cleansing bath is necessary twice a week, and a cold douche at 40° to 60° F. should be taken daily after breakfast.

DIET.-The diet should be liberal as to variety and quantity. The following specimen diet may serve to illustrate what is meant by a liberal diet: Meat, boiled fish, eggs, scraped meat, ham, tongue, oysters, herrings, caviar, sardelles, anchovies, cereals (all kinds), rice, bread, butter, potatoes, green salads, cooked vegetables, soup, milk, buttermilk, matzoon, honey, coffee, chocolate, cocoa, mint tea with tropon, puddings, Roman punch,

ice cream, jellies, whiskey, kirsch, wine, extract of malt, beef jelly, champagne, water, mineral water, and ginger ale.

Fat has a high caloric value and is indicated in wasting diseases, in the shape of sweet butter or emulsion of cod liver oil.

It is best to eat five times a day and not too much at a time. Five drops of dilute hydrochloric acid will aid digestion. The bowels must move at least once a day.

The value of tent life in the country or at the seashore in the treatment of tuberculosis is now generally recognized. The results of tent life show that the appetite increases, nutrition improves, cough disappears, night sweats cease, sleep improves, weight increases, the temperature falls, the tendency to "take cold" diminishes, respiration improves, and the pulse rate diminishes.

The construction of a proper tent or cabin for outdoor life can be studied from the cuts.

Specific and Symptomatic Medication.-Koch's tuberculin is being used in to 1 milligramme doses in a number of sanatoria, and favorable results are reported by some and denied by others. The writer knows of two individuals who became infected with tuberculosis and are cured after a course of tuberculin injections and two years of rigorous hygienic and dietetic

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management. On the other hand, one of his hospital patients, a girl of six years, afflicted with skin tuberculosis of the ulcerative type, was attacked with tuberculous meningitis four weeks after an injection of one

milligramme of tuberculin had given a positive reaction with the temperature above 104°. Inasmuch as tuberculin has been known and used since 1890 in the treatment of tuberculosis, we might reasonably expect a consensus of opinion in its favor if it were a powerful agent for good.

FIG. 150.-OUT DOOR REST CURE. (Dr. S. A. Knopf.)

CREOSOTE. Clinical experience is somewhat favorable as regards the power of creosote to check to some extent the spread of tuberculosis in the tissues. The dose is from half a drop to six drops three times a day, in pill form, in milk, or with maltine. In some patients it distinctly upsets the stomach and its use is followed by a feeling of nausea and weakness. Under these circumstances its use should be discontinued. In the incipient stage hygiene, diet, hydrotherapy, and the x ray or sun baths should be employed to the exclusion of drugs. To aid digestion and thus prevent as much as possible intestinal putrefaction, we frequently administer

Plans for this tent can be obtained from Charity Organization Society, New York City. hydrochloric acid and tincture of nux vomica, five drops of each, in water, after a meal, or two drops of ichythol, in a capsule, twice a day, after eating. COUGH. A cough is Nature's effort to expel an irritant. This should be explained to the patient. Before resorting to medication to check a cough, the patient should be advised to use the nasopharyngeal toilet, and to endeavor to inhibit a dry cough by will power. When the cough is harassing, particularly at night, a dose of morphine (gr.) or heroin (gr.) may be given; or the following combination:

M. S.: A tablespoonful when necessary to check cough.

In urgent dyspnoea morphine injections and ozone inhalations give relief. PAIN. Pain in the chest may often be relieved by applying a hot water bag, a mustard plaster, or dry cups.

Hyperidrosis.-This may be relieved by having the patient rest over night in a coarse linen shirt or short night gown wrung out in cool water with sufficient blanket covering to avoid chilling.

FEVER. In the management of fever, hydrotherapy should come before drugs. Sponging the body with cool water is preferable to tubbing. When the fever curve is suggestive of malaria, quinine is indicated; otherwise it has no beneficial effect and generally upsets the stomach.

INSOMNIA is always an annoying feature in sickness. Before drugging the patient, it is well to try a cool sponge bath. Should this fail, a glass of strong beer or porter will sometimes produce sleep. In obstinate insomnia drugs must be employed, such as hydrate of chloral and potassium bromide, aa, gr. x to xx; (codeine, gr. ; urethane, gr. xxx); dionin, gr. ; trional, gr. xv, in milk; and hyoscine, gr. 8.

The management of hæmorrhage from the lungs and the treatment of genitourinary, intestinal, and laryngeal tuberculosis and other complications is discussed under separate headings, also that of the nervous and mental complications (neuritis, meningitis).

LUNG SURGERY in the early period of cavity formation has a future, particularly when we have the facilities for opening the chest under suction, as with Sauerbruch's apparatus.

BRONCHIAL ASTHMA

Asthma is a term which has been generally applied to various conditions. associated with dyspnoea. Thus, we speak of cardiac, renal, gastric, and thymic asthma. The term "asthma "should be employed only in connection with bronchial asthma, which may be defined as a vasomotor turgescence of the bronchial mucosa, although the pathology of the disease is unsettled. The attacks are usually sudden, and probably take their origin in nasal, gastroenteric, renal, or genital reflexes or strong emotions. The disease is often associated with attacks known as "hay fever," or pollen. fever. Most sufferers from "asthma " have a neurotic heredity. Bakers and workers in fur are afflicted more than any other class. Asthma is a disease of adult life, but is not rare in childhood.

Symptoms. When seen in an attack, the patient's face appears pale and cyanotic, staring and anxious, or dusky and covered with sweat during the paroxysms. The thorax looks enlarged, barrel-shaped, and fixed, and the diaphragm moves but slightly, with retraction of the intercostal spaces and epigastrium.

Palpation sometimes reveals rhonchial fremitus, vocal fremitus diminished or obscured, the apex beat diffused, and the heart laboring. The heart's impulse may be in the epigastrium. The surface of the body is cold and moist.

Percussion shows marked excess of resonance, especially in chronic cases, extending over the cardiac space and low down to the eleventh rib.

Auscultation reveals inspiration short and quick, expiration greatly prolonged, and low pitched wheezing in both acts. Innumerable faint or loud sibilant, and sonorous, musical, squeaking, and creaking râles, followed by moist cooing sounds, are heard, and the vesicular murmur is nearly

inaudible, or of the harsh, cog wheel type. The heart sounds are rapid and feeble.

The cough is tight and dry at the beginning of paroxysms, becoming looser in time. Pain is usually initial, with a feeling of oppression about the chest. Dyspnea is paroxysmal, periodical, expiratory, generally nocturnal, lasting from a few minutes to hours, and may recur during several nights. Expectoration is scanty, hard to expel at first, consisting of rounded gelatinous pellets, Curschmann's spirals; often Charcot-Leyden crystals and eosinophiles, and rarely fibrinous casts. The voice is suppressed during a

severe attack.

There is no fever; the pulse is generally quick, small, and irregular during an attack. A sitting or standing posture is usually assumed by the patient. When bronchopneumonia sets in as a complication, there is a rise of temperature with a mucopurulent, sometimes blood streaked discharge.

Acute emphysema of the lung is observed in severe attacks, and after frequent attacks of asthma, chronic emphysema and bronchitis with enlargement of the heart and congestive conditions in liver, lungs, and kidneys supervene. The course of the disease is variable. The paroxysms may recur for three or more nights and in the interval during the day there may be wheezing and cough. Death during the attack is almost unknown.

Differential Points. The dyspnoea of hysteria and the "asthma " of renal and cardiac disease are not attended by the sonorous and piping râles and other physical signs of true asthma. A careful examination will also enable us to distinguish between true asthma and spasm of the glottis, abductor paralysis, ædema of the glottis, bronchial obstruction, etc.

Treatment of an Acute Attack.-When we are called to a patient suffering from an acute asthmatic attack, prompt relief may be given to adults by means of morphine injected hypodermically (gr. to) with or without atropine (gr.), or gr. each of morphine sulphate and cocaine hydrochloride. Relief may also be obtained by taking a teaspoonful of the following mixture every hour or two according to the severity of the case:

M. S.: A teaspoonful in water every two or three hours.

Potassium iodide may also be administered per rectum, dissolved in water (gr. xxx), and a dose of chloral (gr. x to xx) may be given by the