation has exposed him to much dust or undue fatigue, or has been too confining.

But home comforts with relatives and friends are often a distinct disadvantage in thwarting the orders and efforts of the attending physician. Friends are going to cater to the whims and fancies of the patient, especially if they think the treatment is severe. The patient is not going to stay on the back porch in winter while a good fire is crackling on the hearth and throwing its cheerful glow through the window. The probabilities are that he has never been taught to cover his mouth when he coughs, and he is not going to have the important lesson indelibly impressed upon him during the short visits of the physician. If feeling fairly well he is not going to stay confined to his bed in spite of fever or pulse, and is going to violate a dozen little details which may seem nothing to him, but which in reality do much toward arresting the

progress.

Sanatorium Treatment.

On the other hand, sanatoria treatment means something definite. It means the patient leaving home; that in itself is a definite, positive step that ever reminds him that he has set out to accomplish something.

Passing over the routine examination through which he is put, on arriving at the sanatorium, we will mention but one fact, that is the sputum cups and a bundle of gauze with which he is presented and instructed in their use and penalties for failing to use same.

It is often in the sanatorium that the patient is first introduced to a tooth brush and a dental bowl. An antiseptic solution. is given him in which to keep his brush, which farther impresses cleanliness and antisepsis upon him. He is instructed how to dispose of his soiled sputum cup, and where to put the formalin with which to wash the frame. Finally he is given a list of rules and regulations, all bearing more or less on hygiene in his conduct and relations to other patients and the institution; and is then put to bed out of doors, with positive instructions that he must stay there until he receives instructions from the physician to get up. By this time the patient has gathered a good idea of what is expected of him, and invariably buckles to to reach the desired goal. In addition he sees other patients around him in various stages (misery loves companionship), he

Rarely he may be so unfortunate as to hear of an unexpected death and find one of the fraternity missing next morning, and this impresses him still more that he is battling with no trifling foe, but one that is insidious and relentless. It is wonderful the sobering influence such a calamity has on an institution for a few weeks. One has seldom to reprimand the patients for not taking the cure thoroughly.

Suppose our patient has come through the incessant routine of the sanatorium with the disease arrested, or only partially so, does he go home and drop back into his old habits? Rarely does this occur; the kindergarten lessons have been stamped into his very nature. He has become a devotee to habit. Certainly he will not take the cure at home like he has at the sanatorium, even if the need be urgent, but he will do much better than the home-taught patient, and will become a factor in spreading the gospel of taking the cure.

Not a few States have one or more semicharitable sanatoria, particularly is this so in the North, where a patient may take the cure at the reasonable rate of from $30 to $40 or $50 per month. There are few people who at a pinch could not afford to take three months' treatment at the least at one of these institutions, where they could in that time have the principles of taking the cure inculcated, and then return home and continue under the local physician to better advantage.

The meals should be at regular hours and on time. A good milk should figure prominently; milk and eggs between meals should be encouraged, say at 10 A. M. and 3 P. M.

Fast pulse should interdict exercise, on which a patient should go back A temperature under one degree should permit him to indulge in prescribed

It further lessens tendency to night sweats, and may act as anaphrodisiac, a therapeutic action to be desired, considering that phthisical patients are too often cursed with an inordinate sexual desire.

In a slight hemoptysis, the psychic influence over the patient is only to be obtained by doing something. No matter how slight the hemoptysis, put the patient to bed; find and eliminate the cause if possible (as severe coughing); remove the pillow from under his head; restrict diet (only if severe); give heroin hydrochloride, gr. 1/12. It is doubtful whether the lungs possess much vasomotor mechanism, hence the administration of astringents is of doubtful value. Atropine is perhaps our best drug, with which we can bleed the patient into his own system. Morphine may be added, according as the physician sees fit. Calcium lactate may be given in 10-15 grain doses, t. i. d., for one week or longer, as the system uses a large amount of calcium in combating this disease, which must necessarily diminish the coagulability of the blood.

mem

Iron is contraindicated in tuberculosis, as it produces a tendency to hemorrhage. [Except when combined with arsenic.— Editor.] The anemia is not as severe in these cases as one is led to believe by inspection, as the color of the mucous branes bears no relationship at all to the hemoglobin. It has been shown at Saranac (A. M. A. Journal, p. 1815), where the hemoglobin was measured (Talquist) in 272 patients, incipient and moderately advanced, in which the estimation in every case but one was 90 per cent. Get the patient out of doors and at rest, give plenty of nourishing food, and the anemia will take care of itself.

In regard to cleaning out the alimentary canal, my experience has led me to believe that the majority of these patients do not take calomel kindly when given alone; and better results are achieved when given in combination, as in the compound cathartic pill, or when any of the vegetable cathartics are substituted for it.

Repeated examinations of the urine for indican will give one a good idea as to the frequency and advisability of purging the patient.

Alcohol rubs should also be prescribed when the patient is to remain in bed for any length of time.