in a receptacle separate from that for the other clothes. A phthisical patient should sleep alone, and separate staterooms on steamships should be provided for tubercular cases. Rooms infected by tubercular sputa should be disinfected thoroughly before they are again occupied. There should be governmental inspection of dairies and slaughter-houses, and tuberculosis in animals should be stamped out by killing the infected animals.

Patients with tuberculosis should not marry. In women with a suspected tubercular tendency the risk of developing the disease is largely increased by childbearing.

(b) For the Individual.-A child born of tuberculous parents should receive careful prophylactic treatment. The mother of a tuberculous child should not nurse it nor sleep in the same room with it. The child should enjoy the recreations of an outdoor life, and studious habits, especially in crowded schools, should be sacrificed for athletic pursuits. Sedentary occupations are undesirable. Nasal obstruction, enlarged tonsils, and adenoid disease, if present, should receive prompt attention, so as to allow of the fullest extent of breathing. All intercurrent diseases are to receive more than usual attention, and the general health is to be kept at the highest pitch by fresh air, sufficient sleep, proper food, and tonics whenever they may be required.

2. To arrest the disease two things are necessary—to keep the general health good, and to prevent complicating inflammations. These conditions are complied with by (a) climate, (b) hygiene, (c) diet, and (d) drugs.

(a) Suitable change of climate affords the best chance for permanent recovery. Usually, however, the change is insisted on too late, and hopeless, even dying, patients are sent on long journeys away from friends and home comforts. There is no one climate suitable for all tuberculous patients, and in the selection of a climate good judgment

and common sense must be employed. Generally speaking, the requirements are a pure atmosphere, an equable temperature, and a maximum of temperature. As to the exact choice, much depends upon the patient. Young and robust patients with early lesions do best usually in a cold, bracing climate, where they can lead an active outdoor life and become strong and muscular. Such cases do well in the Adirondacks or in Colorado. Those who are unable to take physical exercise by reason of age, sex, or advanced pulmonary lesions do best in a warm, dry, equable climate, where they can sit outdoors and keep from catching cold without being obliged to exercise. Such a climate is to be found in Southern California, North and South Carolina, Georgia, Florida, Mexico, Egypt, and Algeria. The more unable such patients are to exercise, the warmer the climate they seem to need. Some patients are rendered worse in the cool climates and are debilitated by warm air. Such patients should travel from place to place until they find a climate in which they improve in one or two weeks. Other patients seem to do best by a variety of climates, and they improve by continually travelling.

(b) Hygiene.-Tubercular cases require a maximum of fresh air and sunshine. The sleeping-room should be airy and sunny. Exercise in the open air should be graded to the strength of each patient, much harm being done by conscientious exercise past the point of moderate fatigue. The skin should be kept open by skin-frictions and daily baths. The patient should avoid exposure to inclement weather, but over-coddling weakens him and increases his liability to catch cold. The patient should wear flannels throughout the year, but should not be over-clothed, as the danger of catching cold is thereby increased.

(c) The diet should be simple, wholesome, and abundant. The rule is that tubercular cases should be over-fed. In

addition to the ordinary diet, as much milk and cream as possible should be taken, and all dyspeptic symptoms should receive proper attention. If milk and cream are not well borne, cod-liver oil should be given in as large doses as the patient will tolerate. Superalimentation by the stomach-tube is often of great benefit. Alcohol with meals may be allowed if it agrees.

(d) Drugs.-A large number of specifics are lauded every year, but each one fails in fulfilling expectations. There is no specific treatment. A glycerin extract of the culture of the tubercle bacilli was first used by Koch, and it was found to exert a specific effect on tubercular inflammations. Injections of one milligram were followed by intense constitutional and local reaction, and cures of external tuberculosis, such as lupus, were recorded. In internal tuberculosis, however, old quiescent lesions were stirred into activity, and acute miliary tuberculosis often developed from a local lesion. Various modifications of Koch's lymph have been used, but they should be used with extreme caution. At present the feeling among the profession is strongly against the use of the lymph, but modifications and improvements may in the future place it among the standard list of specific drugs.

Creosote, which has been gaining steadily in favor, is one of the best remedies in use. It may be given in 4-minim doses at first, gradually increased to 10 or 15 minims three times a day. It may be given with compound tincture of gentian or with glycerin and whiskey, and it should be diluted largely with water at the time of its administration, or it may be given in capsules. Only the pure beechwood creosote should be prescribed. The "enteric pill" of Parke, Davis & Co. contains creosote; it is not dissolved until it reaches the small intestine. The patient may wear continuously a perforated zinc inhaler (Robinson's) kept.

moistened with equal parts of alcohol, chloroform, and creosote. Creosote may also be given by the rectum, from 5 to 20 drops being mixed with the white of one egg and water and given every day. Guaiacol or the carbonate of creosote may be used in substitution. Iron, strychnine, and arsenic are useful tonics in combination, to combat the anæmia and to build up the general strength. The hypophosphites are useful tonics, but they have no specific action.

Injections of antiseptics into the diseased pulmonary tissues have been advocated warmly; they are not commonly employed, however, as bad results have occasionally followed their use.

In some cases the inhalation of compressed air has been of great service.

3. To Relieve Symptoms.-Fever, as a rule, is best treated by change of climate and by fresh air. When the temperature is high, however, patients should not attempt much exercise, and frequently they do better when put to bed for a few days. Sponging with cool water relieves the feverishness and makes the patient comfortable, but other more radical measures are to be used with extreme caution.

For the sweating, aromatic sulphuric acid is the best and the simplest remedy. Sponging the body with vinegar and water upon retiring is frequently effective. Zinc oxide, gr. ij, with ext. hyoscyami, gr. iij, in pill is a favorite combination, while atropine in doses of gr. 126 at night is fairly steady in its effects. Picrotoxin (gr.) may be used, but with extreme caution. Strychnine is often of use. Cough, if not too troublesome, is best left alone. If it be dry or harassing, opium or codeine may be given at night to secure sleep. Hydrocyanic acid, belladonna, and the expectorants, in combination with codeine, often relieve this troublesome symptom, but care should be taken that the stomach be not

disturbed by nauseant remedies. If the cough be accompanied with profuse expectoration, the expectorants are not indicated, but reliance should be placed upon creosote, turpentine and its derivatives, and the mineral acids.

Pain in the chest is to be treated by counter-irritation. For the treatment of hæmoptysis see Pulmonary Hemorrhage.

Diarrhoea should be treated on general principles, but opium in some form has almost always to be used.

4. DISEASES OF THE PLEURA.

FIBRINOUS OR DRY PLEURISY; PLASTIC

PLEURISY.

Etiology. This form of pleurisy may be primary or secondary. The primary form may appear to be due to exposure to wet and cold, but modern theories regard cold merely as a predisposing factor to bacterial infection. The secondary form complicates any acute or chronic pulmonary disease involving the periphery of the lung. Thus, pleurisy occurs in conjunction with pneumonia with abscess, gangrene, or cancer of the lung, and with hemorrhagic infarctions. Occurring with pulmonary tuberculosis and phthisis, it may be the earliest indication of tubercular disease, and many cases of so-called "primary pleurisy" owe their origin to a small undiscovered tubercular lesion in the lung that may finally develop and give rise to symptoms.

Pleurisy may be secondary to inflammation of organs other than the lungs. Thus, pleurisy may arise from caries of the ribs or of the vertebræ, from perforation of an cesophageal cancer, from tubercular disease of the bronchial glands, from pericarditis, or from peritonitis. Cases following erysipelas of the chest-wall are not infrequent.