Pulmonary tuberculosis; a handbook for students

Front matter

Book j(uj IS

COPYRIGHT deposit.

A HANDBOOK FOR STUDENTS

Preface

The author has been engaged in teaching the subject of pulmonary tuberculosis for a considerable number of years, and this manual is largely the result of his experience. It is primarily intended for students of the third and fourth years, to be used in connection with clinical work. It is also hoped that the book may not be without value to physicians who desire briefly to refresh themselves upon this ever-recurring disease. Such a handbook must obviously omit much which properly finds its place in large, exhaustive treatises upon the subject. The object has been to give the main essential facts, emphasizing them in accordance with the author's experience and judgment.

One of the difficulties of the student in making an early diagnosis of pulmonary tuberculosis is his inability to correlate the symptoms and physical signs, and to give to each symptom and sign its due proportionate weight; and in this handbook an attempt has been made to aid him in this respect.

The diagnosis of early clinical pulmonary tuberculosis is easy or difficult much according to the way in which the student sums up his evidence from the examination of the patient and the emphasis he places upon the various symptoms and signs. Noth-

PREFACE

ing, of course, will take the place of much clinical work under expert guidance, but it is hoped that this manual will be of assistance in connection with such work and enable the student to lay a foundation upon which he can firmly build from future experience and study.

The method and arrangement are those which the author has found serviceable in presenting the subject to his classes. Most of what the book contains is the common knowledge of the physician, and only the attempt has been made to so present this knowledge as to give the student a clear conception of the subject as a whole that he may not underrate certain aspects of it and exaggerate others. Many authorities have been consulted, to all of which the author makes his acknowledgments.

E. O. O.

Boston, 191 7

Contents

CHAPTER PAGE

I Anatomy and Physiology i

II The History of Tuberculosis 22

Chapter I

"Anatomy studies the organism in space, physiology studies it also in time."

O. W. Holmes

In order to intelligently study the disease of any organ, a knowledge of its normal anatomy and topographical relations, and its physiological function is essential. Although this knowledge as applied to the lungs and their surroundings is supposed to have been already obtained in the courses upon anatomy and physiology, a brief review in this connection will not be without value in the further study of this subject.

The Bony Framework of the Chest The lungs are contained in the bony framework of the chest which serves both as a protecting shield for the enclosed organs and as a mechanical device in conjunction with the respiratory muscles for producing the movements of respiration.

This framework (Fig. i) is composed of the thoracic spine, to the bodies and transverse processes of which are attached the ribs, and the sternum, to which the ribs are united by cartilages. The thoracic spine consists of twelve thoracic vertebrae, and has a hackwork convexity. The ribs, somewhat circular in shape, are attached to the spine with varying degrees of obliquity, but all, however, slope downward, outward and forward.

Movement of the Ribs

The ribs are articulated with the vertebrae in such a way that they form a sort of hinge of limited motion so that in the movements of respiration they swing on the fixed spine, up and down, and when elevated in the act of respiration they push the sternum forward and thus increase the antero-posterior diameter of the chest, and at the same time the intercostal spaces are widened. Another motion also takes place when the ribs rise : they describe a rotary motion outward around an imaginary axis which unites with the two ends of the ribs, and thus the transverse diameter of the chest is increased.

Intercostal Spaces

The intercostal spaces differ in size, being larger between the upper ribs than the lower. The second, third, tenth and eleventh interspaces are the widest, and the widest part of each individual space is near the anterior part of the ribs. These spaces are closed by the intercostal muscles. Lying in a sort of gutter under the rib, at its lower border, are the intercostal artery, vein and nerve; in aspirating the chest, consequently, the arm on the affected side should be brought forward with the hand

Fig. I placed on the opposite shoulder so as to widen the interspace, and the aspirator needle thrust in at right angles close to the upper margin of the rib so as to avoid wounding these vessels.

Counting the Ribs It is often necessary to count the ribs and it is sometimes difficult to do so directly, so that it is helpful to have some landmarks. The following are given by Holden :

(a) " The angle of Ludovici, formed by the manubrium and gladiolus, is at the second rib."

(b) " The nipple of the male is placed, in the great majority of cases, between the fourth and fifth rib."

(c) " The lower external border of the pectoralis major corresponds with the direction of the fifth rib."

(d) "A line drawn horizontally from the nipple round the chest cuts the sixth intercostal space midway between the sternum and the spine." (This is a useful guide in tapping the chest.)

(e) " When the arm is raised the highest visible digitation of the serratus magnus corresponds with the sixth rib, the digitations below this correspond respectively with the seventh and eighth ribs."

(f ) " The scapula lies on the ribs from the second to the seventh inclusive."

(g) " The eleventh and twelfth ribs can be felt even in corpulent persons outside the erector spinse, sloping downward."

(h) " One should remember the fact that the sternal end of each rib lies on a lower plane than its corresponding vertebra " ; for instance, a line drawn horizontally backward from the middle of the third costal cartilage, at its junction with the sternum, to the spine, would touch the body not of the third dorsal vertebra but of the sixth. Again, the end of the sternum would be on about the level of the tenth dorsal vertebra. Much latitude must be allowed here for variation in the length of the sternum, especially in women."

Diaphragm

The base of the thoracic cavity is closed by the diaphragm, a dome-shaped muscle attached to the ensiform cartilage in front, to the cartilages and bony portions of the sixth and seventh inferior ribs on each side, and behind to two aponeurotic arches and to the lumbar vertebrae.

The diaphragm acts actively in conjunction with the intercostal muscles in inspiration, while in expiration it becomes passive and is pushed up by the action of the abdominal muscles. By the contraction of the diaphragm in inspiration the chest is enlarged in its vertical direction. When the chest hr. .; become very rigid, or when the intercostal muscles are paralyzed, the diaphragm becomes the chief or only muscle of respiration. Also in ordinary tranquil breathing of the sedentary person this muscle does most of the work of respiration (abdominal respiration), as can be readily observed in watching the chest of a person at rest. Interference with the free movement of the diaphragm by a distended stomach or fluid in the peritoneum causes dyspnoea. No other muscle in the body, except the heart muscle, works so unceasingly as the diaphragm. Day and night, from birth to death, with only periods of rest of seconds, this faithful muscle does its duty. It is a very powerful muscle, and Campbell speaks of a man whom he knew who could move a grand piano by means of it. In forced inspiration the diaphragm is displaced downward three and one-half inches, which can be determined by the extension of resonance on percussion. The fluoroscope and the " Litten's phenomenon " indicate visibly the movements of the diaphragm. In early pulmonary tuberculosis the excursion of the diaphragm is diminished on the affected side, as can be demonstrated by the fluoroscope. I do not, however, consider this a very important diagnostic sign.

The Thoracic Cavity and Pleurae The top of the thoracic cavity is shut in by the muscles about the neck. The interior of the cavity is lined by the pleurae, a serous membrane whose chief function is to enable the lungs to expand equally in all directions.

When pleural adhesions occur from inflammation of the pleurae, this free movement of the lungs is impeded, and this may be one reason why the apices of the lungs are so prone to tubercular inf ection ; hence, as Campbell points out, " those with pleuritic adhesions should frequently resort to costal breathing." When the pleurae are normal, they are smooth and frictionless, and their inner surface is constantly lubricated with the serous fluid, so that the two layers slide freely upon each other and the movement of the lungs in respiration causes no sensation; if, however, the pleurae become roughened by inflammation, one experiences a " pleuritic pain " on breathing, and hence the reason for strapping the chest over the affected side to restrict the respiratory movement and thus lessen the pain. There is a right and left pleura separated by a space called the mediastinum which contains the heart and great vessels. Each pleura is two- fold, an outer parietal layer which is thick and feebly adherent to the inner wall of the chest throughout its entire extent and is reflected upon the superior surface of the diaphragm below, and above it extends through the upper opening of the thorax into the neck; and an inner or visceral layer which is extremely delicate and very transparent. It is very adherent to the lungs and invests them completely, dipping to the bottom of the fissures which divide the lungs into lobes.

Cavity of the Pleura The interspace between the two layers of the pleura is called the cavity of the pleura, which normally is closed, the parietal and visceral layers being in apposition. When, however, an effusion occurs the two layers are separated by the fluid, and when also the operation of artificial pneumothorax is performed the gas likewise separates the two layers, compressing the lung. The pleural cavity shows a negative pressure, and when opened the positive pressure of the outside air instantly collapses the lung. When the opening to the outside air, however, is closed, the air inside is slowly absorbed and the lung expands again. When from disease an opening from the lungs into the pleural cavity occurs, the lung is likewise collapsed and a pneumothorax is formed, the pressure from the inside being the same as that of the outer air. The parietal or costal layer of the pleura is attached to the chest wall by connective tissue and when from an injury or puncture, as in artificial pneumothorax, air enters into the space between the chest wall and costal pleura, a deep emphysema is developed.

When the cavity of the pleura requires tapping to evacuate fluid the sixth or seventh intercostal space midway between the sternum and spine is usually selected.

The right and left pleural cavities are separate and distinct; and the parietal pleura, at the point of its reflection upon the upper part of the diaphragm is called the inferior cul-de-sac of the pleura; hence, we can have diaphragmatic pleurisy.

Lymphatics of the Pleurae

The lymphatics of the pleura are abundant, both in the parietal and visceral layers, those of the latter connecting with the lymphatics of the lungs, and those of the former with the lymphatics of the thoracic wall. It is through this lymphatic system in conjunction with the respiratory movements that the pleuritic fluid is chiefly absorbed.

The Lungs

The lungs fit into the pleura-lined chest, the rounded apex projecting about one and one-half inches above the sternal end of the clavicle and the concave base fitting accurately upon the convex top of the diaphragm. The lower limit of the lungs can be represented by a line drawn around the chest from the junction of the sixth costal cartilage with the sternum to the spinous processes of the tenth dorsal vertebrae. The right lung (Fig. 2) is shorter and broader than the left and has three lobes and two fissures. The left lung (Fig. 3) has two lobes and one fissure. The lungs occupy four-fifths of the thoracic cavity, the remaining space being occupied by the heart and hilus of the lungs, formed by the bronchi, the pulmonary artery and vein, the lymphatic vessels, nerves and glands.

The normal weight of the lungs varies between 1 100 and 1200 grams (5 or 6 lbs.) in the male, and 900 to 1 100 grams (4.1 to 5 lbs.) in the female.

The substance of the lungs is of a spongy texture, consisting of a mass of minute cavities — the alveoli — which are encircled by a mesh of capillary vessels only separated from the air by the exceedingly thin membrane of the alveoli, By this

Fig. 2. The Right Lung

Fig. 3. The Left Lung mechanism the oxygen entering the lungs is absorbed by the blood and carbon dioxide, nitrogen and watery vapor excreted. Elastic tissue enters largely into the composition of the lungs and upon this elastic tissue their expansibility depends. When the chest is opened the lungs collapse to about a third of their ordinary size. In emphysema of the lungs this elasticity is to a great extent lost and, in consequence, they are in a constant state of distension.

The general shape of the lungs is triangular, or conical, and is conformed to the shape of the thoracic cavity. In front the anterior edges of the lungs do not come together in tranquil breathing, while in forced inspiration they meet over the base of the heart. The anterior edge of the right lung is nearly vertical, while that of the left is oval or oblique.

Boundaries of the Lungs and Lobes

Above, the lungs extend about one and one-half inches beyond the sternal end of the clavicle; below, from the sixth costal cartilage of the sternum to the spinal processes of the tenth dorsal vertebrae. The following table will be useful in fixing in one's mind the boundaries of the lobes:

Right Lung; Three Lobes

Anteriorly Laterally Posteriorly

Upper Apex to To Fourth Rib Apex to Spine

Lobe Fourth Rib of Scapula io PULMONARY TUBERCULOSIS

Anteriorly

Laterally

Posteriorly

Middle Lobe

Fourth Rib to Inferior Angle of Sixth Rib

Fourth to Sixth Rib

Nil.

Lower Lobe

Nil.

Sixth to

Eighth Rib

Spine of Scapula to Tenth Rib

Left Lung

; Two Lobes

Upper Lobe

Apex to Sixth Rib

To Fourth Rib

Apex to Spine of Scapula

Lower Lobe

Nil.

Fourth Rib to Base

Spine of Scapula to Tenth Rib

One can easily remember that in front on the right side we have the upper and middle lobe (Fig. 4), and on the left the upper lobe (Fig. 5), while behind we have an upper and lower lobe on each side. It is helpful to remember the boundaries of the lobes of the lungs, and particularly to bear in mind how large a part of the organ, posteriorly, consists of the lower lobe. It is of aid in determining the extent of a pneumonic consolidation ; whether or not a tuberculous process has invaded the lower lobe; and in making a diagnosis between solidification of the lower lobe and an effusion.

Lymphatics of the Lungs

The lymphatics of the lungs, which are abundant, are superficial and deep and terminate at the root of the lungs in the bronchial glands, which lie along the lower portion of the bronchi and trachea.

Fig. 4. Longitudinal section through the right mammary line From Garre und Quincke, Lungenchirurgie

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ANATOMY AND PHYSIOLOGY n

These glands readily enlarge in various infectious diseases, particularly in tuberculosis. Such enlarged glands can be detected by the X-ray and also sometimes can be made out with more or less definiteness by percussion and auscultation. When much enlarged they give rise to cough and dyspnoea (Fig. 6). (Fig. 6a.)

The Bronchi and Trachea

The lungs are connected with the outer air by means of the bronchi and trachea. The latter starts opposite the lower border of the sixth cervical vertebra and ends between the fourth and fifth thoracic vertebrae. It is four to four and one-half inches long, and bifurcated into the bronchi just above the level of the junction of the manubrium sterni and gladiolus. The right bronchus follows more nearly than the left the course of the trachea. From the two main stems are given off lateral branches and these divide and subdivide until at last they terminate in the lobules and these again in the intercellular passages and air cells.

The bronchi are accompanied by branches of the pulmonary artery, the lymphatics and nerves. The arch of the aorta is in close relation with the left bronchus and in aortic aneurysm we may have partial or complete obstruction of the bronchus, and as a result the development of acute bronchiectasis.

Landmarks of the Lungs (Holden) i. " The apex of each lung rises into the neck behind the sternal end of the clavicle and the sterno-mastoid muscle about one and one-half inches."

2. " There is little or no lung behind the first bone of the sternum."

3. " From the level of the second costal cartilage to the line of the fourth the margins of the lungs run parallel, or nearly so, close behind the middle of the sternum."

4. " Below the level of the fourth costal cartilage the margins of the lungs diverge, that of the right corresponds with the direction of the cartilage of the sixth rib, while that of the left being notched for the heart, runs behind the cartilage of the fourth rib. A line drawn perpendicularly from the nipple would find the lung margin about the lowest part of the sixth rib."

5. " In deep inspiration the lung margins descend about one and one-half inches."

The Shape of the Chest and Its Modification by Disease

In the normal chest the antero-posterior diameter is about one- fourth less than the transverse diameter. The horizontal section of the chest shows the general form of an ellipse. The adult female chest is generally more barrel-shaped than the male chest. As abnormal modifications, we have:

(a) The emphysematous chest which is more or less barrel-shaped.

Fig. 6. The relationship of the bronchial glands to the anterior thoracic walls

From Stoll — "American Journal of Diseases of Children" — 1912 — vol. 4. 333-359

Fig. 6a. The relationship of the bronchial glands to the posterior thoracic walls

From Stoll — "American Journal of Diseases of Children" — 1912 — vol. 4. 333-359

(b) The flat chest, the so-called "phthisical chest," although a flat chest does not necessarily indicate a tendency to tuberculosis.

(c) The " pigeon-breasted," also called the " keel chest " which is characterized by its triangular shape: the sternum is pushed forward, increasing the antero-posterior diameter. This deformity is caused by a long existing impediment to free inspiration, such as enlarged tonsils, adenoids, or by chronic bronchitis or whooping cough.

(d) The rachitic chest where there is a lateral compression of the chest walls and a relative increase in the antero-posterior diameter.

(e) The funnel, gutter or cobbler's chest, characterized by a depression of the lower part of the sternum. This formation may be the result of rickets, or it may be congenital or acquired, as in the case of the cobbler.

(f) The "Alar-chest," in which the angles of the scapulae project which gives them a wing-like appearance. Such a chest is generally of small capacity and is supposed to suggest a predisposition to tuberculosis.

We have also unilateral changes in the chest : one side may be increased in size over the other, as from pleural effusions, pneumothorax, or compensatory hypertrophy ; or one side may be retracted, as from tubercular contractions, the result of long compression of the lung by pleural effusion, or of an empyema.

Again, we may have local changes in the shape i 4 PULMONARY TUBERCULOSIS

of the chest, such as bulging in the lower anterior or lateral region, as in the case of empyema where the pus tends to be evacuated; or a contraction above and below the clavicle, which is frequently observed in tuberculosis. Other causes are atelectasis, bronchiectasis, and pleural adhesions.

Physiology of Respiration

Respiration consists of two separate acts, inspiration, which is essentially active, and expiration, which is almost entirely passive. The muscles engaged in ordinary inspiration are the intercostals, the diaphragm, the levatores costorum, scaleni and serati postici. The movements of expiration are chiefly due to the elasticity of the lungs and the passive return of the diaphragm and chest walls. In ordinary quiet breathing there is comparatively little rib movement, especially in the upper half of the thorax, inspiration being almost entirely abdominal. This is less so with women. In extraordinary inspiration many other muscles come into play, — indeed, all the muscles about the chest, which by fixing their point of attachment can aid in elevating the ribs and expanding the chest, such as the pectorals, latissimus dorsi, quadrati lumborum, sterno-mastoid, erector spinae and infrahyoid. In a severe attack of asthma, for example, many of these muscles can be seen at work in a frantic attempt to get more air into the lungs. Any impediment to the free movements of the chest or action of the muscles of respiration obviously interfere with free adequate respiration. Such impediments may be pathological or mechanical. Of the former we may have diseases of the lungs, pleural effusions, aneurysm of the aorta, curvature changes in the thoracic walls, ascites, peritonitis, abdominal tumors, etc. Of the latter — mechanical — are posture, flatulent distension of the stomach, constriction, like tight corsets.

The general movement of the chest is also greatly diminished in emphysema, in certain cases of asthma, and from injuries to or diseases of the spinal cord which paralyze the muscles of respiration. The movements of one side of the chest may also be diminished, as in pleural effusion, pneumothorax, pneumonia and tuberculosis.

Increased expansion occurs during violent exercise; in the early stages of febrile diseases; from various emotional disturbances, and sometimes in dyspncea. When in the case of an unilateral tuberculosis increased expansion of the other lung occurs, it is a favorable prognostic omen. There is a retraction or general drawing in of the intercostal spaces when there is any obstruction to the entrance of air, as in croup, the pressure of an enlarged thyroid gland, an aneurysm, or a tumor pressing on the trachea or bronchi. This also sometimes happens in bronchial asthma.

The relation of the act of inspiration to that of expiration is as 5 to 6 ; but the relative duration of the sounds, however, are as 3 to 1, while the expiratory sound is often quite inaudible.

The circumference of the normal chest averages 34 inches, or 87 cm., and the expansion on forced inspiration from one and one-half to five inches, or 4 to 13 cm. Much depends upon practice in deep breathing.

Vital Capacity of the Lungs

The vital capacity of the lungs, or the amount of air exhaled on a forced expiration, after a forced inspiration, is about 230 or 240 cubic inches, or 3600 c.c. in men and 150 cubic inches, or 2500 c.c. in women. In one thousand observations which I made upon males from sixteen to forty years of age, I found the average to be 240 cubic inches. The vital capacity is measured either by the water or dry spirometer. The vital capacity is generally diminished in all diseases of the respiratory organs, and hence this measurement is of some value in judging of improvement in a case of tuberculosis, for example.

The " tidal air," the amount of air inhaled and exhaled in quiet breathing, is about 500 c.c or 30 cubic inches. The " complemental air," the additional amount one can take in by forced inspiration, is from 1500 to 2000 c.c. or 90 to 120 cubic inches ; and the " supplemental air," the additional amount one can exhale in excess of the normal tide, by forced expiration, is from 1200 to 1500 c.c. or 72 to 90 cubic inches. The " residual air," what is left in the lungs at the end of forced expiration, is estimated at from 1200 to 1500 c.c. or 72 to 90 cubic inches.

The following measurements which the writer made and collected will serve as fairly accurate standards of chest measurements and lung capacity. The " muscular " circumference of the chest was taken at the level of the nipples and the " respiratory " circumference two inches below :

Measurements of the Chest and Lung Capacity

TABLE I

Chest Measurements

girth of chest, muscular Repose Inflated Difference

Men inches inches inches

Average of Dr. E. O. Otis, one thousand measurements, between sixteen and forty

Average of Dr. Hitchcock, of Amherst College. Eight

thousand measurements . . 34.6 36.5 1.9 Average of E. Hitchcock, Jr., of Cornell College. Fifteen thousand measurements 34-5 36.3 1.8

Women Mt. Holyoke and Wellesley students. Measurements of Miss Wood and Dr. Mary respiratory chest Men Average of Dr. E. O. Otis.

One thousand measurements 31. 1 33-1 2.0

Women Fifty per cent, of fifteen hundred Wellesley students.

Miss Wood 24.6 27.2 2.6

Measurements of the Chest and Lung Capacity Continued. depth of chest Repose Inflated Difference

Men inches inches inches

Average of Dr. E. O. Otis.

One thousand measurements in repose and one hundred and twelve measurements inflated 7.3 8.2 0.9

Women Fifty per cent, of fifteen hundred students at Wellesley.

Miss Wood 6.9

breadth of chest Men Average of Dr. E. O. Otis.

One hundred and fifty measurements 9.6 10.8 1.2

TABLE II

Capacity of Lungs

Cubic Men Inches Average of Dr. E. O. Otis. One thousand measurements 240.6

Hitchcock. Eight thousand measurements 230.0

Hitchcock, Jr. Fifteen thousand measurements .... 236.6

Women

Mt. Holyoke and Wellesley students. Measurements

of Miss Wood and Dr. Mary Colton 145.8

Fifty per cent, of fifteen hundred Wellesley students.

Miss Wood 150.3

TABLE III Comparison of the "Vital" or Lung Capacity and the Amount of Air Expelled after an Ordinary Quiet Inspiration. Average of Dr. E. O. Otis. One Hundred and Fifty Measurements •

Cubic Inches Vital capacity, or the amount of air exhaled after a

full inspiration 230.5

Amount of air exhaled after an ordinary quiet inspiration , 129.3

Difference, or " complemental " or " reserve "air 101.2

Average Lung Capacity for Height

Average for each inch Height. Lung Capacity or Centimeter

in Height.

General average

3.52 cubic inches. 23.19 cubic cms.

As has been said, the expiratory act, although essentially passive as regards the muscles of respiration, takes place by a shrinkage of the lung tissue by means of its elasticity. When this elasticity is impaired by degenerative changes or disease, expiration is incomplete or difficult. Normal respiration occurs at the rate of about 16 times per minute. We may say anything between twelve and twenty is normal. The ratio of the respiration to the pulse rate is about one to four or five.

Abnormalities of Respiration

(a) Dyspnoea — difficult, rapid, labored respiration — occurs in a variety of conditions, such as heart disease, pneumonia, extensive pleural effusion, asthma, tuberculosis, anaemia, and acute infections. We have both expiratory and inspiratory dyspnoea. When both exist, which is commonly the case, it is called mixed dyspnoea. Functional dyspnoea occurs as a result of violent exercise or emotional disturbances.

(b) Orthophoea: excessive dyspnoea, when the patient is obliged to sit up in order to breathe more easily.

(c) Obstructive dyspnoea, from some hindrance to free entrance of the air into the lungs, caused by various obstructions in the pharynx, larynx, trachea or bronchi, such as enlarged tonsils, peritonsillar abscess, oedema glottis, foreign bodies in the upper respiratory tract, stenosis of the larynx or trachea, aneurysm, tumors, etc.

(d) Apncea: a temporary cessation of breathing, illustrated in so-called " Cheyne-Stokes " respiration, which is characterized by a waning and waxing of the respiration. Beginning with a number of superficial respirations, they gradually deepen until full respiration or even dyspnoea is reached ; then the respirations decline in force and length until a state of apnoea occurs which may last so long that one may believe that the patient is dead.

(e) Asphyxia: a sudden arrest of respiration from outward violence, as in choking, or in apparent drowning. In many instances of apparent death from asphyxia, resuscitation may be effected by means of artificial respiration at once applied and continued for a long time.

Other abnormalities of respiration are indicated by the names given them, as stertorous, stridulous, asthmatic, shallow, jerky, sighing, catchy, restricted.

A study of the respiration, both in health and disease, is of much value and conveys much useful information. Breathing exercises are an important preventive measure as well as a valuable aid in some of the abnormal conditions of the lungs. Proper full respiration is, in modern life, more or less of an acquired habit, and it is of importance that the physician himself should first learn to breathe correctly and then he will be able to teach his patients to do the same. There are a few easily acquired breathing exercises, both simple and efficient, which will develop the chest and increase the lung capacity, and which will be of value in preventing disease, as well as helpful in the treatment of various diseases. For an exhaustive study of this subject, one is referred to the treatise upon " Respiratory Exercises in the Treatment of Disease " by Harry Campbell, M. D. N. Y. Wm. Wood & Co.