Cottage Cheese

40 » melted...

20 » vegetable.

20 The specified set has the following composition of basic nutritional substances: Products Calories Proteins Fats Carbohydrates in grams 2 836 1611 79.3 86.8 H,1 118.9 603.1 28.2 Total .... 4 337 166.1 136.3 631.3 In % 15.7 28.1 56.2 This set can be supplemented if necessary with additional portions of: 10 g of sugar, 10 g of butter, 10 g of clarified butter, 200 g of milk, 10 g of cottage cheese, 15 g of sour cream, 5 g of cheese, 16 g of cream, ¹/₂ egg, 25 g of poultry, 25 g of meat, 100 g of fruit, 5 g of caviar, 10 g of potato flour. Thus, the enhanced diet will contain: proteins 189.2 g, fats 173.3 g, carbohydrates 600 g. Total calories 4,963. Protein calories 15.5%, fat calories 32.3%, carbohydrate calories 52.2%. With such a diet and proper organization of the culinary department, any patient can be provided with the necessary diet through individual portions of pantry products.

Much attention must be paid to the dining room environment, table setting, and serving of dishes, as these are important details providing patients with psychological impulses to eat and increasing their appetite. Approximate distribution of meals throughout the day: 8^:/₂–9 hours - breakfast: tea, coffee, cocoa; butter, cheese, cottage cheese, eggs, cold meat; hot dish: porridge, casserole, omelet. 11–12 hours - second breakfast for those requiring enhanced nutrition or unable to eat early in the morning: acidophilus milk, kefir, milk with bread. 13–14 hours - lunch: soup, meat or fish dish with salad and vegetable garnish; fruit or berry juice ¹/₂ glass, dessert. 16–17 hours - afternoon tea: cookies, nuts, fruits, honey. 20 hours - dinner: dairy dish (syrniki, cottage cheese with sour cream, casserole, etc.), meat or fish dish, fruits or salads. 22 hours - before bedtime a glass of milk, acidophilus milk, or fruits or berries.

A tuberculous patient with a treatable process, following the hygienic-dietetic regimen in a proper environment, can improve and recover in a climate normal for them, provided the general conditions of the locality where they live ensure the possibility of carrying out all elements of the regimen (availability of green space, protection from winds, absence of swamps, fogs, etc.). The same patient at any climate station, without observing the regimen and without having the opportunity to fulfill it, can pay dearly and become incurable. Climatotherapy (see) creates a certain optimum of conditions that facilitate the implementation of the hygienic-dietetic regimen and especially mitigate the influence of changing meteorological phenomena for patients with an unstable autonomic system. The requirements for a climate station for tuberculous patients are: climatic evenness, absence of sharp changes in weather, temperature jumps, mildness of climate—absence of excessive heat and excessive cold, absence of strong cold winds, dryness of climate—absence of heavy rains, and, most importantly, porosity and good drainage of the soil. Climate therapy is indicated for those tuberculous patients in whom stable compensation is not established with local treatment, but who have prospects for cure or at least improvement of their condition. Acute, rapidly progressing forms and far-advanced, irreversible processes can gain nothing at a resort, and sending them there is inexpedient. When sending a patient to a climatic resort, one must, firstly, take into account the period when the trip is most expedient according to the climatic conditions of the resort (e.g., wintertime for high-altitude resorts, spring and especially autumn for the resorts of the South Coast of Crimea, North Caucasus), and secondly, the conditions of the institution to which the patient is sent. Sending a patient with an active process to a resort without knowing the conditions they will encounter is an inadmissible risk. Treatment at a resort must necessarily begin in an inpatient setting, and only after acclimatization has set in and the process is compensated can the question of transferring to outpatient status be raised. Short-term trips to a resort for 1.5–2 months are rarely justified, and in cases where serious and lasting success is desired, the duration of treatment should be determined by individual indications in each case, based on medical data. The combination of climatic factors and the therapeutic role of the hygienic-dietetic regimen is most strikingly manifested in the kumys-treatment resorts of the USSR (see Kumys, kumys treatment). Physiotherapy in the treatment of tuberculosis is comparatively underutilized. Light therapy for tuberculosis of the larynx, bones and joints, and skin (see corresponding chapters) is used comparatively widely. Extensive experience exists in the use of ultraviolet rays for the treatment of scrofulous manifestations and lesions of the serous membranes. However, until recently, the use of physical therapy agents in tuberculosis treatment was carried out tentatively and did not receive mass distribution. Manukhin, Bachmeister, and Rickmann report good results of X-ray therapy for chronic fibrous-productive pulmonary processes. V. P. Tsvetkov at the State X-ray Institute in Moscow (USSR) also obtained a good effect. X-ray therapy of tuberculosis requires appropriate technical equipment and staff training. Sobelmann, Grinchar, and Holzmann report favorable results from using a combination of chest vibration massage (10 days for 2–3 minutes a day), irradiation with ultraviolet rays (rays are directed onto the chest corresponding to the location of the pulmonary foci through opaque plates perforated in the form of a grid that are opaque to ultraviolet rays), and rubbing with a faradic brush with metal bristles, included as one of the electrodes of the diathermy apparatus. According to the authors' observations, the combination of these irritations leads in 25–30% of cases to the healing of fibrous-productive foci and even the healing of small, not very old, and thick-walled cavities with the persistent disappearance of bacilli. In addition, one must point out the expediency of using a projector, hot dry air, and other thermal stimuli for the treatment of pleural processes. Finally, mention should be made of the observations of Sobelmann, who uses a large apparatus of the "Fen" type, which alternately emits a stream of hot and cold air. By this method, Sobelmann manages to train patients sensitive to drafts and make them more resistant to changes in meteorological conditions. All available observations clearly show the great value of including various physical therapy influences in the treatment regimen of tuberculous patients. The desire to influence the healing of tuberculous foci by stimulating the reticuloendothelial system (Umstimmungstherapie, Reiztherapie) has led to numerous attempts to introduce various preparations from the group of non-specific irritants into tuberculosis therapy: Romanovsky's phosphacid, Livshits's lipocerebrin, gelpin (an emulsion of glycerin and lecithin), getol, cinnamic acid benzyl ester (Jacobson), colloidal preparations, carbon powder (carbion), and the like. Despite isolated positive reviews, these preparations have not taken root in the tuberculosis clinic because it is impossible to establish their stable and deep therapeutic effect on the active tuberculous process. Calcium preparations (see Calcium, therapeutic use) shared the same fate, retaining a very modest place in the tuberculosis clinic at present in cases of marked hypotension of the autonomic system, excessive sputum production, and pulmonary hemorrhages (hypertonic solutions). Regarding the therapeutic significance of creosote, guaiacol, thiocol, and similar preparations, no one speaks of them at present, and they are practically completely excluded from rational tuberculosis therapy. The same must be said of chaulmoogra oil. Also no longer used are the until recently very widespread rubs of liquid potassium soap (Kappesser) or an oily solution of guaiacol (for diseases of the peripheral lymph glands and serous membranes). Autohemotherapy (see), proposed and theoretically substantiated by Lintvarev for tuberculous pleurisy (Kahn) and chronic fibrous-productive processes, has a favorable effect on general well-being and results in a decrease in adynamia and intoxication. In a number of cases, it is possible to establish an objective effect in the area of the affected organs. In view of the observed severe exacerbations upon the introduction of large amounts of blood, it is recommended to start with 1 cm³ and, monitoring general and focal reactions, carefully increase the amount of injected blood to 10–15 cm³. The therapeutic effect is enhanced and becomes more stable upon repeating treatment courses (stage-by-stage treatment—"training" of the reticuloendothelial system). Tuberculosis chemotherapy was developed experimentally in the 1900s by von Linden (copper salts), while clinical wide-scale experimentation began after the publication of Møllgaard's work on sanocrysin. In view of the high toxicity of sanocrysin, a number of analogous, according to authors' reports, less toxic preparations were released—aurophos, tryphal, ganal salt, but these preparations also still require extensive study of dosage and methods of application. Gavasch (Central Tuberculosis Institute), based on experiments on animals, comes to the conclusion that the therapeutic effect of gold preparations is due neither to their parasitotropism (as Møllgaard and Pointdicker assert) nor to organotropism (Krichevsky, Pagel, Jungeblut, and others), nor to their irritating role (Kolle, Ehrlich, and others), but to a prolonged action on the reticuloendothelial system, especially manifesting in the zone of the tuberculous lesion, accompanied by an increase in monocytes and an enhancement of their phagocytic abilities. Gavasch comes to the conclusion that it is expedient to therapeutically use very small doses of gold salts (hundredth and thousandth fractions of a gram) in periods of quiescence in stages, with the aim of switching the functions of the reticuloendothelial system in a direction that promotes the healing of tuberculous foci. L. Bernard's report at the IX International Congress (Warsaw, September 1934) points to 15% clinical recovery and 45% great improvement in treatment with gold salts. This newest report, along with Gavasch's data, makes it possible to consider the therapeutic use of gold salts in tuberculosis as a method deserving further study with the aim of introducing it into the practice of tuberculosis institutions. Tuberculin therapy was proposed by Koch and studied in the clinic in the early years (1890–91) under his direct participation. The basis for the therapeutic use of tuberculin was Koch's observation studying the reaction of a tuberculosis-infected animal to the repeated administration of an emulsion of killed and crushed tubercle bacilli. Upon administering large amounts, Koch obtained the picture of reinfection (tissue necrosis at the injection site, sequestration, ulcer formation without a reaction of the lymph glands), whereas upon repeated administration of minimal doses (when the emulsion gives a barely perceptible turbidity to the eye), the animals do not die from the spread of the tuberculous process, their condition improves, the ulcer at the inoculation site decreases and cicatrizes (this is never observed without the use of the emulsion), the plumpness of the animals increases, and, if by the beginning of the experiment the process has not gone too far and has not finally exhausted the animal's strength, a subsiding of the disease phenomena is noted. These observations allowed Koch to propose the use of preparations obtained from tubercle bacilli for therapeutic purposes.

Since the tubercle bacillus emulsion is slowly reabsorbed and sometimes leads to the formation of prolonged suppurations, Koch succeeded in obtaining a preparation containing antigenic substances without the debris of tubercle bacillus bodies. This preparation was Koch's original tuberculin (Alt-tuberculin). Applying tuberculin to lupus patients, Koch had the opportunity to observe focal reactions with phenomena of exudative infiltration of the affected areas and with subsequent development of fibrosis. Koch observed the exact same thing with the therapeutic use of tuberculin in pulmonary tuberculosis. This feature of tuberculin to cause, at a certain dosage, acutely proceeding reactive changes in the zone affected by the tuberculous process, with the subsequent development of reparative changes, gives it the character of a specific therapeutic agent. Despite the fact that more than 40 years have passed since the introduction of tuberculin into practice, there are still no sufficiently solid experimental and theoretical works that could explain the essence of the therapeutic action of tuberculin, and Koch's observations remain as before the most valuable proofs of the therapeutic value of this preparation and similar ones. Apparently, tuberculin is a stimulator of trophic processes, causing an intensification of the activity of the reticulo-endothelial system, proliferation of connective tissue, and encapsulation of foci. On the other hand, its influence on bacteriolysis and the creation of conditions inhibiting the growth of the tubercle bacillus cannot be excluded. Excessive dosage of tuberculin, on the contrary, causes exudation, hyperemia of foci, their further growth, and metastasis. These opposing qualities of tuberculin make its use for therapeutic purposes especially difficult and responsible and are the reason for such contradictory assessments of it in practice. After the first period of enthusiasm, which ended in great disappointment due to the receipt of numerous severe focal reactions (excessive dosage, ignoring small reactions that preceded the outbreak), the therapeutic value of tuberculin is still a subject of discussion and it is used far from universally. Along with ardent supporters of tuberculin therapy, who attribute specific therapeutic significance to it, there are authors who cautiously evaluate tuberculin therapy as a method supporting the influence of other therapeutic measures, and numerous skeptics who recognize only diagnostic significance in tuberculin. In addition to the monographs by Bandelier and Röpke, Kremer, Löwenstein, Liebermeister, Denys, Gabrilovich, and Karpilovsky, which represent very solid material proving the therapeutic value of tuberculin, there is also a fairly large number of articles in various medical journals, but nevertheless skepticism regarding the therapeutic value of tuberculin therapy has not been overcome. This is apparently also explained by the fact that the correct assessment of the influence of tuberculin therapy requires very careful clinical observations, the treatment itself sometimes requires a lot of time, during which the patient must be under the observation of one doctor all the time. As a result, treatment often has to be interrupted without bringing it to lasting results. Many are confused by the reactions observed during treatment, and they abandon treatment halfway through and become disappointed in it. The complexity of tuberculosis tuberculin therapy is evidenced by numerous tuberculin preparations (see) proposed by authors in order to mitigate reactive phenomena. Without denying their positive significance and having tested the tuberculins of Denys, Cressling, Holtzman, however, does not attribute any special advantages to any of them over the old Koch tuberculin, one of the most stable and best subject to valorization preparations. Until now, there have been two diametrically opposed methods of applying tuberculin: the anergizing method, proposed by Koch and carried out by Kremer, Liebermeister, and others with the aim of achieving a weakening of allergic reactions, and consequently the desensitization of the organism to the toxins of the tubercle bacillus, and the anaphylactizing method, proposed by Schröder and Bessau, who by introducing tiny doses of tuberculin strive to cause an intensification of allergic reactions, hoping thus to maintain at a higher level the processes of immunity in a given patient. Holtzman shares Koch's point of view and believes that the therapeutic effect of tuberculin therapy is possible only upon obtaining focal reactions capable of causing proliferative processes without causing persistent and severe alterative changes. The anergizing method therefore appears to be the only expedient one. Having tentatively determined the reactive threshold and the nature of the reactions (stormy or weak, short or protracted) in a given patient (skin or intradermal reactions), Holtzman, dosing tuberculin all the time within limits close to the reactive doses, exerts precisely that stimulating action of encystment of foci that is needed. Thus, the moment for discontinuing tuberculin therapy is also determined (either upon achieving stable compensation and encapsulation of foci or upon reaching the limits of favorable reactions, when with a further increase in dosage there is a danger of severe reactions with the possibility of provoking the growth of the focus and metastases). The comparison sometimes made of such a system of using tuberculin with mithridatization is incorrect, since in tuberculin therapy there is no habituation of the organism to increasing doses of poison, but all the time there are living, labile reactions that can be caused by an irresponsible increase in the dose of tuberculin or an increase in the frequency of injections. The gradually onsetting anergy to ever-increasing doses has a great similarity to the positive anergy that the organism strives for during self-recovery from tuberculosis. It is very valuable to repeat courses of tuberculin therapy in stages. As with other methods of treating tuberculosis (physiotherapy, heliotherapy), the stage-by-stage method is the best stimulator of systems playing a role in creating immunity. The anaphylactizing method of tuberculin therapy with minimal doses, apart from the phenomena of sensitization observed in patients with labile reactions, yielded nothing, according to the observations of the authors, and is not recommended. The proposals made by Sahli to introduce tuberculin into the thickness of the skin rather than into the subcutaneous tissue in order to reduce reactive phenomena do not introduce anything fundamentally new. In cases where significant reactions can be feared, it is easier to start with the weakest possible concentrations (see below) and, as if running off a springboard, approach the lower threshold of reaction. Holtzman believes that the subcutaneous method of administering tuberculin is the most convenient both technically and with respect to subsequent observations of reactive phenomena. The introduction of tuberculin through skin incisions according to Pondorf has no advantages over subcutaneous injections, but is associated with the danger of skin infection in case of patient untidiness. The rubbing in of tuberculin ointments (Petruschka, Moro-ectebin, Neumann-Ateban) is indicated in children, especially in scrofula, tuberculous eye diseases, and peripheral glands. Holtzman observed a very good effect using Moro's ectebin (concentrated Koch's tuberculin with an ointment base). Intravenous injections proposed by Bessau and Fernbach require careful clinical verification. The administration of tuberculin orally is not justified by any solid clinical observations. Deike-Much's partigens were proposed in order to ensure the introduction of the fraction that causes the most favorable effect (fraction A - protein group, fraction B - fatty acids and lipoids, fraction C - neutral fat). The determination of the necessary fraction should be made according to intradermal reactions to each of them. The methodology for using these preparations turned out to be so complex, differentiating reactions to individual fractions turned out to be so difficult, that the authors themselves quickly abandoned it and switched to the introduction of a mixture of all fractions obtained after treating bacilli with lactic acid (MTBR). With this, the originality of their proposal was eliminated, and the preparation lost any special advantages over Koch's tuberculin. The use of Koch's new tuberculin (see) alternating with Koch's old tuberculin is very valuable. The preparation of tuberculin solutions is best carried out personally, without using ready-made dilutions in ampoules. It is most advisable to use tenfold dilutions. The first dilutions (nos. 1-6) can be prepared for future use for 10-15 days, the subsequent ones should be made on the day of injections due to their instability. For dilution, a physiological NaCl solution is used with the addition of 1/4-1/2% carbolic acid; dilutions are stored in small dark glass bottles with rubber or ground glass stoppers; all glassware is necessarily sterilized every time the tuberculin solution is refreshed. To obtain dilution no. 1, take 0.5 cm³ of tuberculin and add 4.5 cm³ of carbolized saline solution, to obtain dilution no. 2, take 0.5 cm³ of dilution no. 1 and again add 4.5 cm³ of carbolized saline solution, etc. A label is pasted on each bottle: no. 1 - 1 syringe division = 10 mg of old tuberculin, no. 2 - 1 syringe division = 1 mg of old tuberculin, etc. A label with the dilution number and the date of preparation of the solution is pasted on the stopper. Dilutions can also be made using graduated pipettes for serological reactions.

It is necessary to wash the syringe and needle or pipette with physiological saline every time one passes from one dilution to another. It is best, if possible, to have a separate syringe and platinum needle for each dilution (such as is the design of the Deyke-Much partigen kit). The dosage of tuberculin injections is particularly difficult and responsible when determining the initial dose. Significant assistance in establishing the initial dose and the intervals between injections is provided by tuberculin reactions. Bright, short reactions serve as a favorable indicator for tuberculin treatment, whereas strong but prolonged ones are a signal for maximum caution in tuberculin therapy and indicate the need to start with the smallest possible doses and make the intervals between injections 2-3 days longer than the duration of the reaction. Sluggish, late, prolonged reactions are a warning against starting tuberculin therapy at the given moment, because they indicate exhaustion of the body's reactive capacities and its inability to produce reparative changes in the foci. To determine the initial dose, it is most expedient to perform an intradermal test (see Intradermal reaction), injecting a drop of tuberculin of the 8th, 7th, 6th, and 5th dilutions. If a positive reaction of moderate strength is obtained at one of these dilutions, therapeutic injections are begun with a dilution two numbers weaker (for example, if there is a reaction to No. 6, injections are begun with No. 8). If a reaction is obtained even to No. 8 above average intensity (the diameter of the papule is greater than 1¹/₂-2 cm), then after the subsidence of reactive phenomena it is expedient to check the titer on Nos. 12, 11, 9 and begin therapeutic injections, once again, with weaker solutions than the one that turned out to be the threshold of reaction. In rare cases, allergic reactions occur even to weaker solutions than No. 12, in which case treatment should also be started with even weaker dilutions. With positive reactions to dilutions stronger than No. 10, it is necessary to check whether the patient also reacts to simple carbol-saline solution (Holzmann had to observe such reactions twice in hundreds of cases), and in the presence of such hypersensitivity, puncture reactions can no longer be taken into account. In such cases, it is better to postpone treatment until the next check of reactions. In most cases, with moderate allergy to tuberculin, one can begin with No. 8.

Further dosage may proceed as follows: up to No. 10, 3-4 injections of each dilution can be given (2, 3, 5, 7 divisions of a gram syringe); starting from No. 9, it is better to proceed more slowly (1; 1.5; 2.5; 3; 5; 7) in the presence of high reactivity; and starting from No. 3 and above, to proceed even more slowly (1; 1.2; 1.5; 2; 2.5; 3; 4.5; 5; 6; 7). For injections, it is best to use a gram tuberculin syringe with each tenth of a gram divided into 10 parts. The interval between injections should be at least 48 hours upon reaching the threshold of allergic reactions; starting approximately from No. 5, the interval should be tentatively determined by the duration of skin reactions, which should be periodically repeated. Upon obtaining a local reaction, do not resume injections until the reaction has completely resolved. An even stricter wait-and-see approach is required for the end of a reaction in the case of a temperature reaction and, even more so, a focal reaction. Upon reaching a reactive dose, the same dose must be repeated at the next injection if the reaction was not violent, or else one must immediately drop down by at least 1-2 dilutions. If the reaction is violent, wait for complete subsidence and drop down by at least 2 dilutions. If, upon repeating the dose that caused the reaction, no new reaction occurs or the reaction is much weaker than the previous one (shift of the titer upward), the dosage can be cautiously increased. In addition to reactions, it is necessary to take into account the patient's general condition (temperature, malaise, headaches, increased cough, increased sputum, chest and back pain), blood changes: erythrocyte sedimentation rate, hemogram, eosinophilic reaction according to Mikhailov, and weight fluctuations. Despite the possibility of accidental coincidences between changes in the patient's condition and tuberculin injections, all details can always be taken into account and, if necessary, intervals can be lengthened and the dosage slowed down. In cases where the repetition of a dose that caused a reaction causes an even stronger reaction, and when, after going down and coming back to the same dose, a stubborn reaction is obtained anew, treatment must be interrupted for at least 2 months. With this methodology, it is possible to remain near the threshold of reactive phenomena all the time and consequently influence the processes in the foci in the sense of stimulating healing phenomena without causing severe reactions with the danger of a breakout of the foci and the formation of metastases. The question of the final dose of tuberculin is decided depending on the course of the process: when compensation has set in and the titer is easily shiftable, one can stop at any moment. It is advisable, however, after 2-3 months, to check the titer again and perform another course, starting with the dose that preceded the highest reactive dose of the previous treatment course. Such repeated stages consolidate the achieved results. Indications for tuberculin therapy can be established only after prolonged, careful observation of the patient and clarification of the nature and course of the process. The experience of all those working with tuberculin indicates the inadmissibility of tuberculin therapy in acute exudative reactions (periradicular infiltrates, infiltrates, etc.), and in all acutely progressing processes. Tuberculin therapy is useless and unsafe in old cavernous processes and bone lesions with abscesses. The effect of tuberculin therapy is exceptionally favorable in protracted generalization with a sluggish course, but prominent allergic reactions and minor local changes in the system of peripheral lymph nodes, in the eye (phlyctenules, scleritis, iritis, etc.), on serous membranes (recurrent pleurisy, serositis, protracted serous exudates). Tuberculin therapy is absolutely indicated in limited, sluggishly progressing productive-fibrous foci accompanied by minor breakdown, especially of apical localization. An indispensable condition for tuberculin therapy is the utmost scrupulousness in dosage and careful recording of all changes in the subjective and objective state of the patient. No templates, schemes, or stereotyped actions can be tolerated in tuberculin therapy. Before giving an injection, it is necessary to check the temperature data for the past period, speak with the patient, weigh him, auscultate him if there is the slightest reason to do so, and only after that decide whether to give the injection, what dose to take, etc. Treatment with killed tubercle bacilli, proposed by Möllers, has not gained widespread acceptance and has no advantages over Babes emulsion. Experiments with treatment using live cultures of tubercle bacilli of attenuated or normal virulence (Selter, Langer) are of great interest, but are permissible for now only in the setting of special research institutes. Here one should also include experiments studying the therapeutic possibilities of Calmette's vaccine. Friedmann's vaccine (an emulsion of acid-fast bacteria of not entirely clear nature; according to Friedmann's statement, tubercle bacilli isolated from a turtle that contracted human tuberculosis), despite the loud and unprincipled advertising of the firm manufacturing and selling the vaccine and the extensive literature of the preparation's proponents, has still not received a positive evaluation from competent institutions. The Central Tuberculosis Institute of the People's Commissariat of Health and the Moscow Regional Institute conducted prolonged observations on the treatment of bone tuberculosis and pulmonary patients with the vaccine and did not obtain any encouraging results whatsoever. Drug treatment of pulmonary tuberculosis, despite the countless number of drugs proposed at various times, is completely ineffective. Well-known preparations from the group of creosote, guaiacol, essential oils, and resins exert only a more or less pronounced symptomatic effect on appetite, cough, and sputum production, but no convincing effect on the course of the tuberculous process can be established. Surgical methods of treatment of pulmonary tuberculosis—first of all, artificial pneumothorax (see)—have gained universal distribution and play a colossal role in the treatment of cavernous forms of pulmonary consumption, being the most powerful method for the healing of cavities and rendering patients non-infectious (see also Lungs, Thoracoscopy-thoracocaustics, Thoracoplasty, Phrenicectomy). Symptomatic treatment in tuberculosis, as in other diseases, aims to temporarily alleviate the patient's suffering in the presence of severe painful symptoms. Fever that does not respond to bed rest (in acute galloping processes) usually does not respond to symptomatic drugs either. The best remedy causing a relatively mild and steady drop in temperature is a 1% pyramidon solution, which the patient drinks by a sip every 20-30 minutes, starting 3 hours before the time of the usual temperature rise. A total of 200 cm³ of the solution is given per day. Injections of camphor in an oil solution help the patient tolerate high temperature, but do not affect the height of the fever. In the presence of a good hydrotherapy department, not-very-weak patients can undergo short, 15-20 second cold showers (15-16°) for several days in a row, followed by vigorous rubbing of the entire body and dry wrapping. At the Moscow Regional Institute, in a number of cases subjected to such treatment, it was possible to suppress the fever for a long time. Night sweats can be weakened by careful patient care (changing linen, wiping the body with water and cologne, baths). General weakness and loss of appetite respond to the patient's exposure to the entire complex of regimen measures, and no drugs (phytin, arsenic, bitters, etc.) yield anything significant. Cough yields wonderfully to the efforts of the patient's will, who can be broken of the so-called useless dry cough and taught to cough up the sputum requiring removal briefly and easily. When an urge to cough arises, the patient must breathe shallowly, or make several empty swallowing movements (a few sips of water can also be taken), or suck on a caramel or lozenge. Coughing should be done in short, strong bursts only when the sputum has already reached the throat. With such self-discipline, the use of narcotic drugs (codeine, dionine, lantopon, Dover's powder, etc.) can be minimized and limited only to giving 1 powder at night to ensure quiet sleep. In the terminal period, of course, there is no need to limit narcotics, since they alleviate the last days of life for weak patients. Expectoration of sputum usually occurs freely and mainly during the morning toilet of the lungs. Alkaline mineral water (Borjomi), ammonium-anisate drops (20-30 drops), apomorphine (0.05 : 200) in tablespoons 4-5 times a day are quite sufficient for a temporary effect. With very large amounts of sputum, intravenous infusion of 10% CaCl₂, 5 cm³ every other day, is indicated; if the fluid gets into the perifascial venous tissue, immediately inject ¹/₃% novocaine into the resulting painful infiltrate. Pains in the chest and back respond well to painting with iodine tincture, and often weaken and disappear after warming with a blue lamp, diathermy, or simply a hot water bottle. For severe pleural pain, fixation of the corresponding half of the chest with adhesive tape. Treatment of pulmonary hemorrhage—see Hemoptysis. Shortness of breath within the limits of possible regulation of cardiac activity is alleviated by acting on the heart muscle.

Periodic inhalations of oxygen (for a few minutes 3-4 times a day) provide a temporary positive effect and calm the patient (especially in acute anoxemia due to spontaneous pneumothorax, etc.). Upon completion of the main course of treatment and the onset of a more or less stable compensation, especially upon discharge from the tuberculosis sanatorium and transition to a home regimen, a very responsible period begins (after-care, häusliche Behandlung), when the persistence of the achieved treatment results depends to a large extent on the correct organization of the patient's life. The system of necessary therapeutic measures at this time is largely covered by the system of hygienic-dietetic regimen carried out during the treatment of tuberculosis. The relative role of hardening and sparing measures varies depending on the nature of the tuberculous changes in a given patient. In the presence of abortive foci, general physical weakness, but without manifestations of an active process for 1-2 years, in order to strengthen the body and create the greatest stability, it is necessary to carry out the entire program of hardening with air, water, sun, physical culture (see corresponding chapters) and provide this person with a rational, healthy diet designed to maintain the optimal weight for the given case. In periods of compensation after recently experienced flare-ups, the same procedures must be dosed by the attending physician and carried out under medical supervision, the more frequent and stricter the closer the period of active course, the less studied the limits of the given patient's stability and his reaction to the hardening system. Regulation of work and rest is also determined by the degree of process compensation, the duration of the active flare-up, and the patient's endurance. The criteria for evaluation, in addition to subjective sensations, are temperature, weight, ESR, and the nature of the sputum. In the absence of indicators of exacerbation or activation of the process, in the absence of other pathological changes, the patient's work and rest regimen can be established as for healthy individuals. But the appearance of signs of adynamia, a loss of tone in work (especially in children and adolescents) should draw the attention of the physician managing the patient and serve as a signal for the most thorough examination of the patient and clarification of the nature of the tuberculous process. The question of the resumption of work by tuberculous patients after they have suffered intercurrent diseases (primarily influenza, pulmonary diseases, acute infections) must be decided with particular caution. Release to work in such cases without X-ray control and in any case without a thorough clinical examination, sputum analysis, ESR, etc., is unacceptable, because the phenomena of activation of the tuberculous process may go unnoticed. In cases of activation and the appearance of fresh foci or metastases, referral for special treatment with exemption from work is necessary. Upon achieving compensation—if possible, a gradual transition to working half a working day for some time. In cases of compensation with low stability, it is more expedient to give short vacations for rest (with a certain regimen) more often (2-3 times a year) than a long rest 1 time a year. Of course, all these measures have to be individualized. It is especially important to carefully regulate night rest and by all means achieve the exclusion of the patient from evening and night shifts, providing him with 8-9 hours of sleep. Categorically demand to finish all work no later than an hour before sleep and prohibit reading in bed. Days of rest should preferably be spent in the fresh air outside the city (one-day rest bases, excursions, sports). Of sports activities within the limits permissible by the general condition of the body, rowing, skiing, and skating are most recommended. Tourism, especially for children and youth, is a powerful strengthening agent. Bathing and swimming during the period of compensation and with abortive dormant foci are permitted under the condition of regular medical supervision and in moderate amounts. Underwear and clothing should ensure, first of all, dryness and warmth of the feet (changing stockings upon returning from work, a walk, etc., putting on dry stockings at night in case of chronic chilblains of the feet); hygroscopicity for rapid sweat absorption (mesh fabrics, cotton knitwear). Woolen underwear is not recommended due to the rapid loss of hygroscopicity; the same applies to flannelette, flannel, and artificial silk. In cold weather, woolen sweaters and jumpers over underwear to prevent hypothermia. Heavy fur outer garments that fatigue the chest muscles are not recommended. Outer clothing should be light and warm. Waterproof rubberized coats should be completely prohibited, and if they cannot be replaced by an umbrella or a coat made of impregnated material, their wearing should be restricted to moments of extreme necessity. Wearing felt boots in winter is not forbidden. The dwelling must be provided with a window of sufficient size, in which it is recommended to make a transom instead of a small vent for room ventilation even in the cold season. Rooms with windows facing southwest and away from the street are best. For better disinfection, the floor should be covered with linoleum, the walls coated with glue paint, which is easily renewable and does not disrupt natural ventilation to the extent that oil paint does (linorust or washable wallpaper is very rational). In case of unstable weight that tends to fall—additional food rations, but without the tendency to excessive overfeeding observed at present (an additional ration to the usual diet containing approx. 120 g of protein, 90-100 g of fats, and 500 g of carbohydrates for an adult should not exceed 2 eggs, 50 g of butter, 1/2 liter of milk, 100-150 g of meat, and similar products and 50-75 g of concentrated carbohydrates). Excessive accumulation of fat reserves must be treated with particular caution, since this creates the danger of developing persistent obesity and cardiovascular disorders. It is very important to ensure regularity, hygienic surroundings, and the culinary qualities of the diet. Often this alone is enough to establish a dietary regimen without special rations and keep the patient's weight at the required level. Wine, especially light grape wines, and beer occasionally and in small quantities can be permitted. Regarding sexual intercourse, the doctor should recommend restraint, taking into account the individual characteristics of the case. The role of the physician regarding female patients is especially responsible. Here it is necessary to take into account the danger of a flare-up of the tuberculous process during pregnancy and after childbirth and, focusing on the nature of the process, the reaction to previous pregnancies and childbirth, taking into account the age of the woman, the presence or absence of children, social and material conditions, and finally the desire of the patient, to allow the possibility of conception or to provide the woman with the necessary contraceptive measures, and in the event of pregnancy, its timely termination. If in abortive processes and in the case of many years of compensation pregnancy can pass without activation of the process, then in the presence of destructive changes in the lungs and other manifestations of the active process, the risk becomes very serious and the doctor's position very responsible. If it is possible to induce an artificial pneumothorax (see), the situation can immediately change for the better. If advanced pregnancy is discovered or if the patient categorically refuses to terminate it, accelerated delivery (Cesarean section, high forceps, and other means) must be provided in order to shorten the duration of labor efforts. Careful implementation of the hygienic-dietetic regimen, if possible in the setting of a special sanatorium, is mandatory for tuberculous women during pregnancy. In cases of a patient's propensity to pleurisy and upper respiratory tract diseases in the presence of pulmonary tuberculosis, it is very rational to move away for a long time or even forever from the continental climate with sharp weather changes and winds to a mild, dry, steady climate. In the European part of the USSR, the most favorable zones are the South Coast of Crimea, the North Caucasus, and Georgia. In the Asian part of the USSR—the mountain regions of Western Siberia (Altai). In individual cases, it is advisable to leave the permanent place of residence and travel to climate stations in autumn and spring, during periods of unstable, damp, windy weather.

V. Kholyschian. VII. Pulmonary tuberculosis in children. In view of the fact that in the overwhelming majority of cases the lungs are the site of the primary localization of the tubercular process, as well as of its further progression, it is natural that in children, as in adults, they are affected most frequently (see above - pathological anatomy). Clinic. Upon the introduction of the infection into the body, within 3 weeks to 3 months (Levesque), and most often apparently within 7 weeks (H. Koch), no signs of the disease can be detected clinically, biologically, by X-ray, or on the autopsy table. This incubation, or antiallergic (Debré) period is characterized by general bacillemia (L. Bernard, Besançon), as occurs also in syphilis before the appearance of the chancre. In the guinea pig, such dissemination in the body can be observed as early as the 4th day after infection. The end of the incubation period is characterized by the appearance of allergic skin reactions. At the same time, the primary affect in a number of cases, especially at an older age, manifests itself in no other way besides these reactions, but in the majority of cases, especially in small children, there is a series of symptoms of the action of tubercular endotoxin on the organism. This period of invasion is characterized primarily by the formation of a primary focus, representing the first stage of the macroorganism's struggle with the microorganism. Here, upon the disintegration of the tubercle bacillus, there is a release of endotoxin, which has a caseating effect on the tubercular tissue, but at the same time there is also the production of antibodies neutralizing the excess toxin. The further progression or arrest of the process in the stage of the primary complex (see above - pathological anatomy) depends on the ratio of the forces of the macroorganism and microorganism. Sometimes the pleura is also affected, where near the primary affect an eruption of tubercles is noted, and subsequently an exudate effusion either into the free cavity or interlobarly, if the focus is located near the interlobar fissure. As a rule, the primary focus reaches the size of a pea or a hazelnut and is inaccessible to percussion-auscultation examination; radiologically it is also difficult at first to differentiate from other shadows of the lung until it is impregnated with lime salts. Usually, shadows in the region of the hilum are treated as bronchial lymph node tuberculosis, although Levesque disputes this position, believing that in the majority of cases they are the manifestation of a primary focus with a perifocal infiltrate around it. In any case, most authors currently accept that, since the primary focus is little accessible to our diagnostic capabilities due to its small size, and the regional glands are significantly larger than it, these latter are accessible for detection. By virtue of this proposition, bronchial lymph node tuberculosis plays a major role in the pathology of intrathoracic lesions (see Bronchial lymph node tuberculosis). Strictly pulmonary manifestations of tuberculosis in children are detected only when the process spreads further from the primary focus, capturing ever larger areas of lung tissue. In this case, the process can spread either per continuitatem, capturing neighboring areas of the parenchyma, or bronchogenically—by the transmission of the infection through the bronchi, or lymphogenically, or hematogenously. All these pathways give diverse clinical pictures, determining the mottled nature of pulmonary manifestations. In general, the course of the pulmonary process in children is characterized by a tendency to caseation with subsequent expectoration of the breakdown products and the formation of cavities. But it must be said that this tendency to caseosis, determining the acute course of the process leading rapidly to the death of the child, is characteristic predominantly of early age children who, due to purely age-related features, do not possess resistance to the infection. The older the child, the more pronounced is the tendency toward slower-proceeding productive forms, and the propensity for caseation and breakdown becomes less. The second main feature of the course of tuberculosis in general and pulmonary tuberculosis in particular is the tendency to dissemination of the process by the hematogenous route, determining the development of miliary tuberculosis. And once again, the younger the child, the greater is the tendency to miliary transformation of the process noted in him. Observing the manifestation of individual forms of pulmonary lesions and their course, one can note that individual clinical pictures are in close connection with the phenotype of the child, with his constitutional makeup. In children with an irritative constitution, which includes manifestations of exudative, lymphatic, arthritic, and neuropathic diatheses, a mild course of the process is generally noted, and the tendency to caseation is not sharply expressed. These children, usually reacting vagotonically, possess the ability to rapidly mobilize fibroblasts, which help to demarcate the affected focus from the normal parenchyma with scar tissue, as well as the ability to produce extensive perifocal infiltrates that subsequently resolve without a trace. In children of asthenic constitution, reacting usually sympathicotropically, these defense resources are absent, and they as a rule exhibit an unbridled tendency to caseation with subsequent breakdown, which is absent in children of the first group. Regarding the classification of pulmonary lesions, it must be said that the majority of pediatricians approach it from a purely clinical point of view. The Turban-Steinberg classification adopted by the Tuberculosis Congress in Tiflis in 1927, which is mandatory for pediatricians working in tuberculosis children's institutions, does not satisfy the clinician. Besides miliary pulmonary tuberculosis, Marfan describes paratuberculous bronchitis and bronchopneumonia, secondary tuberculous bronchopneumonia, and ulcerative pulmonary tuberculosis. Schlossmann speaks of tuberculous pneumonia, miliary and submiliary pulmonary tuberculosis, and chronic pulmonary tuberculosis (phthisis pulmonum). Kleinschmidt (1923), in agreement with Finkelstein, distinguishes chronic lung caseosis, acute caseous pneumonia, and the disseminated form of pulmonary tuberculosis. According to Lepsky (1923), pulmonary tuberculosis manifests in children in the form of bronchitis, bronchopneumonia, and caseous pneumonia. He describes perifocal infiltrates and miliary pulmonary tuberculosis separately. Simon and Redecker (1930) classify pulmonary lesions taking into account the stages according to Ranke. They consider it possible to differentiate primary and secondary perifocal infiltrates, which is hardly practically possible or necessary. Equally practically inadvisable is the isolation of pulmonary lesions of the tertiary stage of Ranke. While pathogenetically it is necessary to adhere to Ranke's views, in the clinic the division of pulmonary forms sins with artificiality. Unfortunately, this artificiality is also present in Pirquet and Engel, who in their manual also examine pulmonary lesions with Ranke's approach. Simpler and more viable is the approach taken by Levesque (1931). In the course of tuberculosis, he distinguishes two major stages—primary tuberculosis infection and reinfection. The duration of the first period is 1.5–2 years. It consists of the incubation period, the invasion period corresponding to the primary stage of Ranke, and the height period, manifesting itself on the part of pulmonary manifestations either by curable forms, splenopneumonia (trifocal infiltrate of German authors), or severe forms in the form of glandular-mediastinal, bronchopneumonic, and caseous ones. The period of primary infection ends either with complete recovery or fatal miliary transformation. Reinfection is noted in preschool and school age. Extrapulmonary localization is more frequently noted. Among pulmonary manifestations, acute pleuropulmonary forms, transient congestive forms, and perifocal infiltrates with a good prognosis despite their sometimes stormy course are often noted, but most often the ulcerative-caseous form is noted, resembling the bronchopneumonic type of galloping consumption in adolescents. Medovikov considers Lepsky's classification to be the most practically useful, according to which all pulmonary lesions can be divided into 4 groups: 1) peribronchitis tuberculosa, 2) pneumonia catarrhalis tuberculosa, 3) massively infiltrative forms (pneumonia caseosa and infiltrat. perifocalis), and 4) tuberculosis miliar. pulm. 1. Peribronchial localization of the process, noted at all ages, is clinically characterized by the presence of dry rales localized in certain areas or scattered in both lungs. These rales persist for months, decreasing in number or disappearing entirely, then appearing anew, recurring. Exacerbations characteristic of tuberculosis are manifested in children by the new appearance of dry rales. Percussion-wise, no changes are noted in the initial stages. Only after many months or years can one note a shortening of the sound and harsh breathing in one area or another in connection with abundant proliferation of connective tissue, and sometimes symptoms of bronchiectasis can be observed. The general condition usually does not suffer. With a propensity for pastosity, which is more often observed at infant age, children look well-nourished, their temperature is usually normal or occasionally gives negligible spikes, and their mood and appetite are within the normal range. Such a favorable course of the tubercular process is as a rule observed in children of the irritative type with manifestations of exudative-lymphatic diathesis with a vagotonic makeup. The development of children does not suffer, the process is fully compensated, and the immunobiological equilibrium is quite stable.

Until the development of peribronchial connective tissue, the process is not detected at all on the roentgenogram; only many months later, with the development of fibrosis, a distinct pattern of the bronchial tree is noted, either diffuse or in separate areas. In fibrous pneumonias, X-rays show extensive darkening, sometimes with a honeycomb-like cellular structure, with a shift of the mediastinum towards the affected side. The outcome of peribronchitis is restitutio ad integrum with the development of peribronchial connective tissue or chronic fibrous pneumonia with bronchiectasis. In differential diagnosis, it should be noted that the same symptoms are observed in non-specific protracted peribronchitis after measles, whooping cough, and other diseases with the same outcome as in tuberculosis. Negative tuberculin reactions, however, make it possible to make a correct diagnosis, but the possibility of non-specific peribronchitis is not excluded even in the presence of tuberculosis of the peribronchial glands, which differentiation is impossible to carry out during life.

2. Pathogenetically, catarrhal pneumonia is a further evolution of peribronchitis and cannot be regarded as arising endobronchially (Rubel). Since the hyperemia preceding catarrhal pneumonia is a function of the autonomic nervous system, the predisposition of which depends on the age and phenotypic characteristics of the individual, it is the state of this system that determines whether the process is limited to peribronchial localization or transitions into pneumonia (Rubel). Such a constitutional understanding is fully applicable to tuberculous catarrhal pneumonia as well. Clinically, pneumonia is diagnosed when, alongside dry rales, moist fine-bubbling rales are auscultated in one or another area of the lungs. Subsequently, as individual lobules merge into a larger conglomerate, shortening of the percussion note and replacement of harsh breathing by bronchial breathing are noted, with the rales acquiring a sonorous character. Like peribronchitis, such pneumonia is characterized by a protracted course. It represents the most frequent form of pulmonary manifestations of tuberculosis in children of all ages and usually lasts for months, especially in older children. The course of pneumonia and dynamic disorders are closely connected with the child's phenotype and age. The older the child is, or the more pronounced his vagotropic predisposition (status irritabilis) is, the more the process assumes a protracted course with a tendency to produce perifocal infiltrates around small caseating acini and the ability to mobilize fibroblasts to demarcate caseous foci from the surrounding tissue and penetrate them with fibrous tissue after calcification. At the same time, dynamics suffer little, the process is compensated, with occasional slight shifts towards subcompensation. Even if, under the influence of endo- or exogenous adverse factors, cavity formation occurs, these cavities are surrounded by a dense connective tissue capsule and subsequently scar (fibro-caseous forms). The younger the child is, or the more phenotypically predisposed he is in the sympathicotropic direction (status asthenicus), the faster the process proceeds, with unbridled caseation and disintegration, with the manifestation of cavernous symptoms, resulting in massive caseous lesions of an entire lobe and more. At the same time, dynamics are sharply disturbed; the process is subcompensated at first, and subsequently decompensated. Weight drops irresistibly, temperature is high, anorexia, diarrhea, adynamia. On the roentgenogram, in the initial stages of catarrhal tuberculous pneumonia, moderate-sized shadows are visible, scattered in various fields and partly merging due to perifocal infiltrates, with rounded clearances of cavities noted in places. The outcome of this form of manifestation of the process is progressive tissue breakdown with a sympathicotropic predisposition of the phenotype or scarring with its vagotropic predisposition. At autopsy, acinous-nodous areas are noted, partially merging and giving cavities. At the same time, if status irritabilis was noted during life, perifocal infiltrates and the development of connective tissue are more pronounced, whereas in status asthenicus there is a greater tendency towards caseation and breakdown. These pneumonias must be differentiated from non-specific ones, since the same symptoms are observed in protracted non-specific pneumonias after measles, whooping cough, and influenza. Even cavernous symptoms can sometimes simulate bronchiectasis when this form is combined with peribronchitis. Of differential diagnostic importance are the absence of tuberculin reactions down to Mantoux 1 : 10 and the absence of mycobacterium tuberculosis in the sputum, but, as with peribronchitis, the possibility of non-specific pneumonias in the presence of tuberculosis of the peribronchial glands is not excluded. 3. The group of massively infiltrative forms clinically includes pulmonary lesions encompassing an entire lobe or the greater part of it. This group includes two forms that are completely different pathogenetically and in their course, yet produce the same percussion, auscultation, and radiological data in the initial stages, which makes it necessary to group them together. In caseation of an entire lobe or a large part of it, as well as in massive perifocal infiltrates, there is a sharp muffling of the percussion note, weakened breathing, sometimes with a bronchial tint and the absence of rales. Only upon the advancement of the perifocal infiltrate and its resolution can fine-bubbling rales sometimes be heard, and in caseous pneumonia, in the stage of melting and cavitation. On the X-ray, in both cases, extensive shadows are noted, yielding rounded clearances upon breakdown only in caseous pneumonia. Both forms are encountered at all ages, with caseation being more frequent at an early age, and the trifocal infiltrate at an older age. Nevertheless, both of these forms can be easily differentiated from each other by taking into account the child's phenotype. At the height of caseous pneumonia, a sympathicotropic predisposition of the child (status asthenicus) is the rule, while the perifocal infiltrate is always combined with a vagotropic predisposition (status irritabilis) (Medovikov, Klare). In this regard, in the subsequent course of these forms, there is also a sharp difference in the dynamics of the children. In caseous pneumonia, there is emaciation, elevated temperature, leukocytosis with a shift to the left, acceleration of the erythrocyte sedimentation rate, and cavernous symptoms upon expectoration of caseous masses. Meanwhile, in perifocal infiltrate, the general condition is hardly affected, the children are sufficiently well-nourished, and only occasionally show slight temperature elevations. There are no deviations from the norm on the part of the blood, and the erythrocyte sedimentation rate is not accelerated. The further course of these forms is, of course, different. Caseous pneumonia, with markedly expressed symptoms of decompensation, lasts 1–2 months and as a rule ends in death. At autopsy, continuous caseation of extensive areas with the presence of cavities is noted. Perifocal infiltrates, located in the vicinity of primary or secondary caseous foci, rarely resolve quickly; usually they last for months, occasionally up to 2–3 years. At an early age, one still has to observe, even in irritatively predisposed children, the transition of a perifocal infiltrate into caseous pneumonia ending lethally after 6–10 months. Non-specific processes, such as protracted croupous pneumonia, as well as exudative pleurisies, yield the same percussion and auscultatory data. Clinical observation, X-ray, and puncture make it possible to differentiate these forms from massively infiltrative forms. 4. Miliary pulmonary tuberculosis is usually a partial manifestation of generalized miliary tuberculosis. The latter is most often noted in early childhood, when its pulmonary localization is observed most frequently. Clinically, miliary pulmonary tuberculosis manifests itself only when its pulmonary (asphyctic) form is present, yielding the triad of symptoms: dyspnea, cyanosis, elevated temperature. On the basis of these symptoms, if auscultation reveals no rales—aside from emphysema and harsh breathing—or a small number of them with variable localization, one can suspect the presence of dissemination of tubercles in the lungs. After a prodromal period of varying duration, characterized by mild general phenomena indicating tuberculous invasion, and sometimes without any prodromal symptoms, the child rapidly develops threatening signs of asphyxia with persistent dry cough, nasal flaring, cyanosis, agitation, and subsequent prostration. The picture resembles banal capillary bronchitis. The temperature rises to 39° and above. The disease quickly ends in death. Vital confirmation of the diagnosis is provided only by the roentgenogram—both lung fields are densely dotted with small shadows, giving a marbled lung pattern. Even more difficult is the diagnosis of the typhoid form of miliary pulmonary tuberculosis, since apart from weight loss and protracted fever, there are no symptoms indicating pulmonary involvement. The presence of an enlarged spleen, tuberculids, and slight coughing may, it is true, bring to mind miliary tuberculosis, but on the part of the lungs, if there is no combination with the forms described above, there is no data indicating their lesion. Only the roentgenogram clarifies the diagnosis in this case as well. The disease lasts 1–2 months and usually ends in death, but in a number of cases the process can assume a chronic character and end in complete resorption of the tubercles after 1–2 years, which can be clearly traced on a series of roentgenograms. The phenotype in miliary pulmonary tuberculosis does not play the same role as in the previous forms. Status irritabilis does not guarantee against miliary pulmonary tuberculosis (Klare). For the differentiation of non-specific lesions, it must be borne in mind that the pulmonary form of miliary tuberculosis can be simulated by acute non-specific catarrhal pneumonias originating from the center, not manifesting themselves immediately, of the Nassau cardiovascular type. Sepsis and typhoid fever can also simulate the typhoid form of miliary tuberculosis. The 4 groups outlined cover all manifestations of pulmonary tuberculosis in children.

If we add that the pictures of pulmonary lesions in a number of cases can be complicated by effusion into the free pleural cavity or interlobar space, that the caseous areas of lobar and lobular forms can, upon softening and emptying, produce cavernous symptoms sometimes culminating in symptoms of spontaneous pneumothorax, and that frequently individual main types intertwine to produce a mixed picture of lobar and lobular lesions, then all clinically observed intrathoracic lesions will have been exhausted.-In its further course, depending on the stability of the child's phenotype or its lability under the influence of various factors (social and living conditions, changes in weather, seasonal influences, psychic experiences, intercurrent diseases, etc.), the process either proceeds with the outcome of lesion scar formation, or at times produces perifocal exudations of greater or lesser extent ending in resorption, or culminates in increasingly greater caseous breakdown with the advancement of the infection via various pathways (bronchogenic, hematogenic, and lymphogenic). In the first case, there is no reaction on the part of the organism. In 75% of all infection cases, it concludes precisely thus. With perifocal infiltrates, minor shifts toward subcompensation are sometimes noted, whereas in caseosis, significantly greater disturbances of dynamics are already observed, again in accordance with the degree of constitutional resistance, which is expressed by a greater or lesser advance of caseation. Exacerbations of the process must be explained by the constitutional instability of the organism with a tendency toward sympathicotopy. The more frequently the latter is manifested in the phenotype, the more frequent and prolonged the exacerbations will be. Differential diagnosis and prognosis are set forth under each of the main forms.-T r e a t m e n t. In addition to general hygienic and dietary measures for pulmonary localization, one has to employ thiocol preparations, as well as collapsotherapy, most often in the form of pneumothorax.

P. Medovikov.