for two hours before or after eating. For those sleeping in the open air, the afternoon bath is preferable.

no

Smoking in moderation can be indulged in by those who have

marked cotarrhal condition or throat irritation. Cigarette smoking and tobacco chewing cannot be too severely condemned.

The patient should be impressed with the importance of not only protecting those with whom he is associated from acquiring his disease, but also of protecting himself from re-infection. He should be cautioned against coughing directly in

the

face of others, being instructed to always place his hand before his mouth during the paroxysm. This necessitates washing the hands before handling his food at meals. He should be further instructed not to cough or laugh in the faces of those with whom he is conversing, for while under ordinary circumstances there is no danger of infection from his breath, still during coughing, loud talking, sneezing and laughing, particles of infected sputum are propelled several feet.

The care and disposition of the sputum should receive unremitting attention on the part of the patient and of those caring for him. It should be received into paper receptacles, preferably a paper cup, or perhaps a paper bag containing a little saw shavings or cotton. Whatever receptacle is adopted should have suitable protection against flies. All paper receptacles should be burned, and the holders disinfected daily. There are many devices on the market, but I think the most satisfactory paper cups, their holders, and pocket paper cups,

dust.

are

anufactured by the firm of Seabury & Johnson, of New

York City. They are economical and absolutely safe. patients must be cautioned against expectorating in their handkerchiefs or on the ground. Under no circumstances should

the

expectoration be swallowed. Further, the consumptive's

eating utensils should be kept for his exclusive use, being boiled after using. It should also be customary to boil his bed linen when it is laundried, and never to allow him to occupy a bed

or

in

even a room with another member of the family. A room which a tubercular person has lived should be disinfected.

before being occupied by another person.

Sweeping with a broom in the sleeping room should never be permitted unless it is covered with a damp cloth.

As to amusements, there are two extreme courses-one in which all social intercourse, reading, correspondence, and even

any sort of light work is prohibited; the other in which the patient is permitted to follow his own inclinations without restriction. Personally, I advocate a middle course for the average individual. A certain amount of recreation is necessary to prevent the patient's becoming unhappy and morbid, for the mind exercises a great influence over the bodily condition, especially in neurotic types. Games of chance, however, should be prohibited as being over exciting.

Good food, fresh air and rest, in the treatment of tuberculosis, are dwelt upon and emphasized by men in this line of work, and very rightly; but they are inclined to neglect a fourth factor of prime importance: i. e., discipline or control of the patient. The individual taking the open air treatment is necessarily obliged to give up for the time being a great many pleasures. In fact, self-denial enters decidedly into his programme. The average patient, however, thinks that if he iollows the physician's directions a few hours during the day, he has done his share in the getting well process. He does not appreciate the fact that the germs of tuberculosis are active day and night, week in and week out, and that it therefore behooves him, if he wishes to making a winning fight, to be always persistent in carrying out the open air treatment. This is a campaign in which eternal vigilance is imperative, and in which leaves of absence cannot be granted without the gravest danger, for the enemy is always alert to take advantage of a weak defence. The physician is the general who merely directs; the patient is the soldier who must do the fighting.

It is of the utmost importance that the physician have the absolute confidence not only of the patient, but also of the members of the patient's family, who can either assist or retard the recovery of the invalid, as they are or are not in sympathy with the physician's treatment. The immediate family should be thoroughly instructed in regard to the reasons for, and the importance of, every rule that is laid down; otherwise they may be more or less influenced and guided by outside suggestions. I have found it of great service to outline for every patient, on a special printed form, a plan which fully regulates his daily life, leaving him no excuse for neglecting his instructions. I give below one of these blanks, which although intended for institution work, can be well adapted to home treatment.

The physician can fill out such a form, and change it from time to time as he finds his patient progressing towards recovery. It gives explicit instructions to be carried out from the time of rising in the morning until retiring at night. Even with these instructions, however, the patient, no matter how conscientious, cannot be entirely depended upon to always carry them out unless he is under the supervision of some member of the family-a person who must be gifted with great tact, and who can be depended upon to hold him to the task in hand. Physicians are too much in the habit of taking for granted that their instructions will be carried out; there are very few consumptives who after a few days of hard "chasing," do not think that they may reward themselves by some self-indulgence, which is more than likely to undo the good they have accomplished. The physician must recognize this fact and act accordingly.

Under the open air treatment, the tendency to night sweats, annoying cough, etc., usually disappears without the aid of medicine. Creasote and Cod Liver Oil are remedies that are not considered a part of the armamentarium of the phthisiologist. It is an unfortunate fact that many physicians are still using these remedies. I would suggest to any such that they will get better results by substituting plenty of butter, cream or olive oil, which in no way disturbs the digestive apparatus. There are a certain number of consumptives, however, whose physical condition is so far below par when they first come under observation, that tonic treatment is advisable. I have found the bitter tonics, or a combination of iron, arsenic and strychnine, very satisfactory. As a rule little or no medication is necessary in the open air treatment, but strict attention must be paid to keeping the eliminative organs active. This is best accomplished by the use of the natural mineral waters, alkaline salts, or the cascara preparations. Cough mixtures should be resorted to only when coughing at night interferes with sleep. Where an unnecessary nervous cough, or frequent coughing without expectoration, is present, it becomes necessary to teach the patient how to restrain it. The rapidity with which the cough is controlled after the adoption of the open air treatment is most gratifying.

Most encouraging results can be hoped for in home treatment, especially among the white race. The problem of tuber

culosis among the negroes is one with which you are more familiar than I, though I am told that their mortality from the discase is twice as great as that of the whites.

Much can be said upon the subject of the home treatment of the consumptive, but time has permitted my taking up the subject only in a general way. The suggestions which I have offered are perhaps familiar to most of the physicians here, but the thought with which I wish to close is that their importis too seldom strongly enough impressed upon the mind

of the patient.

DISCUSSION.

Dr. Blake: I have listened to these papers with more than orclinary interest. Most of you will remember the interest I displayed in this matter some dozen or more years ago. I have little to say along the line of treatment, for I agree eagerly with what has been said. Possibly some of you will remember two experiments which I carried out and reported to this Associa

tion

andl

Some eight years ago. I took two patients and weighed them, taking note of their condition, temperature, pulse, etc., Put them on a diet of milk and eggs. I fed them fruits and peanuts and encouraged them in the use of fresh milk; and with very good results. My work has been largely among the negroes. The most important point in the treatment, as I see it is the diet. In regard to diversion, I would encourage everything that does not tax the patient's strength. The more he can keep his mind off of his condition the better. Some years ago, ibega visiting every gypsy tent that I could find to ascertain whether they, living as they do out of doors, were af

ficted

with this disease. I have yet to find the first case of con

Sumption among people reared in tents. This applies only to my own observation.

to the

as

we

We must expect the best results to come people as a whole by teaching the children. It is a fact, all know, that there are many people who become in

fected who are strong physically. I am now treating a man who is tuberculous himself and who has buried his second wife from tuberculosis. If our children were taught the importance of avoiding unnecessary exposure to contamination, by this disease and if the tuberculous patient can be taught not to infect those around him by reckless spitting, we will have accoma great deal. It is a fact that people well informed

plished