on the time and energies of the physician; and can be of no avail unless it is met by the earnest intelligent co-operation of the patient. It is, of course, impossible for all the details of the treatment to be gone into minutely during the time the physician has at his disposal for a visit at the home or at his office. It is only by means of a diary kept by the patient and given to the physician each week to study at his leisure, that the latter can really keep in touch with the patient's daily life. In this diary should be recorded, either by the patient or some member of the household, the temperature pulse and respiration of morning, afternoon, and evening, the weekly weight, the number of hours spent out of doors the hours of rest and of exercise, with the amount of the latter, as accurately expressed as possible, and the ways in which the rest hours have been whiled away, whether reading, sewing, playing games or whatnot. In short it should give an accurate account of the patient's daily life, and include any noticeable changes in any of the constitutional symptoms, such as cough, expectoration, pleurisy, hemorrhage, sweats, etc. This daily diary is also of great value in that it teaches the patient to keep track of his symptoms and enables him to guage their importance; and because it will help to impress upon his mind the fact that on his part, regularity in his daily life is the main requirement, and his chance of ultimate recovery is in almost direct ratio to his appreciation of the importance of such regularity.

By this means the physician can keep closely in touch with the patient and learn of indications in the treatment long before the patient would deem them of sufficient importance to mention. The study of this diary, combined with a monthly examination of the lungs, will enable the physician to dictate the course to be followed from month to month. And this course must be vigorously pursued until the disease is thoroughly arrested and the patient able to take up work. After that, this patient should report for examination and advice every two or three months and whenever any symptoms arise that cause him the least uneasiness.

One of the greatest handicaps with which the physician must contend, is often to be found in the family of the patient, who are sometimes, I regret to say, only too ready to view the physician as

an alarmist and to minimize the importance of his continued caution, once the patient really begins to improve. They, too, must be impressed with the necessity of each little detail of the treatment being observed, and made to realize the importance of their cooperation toward keeping the patient cheerful and contented.

There remains yet to be mentioned one great aid toward the training of the patient and his family so that they can intelligently co-operate in the treatment. The Journal of the Outdoor Life is a monthly publication edited in the Adirondack Cottage Sanatorium at Saranac Lake, and published at the rate of $1.00 per year. Its pages are devoted chiefly to articles on the practical details of the treatment of tuberculosis, contributed by physicians engaged in this work in various sections of the country, and by laymen who have been through the cure themselves and are endeavoring to point out for others the obstacles they encountered and the mistakes they made and paid for. The Journal is written in a practical readable manner that makes it of greatest value to anyone whether in or out of a sanatorium, who is trying to get well of tuberculosis, and I advise every physician who is treating a case of tuberculosis at home to have his patient subscribe to this Journal with the assurance that he will never spend a dollar that will bring so full a

return.

It has been my endeavor to present in general terms the main requirements for the successful home treatment of tuberculosis, which, as I have said, I regard as one of the most difficult problems with which the general practitioner has to deal. But though clinics, sanatoria, and charity organizations have a part to play in the crusade against this disease, the main burden of the fight for its control falls on the family physician, who, though he may not be able to report many cures and often sees months of work spent with apparently no return, is nevertheless the one on whom the instruction of the public most depends, and to whom they will be most indebted for the eventual fall in the death rate from this disease.

DISCUSSION.

Dr. Henry F. Stoll (Hartford): There is really nothing that I can add to this paper, so I will simply mention one or two of the points that seem to me particularly deserving of notice. I think Dr. Lyman sized it all

up when he spoke of the attention to details. There can be no doubt but that sanatorium treatment is the ideal treatment; but that is only available, of course, to a very small number of people, and therefore I think it behooves us to study the methods in vogue at the sanatorium, and endeavor to incorporate as many as possible in the home treatment. The Doctor mentioned the importance of seeing the bedroom; it should be light and the windows wide open. It may be the window opens on an air shaft, or it may have no window. It is well to suggest then that the patient take the front room in the house, where probably he can have three windows open instead of one.

Then I frequently have been interested when I asked patients if they had the window wide open at night. Yes, they had it wide open. Blinds wide open? Yes, blinds wide open. Shades up? No; shades down. Well, of course, with the window wide open and the shades pulled down, they might just as well have the window shut. They must understand that the window must be wide open, blinds wide open, shades way up and curtains pulled clear back. If they do that they will get a surprisingly larger amount of air than they have been used to.

The daily record of which the Doctor spoke, I am heartily in favor of. It not only shows the patient you are really interested in his condition, but it gives him something to take up his time, and often affords you means of knowing the reason why he is not improving if he does not gain. When you tell him he must be out of doors all the time, he cannot grasp it. If you said half an hour or two hours, he might understand it, but all the time, three hours in the morning, and three hours in the afternoon, or four hours, as the season may be, he absolutely cannot understand. And unless you have him put down the time each day that he spends out of doors, very frequently he will cut the time down, particularly if the wind or weather is unpleasant, and stay out of doors half an hour, or not at all.

In regard to rest, as the Doctor has said, a patient with a temperature of 100%, and a pulse of over a hundred, requires rest, and I have repeatedly seen cases that have been up and dressed but lying on the bed a great part of the day, and really not exercising at all, that still continued to have a temperature. When they were undressed and put in bed their temperature and pulse would come down. There is no question but that rest in bed is essential, and not lying on the bed with all the clothes on.

In regard to instructing the patient as to the real nature of the disease.- -I saw a man recently in the dispensary who had been examined a little over a year ago, and he had not been told what the trouble was. He had been advised to go away to some sanatorium where he could be treated, but he wasn't told what his condition really was. He improved for a time and then relapsed. I asked him: "Do you think if you had been told that you had tuberculosis that you would have taken better care of yourself?" and he said, "Yes; I honestly do." The Doctor simply had told him to be outdoors and take care of himself, but did not tell him he had

tuberculosis. The result was he improved for a time, and, not considering his condition very serious, he stopped his treatment and relapsed. When I saw him his lungs were very extensively involved.

Ambler has mentioned a very important thing, and that is in regard to the condition of the other members of a family where one is tuberculous. He has written two or three articles urging the examination of all members of the family once in six months or once a year; because where a case comes to you very much advanced there is a strong probability that some other member of the family has incipient tuberculosis. They may be called neurasthenic," they may have " stomach trouble," but if one examines all of the family once in six months he will be surprised to discover cases of tuberculosis that were not suspected by anyone.

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Dr. J. P. C. Foster (New Haven): Mr. President and Members: There is nothing that I can add as far as the home treatment of tuberculosis is concerned to what has already been so well said by Dr. Lyman and Dr. Stoll. But I would like to take a few minutes to say a word as to whether we should use the home treatment for tuberculosis always. I am an older man than some of you, but I have seen the day when it was all climate, and yet I have heard our admirable President say today that climate wasn't in it.

I have just come in from a meeting of the national association in Washington, where I heard men of the highest authority say that all cases should be treated at home, and that it was very desirable that they should be.

Now, I think there is a mean between all this. I think we are getting a little wild about home treatment. You have three classes of patients, everyone of you; you have (1) the rich man, you have (2) the middle man, and you have (3) the hopelessly poor man. If you get a man who is rich and able to do as he pleases, I think you make a great mistake if you do not put that man in a different climate from the one he is in now, if he lives in the State of Connecticut. He may go north, south, east, or west; it is for you to decide. We cannot all go to the same place. I wouldn't go to the Adirondacks for anything in the world. If I had got tuberculosis I would go to Florida, as I did before. poor old Florida. Some say that Denver is the place; have got a certain cure for every one of your patients; go there, for they are the people who will be content to go away from home and receive the treatment.

I will stand up for that in Denver they let your rich people

A case came to my knowledge within the last three years of a prominent New York gentleman who happened to be in the city visiting and strolled into my office and said he thought he had a cold. I examined him and told him he had tuberculosis, and of course made a sensation. He talked about his life then, and Colorado, etc. I said, “Never mind.” I knew he was a man of wealth. I asked him about his country place and found he had a beautiful one up on the Hudson river. I told him to go there. He went there and did splendidly, until his friends in New York

got hold of him and told him he had nothing but the opinion of a country doctor and must have a specialist. The specialist considered him lost, and he went to Saranac Lake, Colorado Springs, getting worse and worse, until finally the family consulted me to know what I thought of a last device, of his going to Asheville. I told the patient to keep on, and the last specialist would have him dead on his hands. (Laughter.) They treated him at home and he is well and is at work. A case that is going to be as nervous as that had better stay at home.

The middle class of people (the class of people we are getting at the sanatoriums in different parts of the country) can have home treatment or local treatment and do exceedingly well. I advise most thoroughly, though, that they may be taken out of their homes, and I advise you people in Hartford to find some place a few miles out. I advise New Haven people go to Woodbridge or Bethany where they can see their friends occasionally, and then you haven't got the bother of looking after the family.

I am so hurried, I can't begin to tell you what I want to about this thing. I think we have got it on a basis where we can do well. The great problem we have got on our hands is what on earth are we to do with the great unwashed? Those are the people that make the trouble. They are infecting towns, they are infecting everything, they cannot go anywhere, they cannot go to a sanatorium and they won't be treated at home. The day is coming, I know, when our municipalities will have suitable tuberculosis shacks and wards connected with their town-house where these people can go and be properly cared for. When they don't behave themselves, I hope the law will be as it is in New York City, that the health officer can compel their residence in such a place. (Loud applause.) You once get those people cleaned out and cleaned up, and you are going to get your tuberculosis problem settled very, very quickly, and it is to that end we have got to talk. I am not worrying a bit about these people in our walk of life and the men who have a respectable livelihood, because they do get taken care of. I want to say one word more, and then I will close.

Do not be too favorable in your prognosis. I have heard this last week an eminent man who said "Give me 100 cases of incipient tuberculosis, and I will give you 100 cures." That man ought to be prayed for. (Laughter.) He can't do it. (If you get 50% or 60% you get a great deal more than you used to get.)

Dr. Rienzi Robinson (Danielson): I used to be, years ago, when I was younger, a crank on the subject of change of climate. I sent my patients away, and I don't remember that anyone ever came back-cured. I remember sending a good many away. I have had some of the great unwashed that got well under the most unfavorable circumstances and remained well for the last ten years. Why they got well I don't know, but they got well. One case in particular was in a family of a dozen or fifteen, with five rooms