The walks are gradually increased in length over paths laid out on a rising gradient. Every effort is made to increase the patient's power of resisting temperature changes by improving the re-active power of the skin. During the toughening process the patient passes through a course of treatment beginning with dry and alcohol rubs, followed by graded baths until he anticipates his cold douche with pleasure and can stand exposure to all kinds of weather with impunity.

That these hygienic measures should be deemed paramount and drug administration-invaluable in meeting many of the complications and emergencies arising in the course of the disease-counted a secondary factor, does not mean the patient's emancipation from medical supervision. The patient's idiocyncrasies and age, the condition of his heart and nervous system, and the stage of his disease influence the choice of climate, altitude and mode of treatment so much that a competent physician's advice, given only after most painstaking examination of the patient and careful inquiry regarding his environment and material resources, should determine where he is to go. Manifestly the details of medical treatment, the amount of absolute rest, the time spent out of doors, the details of bathing and massage and diet must be carefully directed by qualified observers who should have the patient under constant surveillance and who should be in a position to effectively interdict harmful and vitiating habits. Such control can be satisfactorily carried out only in what the Germans call a "geschlossene Heilanstalt"-a closed institution of healing, or sanatorium, in contradistinction to the open health resort, where the patient is subject to no controlling influence and where his habits are directed by the dictates of capricious appetite and restless ennui.

To Doctor Herman Brehmer, of Goerbersdorf, is given the credit of initiating in 1859 the sanatorium treatment of tuberculous patients, following suggestions first made by Dr. George Bodington, an obscure English physician. His sanatorium is situated at an altitude of about 2,000 feet, in a beautiful location on the southern slopes of the Riesengebirge in southeastern Germany.

Falkenstein, in the Taunus Mountains, not far from Frankforton-the-Main, presided over by Dr. Dettweiler, is perhaps the best known of European sanatoria. Rupertshain, not far from Falkenstein, is the first sanatorium in Germany founded for the treatment of the poor consumptive. It owes its existence to the energy of Dr. Dettweiler and the generosity of the wealthy patients of Falkenstein and the philanthropic citizens of Frankfort. These institutions have since largely multiplied throughout western and central Europe, numerous

sanatoria being maintained by municipalities, insurance companies, and even large industrial corporations.

In our own country the sanatorium idea is making satisfactory progress. Well equipped private sanatoria are located in nearly every section of the country presenting favorable climatic conditions. To Massachusetts belongs the honor of having erected the first State institution for the treatment of tuberculosis. This sanatorium was opened in 1898 and is located at Rutland, among the high hills in the central part of the State, at an elevation of about 1,000 feet, being protected from the north and west winds by a heavily wooded knoll. In style it occupies the mean between the large single building type of the older European sanatoria and the isolated cottage plan as represented by the Adirondack Cottage Sanatorium. The institution consists of a semi-circular aggregation of pavilions in the center of which is placed the administration building and in the rear the dining hall and a large assembly room, all connected by corridors and covered walks. Each pavilion contains the requisite number of baths and toilet rooms, a number of individual sleeping rooms, and a ward containing from fifteen to twenty-five beds, and terminates in a large solarium. At the opposite end of the pavilion across the common corridor, is a small reading room, usually occupied by the nurses. All the buildings are surrounded by wide verandas with large doors, so that the beds can be readily rolled out of doors in suitable weather. The windows are wide and are kept open on at least one side of the building all the time.

In this connection it is interesting to note that the experience at Rutland favors the open ward rather than the individual sleeping rooms. Rutland is in every sense a sanatorium-an institution for healing tuberculous patients. Only incipient cases are received and patients who do not improve after a stay in the sanatorium sufficiently long to test the effect of treatment are advised not to remain. In spite of the above rule it is stated that the percentage of really incipient cases received is small and that the majority of cases treated have well marked symptoms of tuberculosis, with in many cases, advanced signs of disease in the chest. Of all the cases treated 45 to 50 per cent. leave with the disease "arrested," while of the incipient cases 75 to 80 per cent. leave with the disease "apparently cured." The directors refuse to speak of cases as cured, preferring to use the terms "disease arrested" or "apparently cured," believing that it requires years to demonstrate an absolute cure. Dr. Trudeau, of the Adirondack Cottage Sanatorium, which has been in existence for a much longer period, commands data showing that patients are well and actively engaged in

business who were discharged from that institution from ten to fifteen years ago.

The cost of maintenance per patient per week at Rutland is between $9.00 and $10.00. Of this the patient pays $4.00 per week, the balance being furnished from the State treasury.

The incurable tubercular, who from among the incipient cases are fortunately few, form an appalling proportion of all cases that came under observation, it being estimated that about 70 per cent. of all applicants for admission to State sanatoria are rejected because they have already reached the incurable stage. These unfortunates should be cared for in tuberculosis hospitals, as distinguished from sanatoria. Here the lives of the patients should be as rigorously supervised and the treatment as carefully regulated as in the sanatoria, in the hope of securing amelioration of their symptoms or a possible cure; but manifestly their comfort and a minimizing of the menace they would be to their friends and families if they were at their homes would be the only result attained in a majority of these cases. State and municipal relief must necessarily be planned with the end in view of the greatest good to the greatest number. Sanatorium treatment is relatively expensive and its facilities comparatively limited. It seems but just that its special privileges should be reserved for those who will be enabled through its aid to resume their places as producers in the community.

In closing permit me to summarize as follows:

Pure air, proper feeding and rest are the important factors in the treatment of tuberculosis.

In no disease is constant, painstaking supervision of every detail of the patient's life by a competent physician of such great importance. This can be best accomplished in special institutions situated in elevated localities where there is a maximum of pure air and sunshine. The difference in available sites for tuberculosis sanatoria is one of degree and not of kind. A high altitude is not essential and temperature, unless subject to sudden and great changes, is of little importance to the majority of patients. Pure air, moderate altitude, protection from wind and freedom from smoke and dust are the chief requisites for a satisfactory site for a tuberculosis sanatorium.

To be effective, treatment must be begun early, and to that end the disease must be recognized early. Patients often neglect consulting a physician until the disease has reached the incurable stage.

Sanatoria accepting only incipient cases for treatment report 75 per cent. cured. Sanatoria accepting cases indiscriminately, report only 25 per cent. cured. The most effective and most lasting cures are

those accomplished under climatic conditions similar to those the patient has always been accustomed to and to which he will be obliged to return after his discharge from the sanatorium. This point is of especial value in the consideration of the destitute consumptive, for whom distant sanatoria are not available and for whose maintenance the municipality is bound to provide sooner or later. Far better to provide a place where he can be cured and returned to his family a bread winner in five or six months, than to care for him later an equally long time as a hopeless invalid and for his family an indefinite time, several of whom he has perchance infected and who will sooner or later follow in his footsteps.

520 Rose Building.

SALINE INFUSIONS IN PUERPERAL INTOXICATIONS. *

By Hudson D. Bishop, M. D., Professor of Surgery, Cleveland Homeopathic Medical College. The credit for the origin of the method of washing out the blood ("lavage du sang") of toxic substances contained in it belongs to Dastre and Loye. The experimental work of these authors demonstrated conclusively that the kidneys excreted an increased amount of liquid in direct proportion to the amount of saline solution introduced. into the circulation-thus washing away and diluting the toxic substances contained in the blood stream.

The therapeutic applications of this discovery have been many. Normal salt solution has been used with success in the acute infectious diseases, typhoid fever (Landauzy), pneumonia (Henry), tetanus, erysipelas, the auto-intoxications-such as uremia, eclampsia, diabetic coma, and the intoxication resulting from severe superficial burns.

In sepsis-of whatever bacterial origin-it has had most successful use-and it is of these conditions that I wish to speak in particular. In every case of puerperal infection, whether it be sapremic or septicemic, the constitutional symptoms manifested by the patient are those of an intoxication from toxins absorbed by or toxins liberated in the blood stream.

The clinical data of septic cases in which saline infusions have been used seem to corroborate the experimental observations of the above mentioned authors. The blood seems to have been washed of its contained toxins,-perhaps not completely, but to a sufficient extent to enable the normal phagocytic powers of the body to re-assert themselves and successfully cope with the invading micro-organisms or toxins.

* Read at meeting of Cleveland Homeopathic Medical Society.

During the past three years I have used saline infusions in seven cases of puerperal infection of varying degrees of intensity,—and in every case I have felt that the action of the saline was almost specific -in bringing about a return to normal conditions. I have been so impressed with the results noted that I have come to believe that every case of puerperal infection, whether sapremic or septicemic, no matter how slight, should be given the benefit of saline infusion. I will not go into the details of the histories of these cases, because there were no differences between them, except the degree of the intoxication. All received other methods of treatment as it was indicated. Sapremic cases were curetted and in all the resisting power of the patient was stimulated by food and alcohol.

The method of administration of the saline solution I consider as very important. Enteroclysis, while of undoubted efficiency in cases of anæmia from hemorrhage-is not satisfactory in this class of cases, and this is especially true when a septic diarrhea has begun. No matter with what care a high enema is given in such conditions its only effect is to cleanse the colon and rectum-very little of it being absorbed.

Hypodermoclysis is the method to be used in the majority of cases. It is almost as simple a procedure as enteroclysis and has the undoubted advantage of accuracy of amount of solution added to the blood. In its simplest form all the apparatus that is necessary is a sterilized fountain syringe and a large sized aspirating needle, such as should be carried in every pocket case. If the fountain syringe is not available a pint or quart bottle can be used and the solution be removed from it by siphonage.

The chief precaution in hypodermoclysis is that of surgical cleanliness. The solution must be sterile, the apparatus must be sterile, and the skin of the patient at the point selected for the insertion of the needle must be sterile.

The best locations for the infusions are in the loose tissues at the anterior border of the axilla and under the breast. Before inserting the needle the solution should flow through the tube and needle until all the air bubbles have passed. If the patient is very nervous and dreads the operation, the skin at the point selected should be infiltrated with a few drops of 2 per cent, Cocaine solution. After the needle is inserted the solution-container is raised above the patient's level sufficient to cause the entrance of the solution into the tissues. This entrance should not be forced-no faster than absorption takes place. The distension of the tissues with the formation of a tumor is nothing more than a traumatism of the part and not only causes sub