236 ON VARIABILITY AND ADAPTATION 



is"! more, our ablest diagnosticians recognized a small area of 

 dulness at the right apex ; they were doubtful as to whether 

 there was a still smaller area to the left. But no bacilli could 

 be discovered. The patient was sent to Lakewood, and there 

 at last, after two negative reports, a search through something 

 like seven slides revealed a single definite tubercle bacillus, 

 with a suspicious second. This was years before the development 

 of the finer modern methods of diagnosis, but it has always 

 seemed to me that here was a case in which the disease was 

 suspected and then recognized in its earliest stage. The patient 

 was immediately packed off to Dr. Trudeau at Saranac Lake, 

 and from the first week put on weight, gaining fifty pounds in 

 five months, and rising from one hundred to one hundred and 

 fifty pounds in weight. The effect of treatment, that is to say, 

 was immediate. Only once in the first fortnight of her stay 

 there was a doubtful bacillus or two recognized in the sputum. 

 From this time onward the sputum was uniformly negative. 

 That was twelve years ago, and the patient has never shown 

 a sign of set-back. 



The point that I want to make is this : that here there was 

 undoubtedly tuberculosis, but that of the very slightest we 

 could then diagnose, and, with proper treatment, the bacilli, 

 never present in any number in the sputum, disappeared within 

 a week or two. The fever went down, the weight went up. 

 Notwithstanding this, for more than six months — I do not 

 believe I exaggerate when I say for at least a year — that patient 

 not merely had a cough, but brought up, particularly in the 

 morning, an excessive amount of thin mucoid expectoration. 

 The cough I could understand — the healing of the tuberculous 

 process in the lungs and the formation of fibrous tissue might 

 well set up a certain amount of local irritation, and reflexly in 

 this way induce cough. Nevertheless, the cough very soon took 

 on what we term the nervous character. The patient was 

 highly strung, and this might well be a nervous habit. But I 

 could not well explain the abundant expectoration continuing 

 all these months after the evident healing of the lesions, save on 

 the theory of habit, the theory, namely, that a definite irritant 

 had in the first place stimulated the production and discharge 

 of mucus, with associated congestion of the peribronchial vessels, 

 and that the irritant had continued active for a sufficiently long 



