portionate to the degree of involvement of the lungs and pleura. It rendered invaluable services in persons who have had pneumonia a short time previously, pleurisy or bronchitis or who have valvular lesions of the heart, for many of these cases present symptoms and physical signs that are very suggestive of tuberculosis. I have not found it of value in locating cavities in advanced cases; as the contents of the cavities, the consolidated infiltrated lungs tissues surrounding them and the thickened pleura were sufficient to compensate for any loss of lung tissue. The use of the X-ray for therapeutic purposes was disappointing in 15 cases in various stages of the diseases in which I gave it a thorough test. Its effect on relieving pleuritic pains was marked.

It is unnecessary to specify the various drugs used to combat annoying symptoms. Remember, however, that by temporarily relieving the patient of a symptom we may use drugs that have a bad general effect. The chief ones in this category are opium and alcohol.

The Treatment of Pulmonary Tuberculosis By STARLING LOVING, M. D., Columbus

I have absolutely nothing new to offer concerning the treatment of the disease named in the caption of this paper, but I wish to express briefly my own views founded upon reading and a lengthy and somewhat extensive experience.

It is fortunate that the infective power of the tubercle bacillus is comparatively feeble. Were it so strong as that of the germs of some other diseases, smallpox for example, all endeavor to prevent its dissemination and to control its effects would be useless. But understanding as we do, in a measure, the limits of its infective powers, and the inherent power of resistance to its ravages constantly shown by the human organism, and knowing that many recoveries

occur through the unaided efforts of nature, and through the efforts of nature aided by our art, there is strong encouragement for us to continue the effort which began almost with the dawn of time, to overcome the most persistent and dangerous enemy of our race. The experience of the ages past has demonstrated the uselessness of all special and, in large measure, of all medication, and we are forced to consider prevention and general sanitation as the only means by which we may control the malady.

Since the discovery of Villemin and the more recent advances in sanitation, much has been done in the way of prevention, but, while through the influences mentioned and perhaps others not yet well understood, tuberculosis is diminishing in all civilized countries, much more must be accomplished before it can be said that it is even measurably under control; for it is still the cause of seven percent of the total mortality of the earth. To forward the end it is necessary that we of the medical profession shall extend our own knowledge and that we instruct the laity in regard to the communicability of the malady and the steps necessary to prevent the dissemination of its cause. When it is generally understood that the disease is directly communicable through the depraved secretions of the infected body, mainly through the expectoration, and that the sufferer disseminates the contagium as he walks, it is to be hoped that the main source of infection may soon cease to exist. When it is understood (as has been the popular opinion in Italy for 400 years) that a tuberculous member of a family is a constant menace to all other members, and the invalid is placed for the night in a separate chamber, another fruitful source must cease.

It should be generally known also that infection is not conveyed by contact, through halitus gaseous connections, nor through the expectoration or other secretions when moist, but mainly through the expectoration after it has fallen upon the ground, become dry, reduced to the pulverulent state, to be borne with the dust by the winds in every direction and

often to great distances, to find entrance to the body through the respiratory and possibly other mucous surfaces. What has been stated in regard to the presence of the bacillus in the expectoration is true also of the excretions from the intestinal canal, the kidneys, and possibly of the perspiration, and in order that the danger of infection may be reduced to the minimum, not only the discharges from the lungs but those from other parts should each day be carefully collected and disinfected or destroyed by burning.

The widely prevalent opinion that the infection may be conveyed through articles of food, particularly milk and the flesh of tuberculous animals, though it may not be well founded, as appears from recent experiments, demands consideration, for though the bovine and the avian bacillus be not communicable to man, milk and meat from diseased animals cannot be considered wholesome, and, though thorough cooking destroys the tubercle bacillus, both should be rejected like other tainted articles of food. If the infection cannot be conveyed from animals to man through their flesh and milk as taught by Koch, the medical profession is responsible for the unnecessary expenditure of vast sums of money and much discomfort and mental distress.

Much help is gained from the influence upon the general health and upon the bacillus by the free admission of light and air into habitations of all kinds, and the avoidance of crowding. The notable diminution of tuberculosis in London, Boston, New York, and other large cities may be attributed in a large measure to the improvement in the dwellings of those cities. Dwellings which have for a length of time sheltered one or more persons suffering from the disease eventually become infected and the surviving members of the family should be warned and appropriate measures for the destruction of the bacillus taken.

The public should be taught that cleanliness of person and premises and the avoidance of excesses, especially in the use of alcoholic drinks, are strongly protective against all diseases, tuberculosis included.

Climatic and Hygienic Treatment. While the number of cases is undoubtedly reduced by preventive measures, climatic and hygienic treatment affords the only hope after infection.

Change of habitation is often followed by speedy improvement, and, if associated with other appropriate measures, is often sufficient for the cure. Except so far as the personal comfort of the patient is concerned, the results obtained in various countries seem to prove that the choice of climate (avoiding extremes) is not important; but other things being equal, it is better to select a locality where the patient can spend a great part of the day in the open air without discomfort, and consequently most patients should be sent, say from Ohio, to a more equable or warmer climate, the choice being governed by the condition, and often the preference of the patient.

Residence in Florida is objectionable because of the liability to malarial infection, but residence in the southern part of the State, say Palm Beach, during the winter months when mosquitoes are less abundant, is to be preferred to residence in Ohio or any of the States so far north. The climate of California is also better than that of Ohio, but most points on the coast are objectionable on account of the difference between the temperature of the day and night, but some of the interior valleys, while too hot during the summer, are admirably adapted for winter residences. Owing to the greater dryness and cleanliness, and, as many think, the altitude, the climates of Colorado, New Mexico, and Arizona is beneficial, as proved by the results in thousands of cases. Unfortunately, the number of persons who have gone to Colorado is so great that the bacillus (as in Minnesota, which 40 years ago was considered better than any other resort) has become implanted and tuberculosis originating there is as common as elsewhere, and while many thousands who still go annually with the hope of recovery are cured or benefited, the effects of the changes are not so notable as in former years. Fort Bayard and Las Cruces in

New Mexico, Tucson, Phoenix and Yuma in Arizona are becoming popular and are undoubtedly good localities for winter residence. Within the last year or two, typhoid fever has become rather common in Phoenix and is of course a menace to all susceptible persons. Where suitable accommodations are obtainable, the interior of the central portions of Cuba, the Isle of Pines, and the Tierra Templada, Mexico would be almost ideal localities. Many have been benefited by a sojourn at Orizaba in Mexico. The climate of the Bahama Islands is remarkably favorable, especially for neurotic and excitable subjects and those who suffer from hemorrhages and cardiac lesions, but the isolation of the group and the lack of accommodations, except in the city of Nassua, causes one to hesitate before recommending those Islands to any except those of adventurous turn. Of northern regions, judging from statistics and, to a limited extent from personal observation, I am of the opinion that the western portion of Oregon and that of the State of Washington, although in the latter the rainfall is very great, deserve more attention than they have had, and that both regions will eventually become popular. Many persons suffering from hemorrhages, after having failed to get relief in other places, have recovered at Tacoma and on the islands in Puget Sound. Many persons suffering from subacute and chronic bronchitis have recovered during sojourns on the north shore of Lake Superior where the air is singularly pure and bracing, and doubtless, when suitable accommodations have been provided, that region will become a favorite resort for persons suffering from tuberculosis.

European physicians, regarding purity of atmosphere rather than temperature, select almost extremes of climates. Davos, and St. Moritz in the Engadine, with a dry and cold but pure atmosphere, are popular resorts with excellent accommodations, and many attest the benefits of prolonged residence in the one or the other place. The southern parts of Europe, including the Riviera, the Ionian Islands, Egypt,