as is so frequently and so illogically done, increase the blood pressure by the use of vasoconstrictors. For nervous and excitable patients morphine in small doses may be given, but its use is not unattended by danger for reasons already given. Night Sweats. Hygienic treatment greatly decreases their frequency. The skin should receive careful attention. Clothing should not be too heavy and should be kept dry. Just before going to sleep the patient should be sponged with alcohol and water. Many drugs have been recommended for this symptom, but none seem to be of much value.

Tuberculin. The use of tuberculin is undoubtedly of value in many cases. It is, however, much more available for sanatorium than for dispensary use, as its effect on each patient must be carefully watched. Personally I have had little experience with tuberculin except for diagnostic purposes, and therefore am not in a position to discuss its merits.

CONCLUSIONS.

As we have stated, tuberculosis is a disease which needs careful medical attention and nursing.

The attempt at treatment outside of sanatoria for patients in the social station in which the disease abounds is a poor substitute for sanatorium treatment.

The disease will not be eradicated by the establishment of sanatoria which admit only incipient cases, while they reject the advanced cases and discharge cases which fail to improve and will sooner or later become advanced cases and thus spread the disease among others.

We hear a great deal about tuberculosis being preventable— it may be, but not without the expenditure of vast sums of money to care for advanced and chronic cases in sanatoria, and to aid the dependent families thus deprived of wage-earners.

While a conscientious and properly trained arrested case is often, by his example, of distinct benefit to the community or shop to which he returns, the giving of employment to uncured cases discharged from sanatoria is not unattended by danger to the community.

DISCUSSION.

Dr. David R. LYMAN (Wallingford): The subject of this paper properly takes in the biggest portion of the treatment of tuberculosis, for there is no case of this disease that does not have to be treated outside the sanatorium. The sanatorium does only a part of the work in any case. The treatment of tuberculosis may be divided into two parts, the treatment before the arrest of the disease and the treatment after the arrest of the disease. Practically all that the sanatorium does is to arrest the disease and put the patient on his feet, so that he may go home and work with his doctor to accomplish the rest. Every tuberculosis patient needs treatment for years after he gets home from the sanatorium. This is, to my mind, the chief stumbling-block in the treatment of this disease. We have hitherto paid too little attention to the patients after they get out; but now we try to get in touch with them afterwards, in their home life.

The chances are that if the patient goes back to his family doctor, the latter will forget that the most dangerous point in the case is when the man has got where he looks and feels perfectly well and has no symptoms. He then has an anatomical tuberculosis, but not a clinical one; and he must be watched for several years, to make certain that this anatomical tuberculosis does not develop into a clinical one. Ambrose Paré said that he was interested in cases, but still more so in persons. It is not the disease that is interesting, but the man. We often see cases of tuberculosis carried on to arrest by the general practitioner as thoroughly as in any sanatorium. The trouble is that if the general practitioner carries his case on to arrest, he says to the patient: "Now you are all right, except for a slight cough; come back, if you are feeling badly." The patient should come back, whether he is feeling badly or not, at regular intervals for examination. He must be told that the trouble has not cleared up yet, though he is better; and that he must be still helped for a year or two before he will be quite well.

Another way for the general practitioner to help the patient is in regard to occupation. I do not believe that a good indoor sort of work is so bad as it is often considered to be. The work must be light and suited to the patient's strength. For men in stores or in watch shops or factories, sitting down, there is no physical strain and no exposure. If you can regulate the patient's life for the fourteen hours of the day spent outside the shop, you can very often get him well after a brief interval of training in the sanatorium. The point of having a sleeping-porch is most important. If you can do that, you are sure that you have the patient out of doors a good part of the time. If a man is working in a shop, the doctor, who is usually a man of influence in the community, can nearly always induce the patient's employer to give him a favorable position.

Another point is the question of feeding. I do not believe in forced feeding or overfeeding. We give the patients meat at two meals a day, and allow no raw eggs. The average gain in weight in our sanatorium last year was 17.9 pounds apiece, while the highest gain in any other eastern sanatorium was 15.1 pounds. Dr. Landis, in the Phipps Institute, Philadelphia, found that the incidence of ulcers was exactly the same as in Professor Welch's series of two thousand autopsies. Most of the stomach symptoms were due to forced feeding and overloading the stomach.

DR. HENRY F. STOLL (Hartford): A couple of months ago the Journal of The Out-Door Life contained an editorial on the Treatment of Tuberculosis Outside of Sanatoria, and one of the statements made was that there are a good many people who can work and get well from tuberculosis, a good many who can play and get well from tuberculosis, but very few who can both work and play and get well. If we impress this upon the patients and look out for the fourteen hours when the patient is not at work, he will get along. If the men will go to bed at half-past seven, a good many will get well and stay well under home treatment and, at the same time, not have the pecuniary loss of going to a sanatorium.

Regarding tuberculin, I think that it is hard to control dispensary cases, unless you have an extremely good visiting-nurse association; but with private patients, you can get very good results. It relieves the toxic symptoms, and that is a great help. Statistics show that patients who take tuberculin relapse less frequently and live longer than do those who do not take it. It should not be used by a person unless he has had experience and has observed others use it, as great harm can be done if it is not used carefully

DR. IRVING E. BRAINERD (Wallingford): The treatment of tuberculosis outside the sanatorium is undoubtedly preventative treatment. Dr. Deming brought out one point, that when a patient coughs, he should put a handkerchief before his mouth; but I have never seen, in any book that I have read, in the pamphlet issued by the State Board of Health, or anywhere else in print, any precautions mentioned that the patient should use regarding the disposal of that handkerchief. We should bring up that point. The handkerchief should be well taken care of afterward, and, not stuffed into the pocket with damp sputum on it.

DR. DUDLEY B. DEMING (Waterbury): Regarding the question of keeping the patients out of doors, I think the matter of climate and location must be taken into consideration. Getting dust into the throat

is an important factor in this consideration. One of the greatest advantages of keeping the patient out of doors, even when it injures him, is the lessened risk of exposure to other members of the family.

Regarding the care of the handkerchief, that is an important point. I think that a piece of gauze which can be burned, sufficiently thick so that it will not wet through, is better than a handkerchief.

Some Features of Rectal Alimentation.

LOUIS M. GOMPERTZ, M.D., NEW HAVEN, CONN.

While it has long been the custom to administer nutrient enemas by the rectum, the value of this method of artificial feeding has often been questioned by physiologists and clinicians, because of its failure to accomplish beneficial results. This no doubt, in many cases, is due to the composition of the enemas used. A wide difference of opinion exists, between the two classes of investigators mentioned, as to the comparative absorptive powers of the rectum for the different food stuffs. All seem to agree that water and a certain amount of salts are absorbed, but beyond that there are two divergent views.

On the one hand, it is claimed that the nutrient enema owes its virtue solely to the salts and water therein contained and that the rectum has not the power to utilize the other food constituents, such as sugars, starches, proteins, and fats.

On the other hand, it is maintained, in spite of the chemical propositions involved, that the mucous membrane of the rectum and sigmoid flexure has the power to absorb certain nutrient materials and pass them into the blood vessels and lymphatics in sufficient amounts to sustain life for a period of weeks. This latter contention is supported by competent observers, not only on the theory that the rectum itself possesses the inherent power of absorption; these observers go a step further and state that the injections of nutrient enemas are carried by reversed peristalsis into the small intestine, where they are acted upon by the alimentary digestive secretions, so that the function of absorption takes place in the same way as that resulting from food taken through the mouth. The following résumé may be found of interest in this connection:

In 1894 Grützner (1) found that certain easily recognizable substances, such as starch grains, hair or charcoal, when