These cases do not come to see us early enough; they are usually infected some time before realizing they are not well, and in many cases the harvest time is over before they have had a diagnosis.

About this stage of the case the question of climate will arise, and your patient will have been advised by friends with good intentions, but poor judgment in this case, of the wonderful cures at the different health resorts. Fortunately, the physicians who made a specialty of climate and directed all their patients to places of different elevations and humidity are slowly passing away.

I wish to condemn the practice of sending a patient who is infected with tuberculosis on a wild goose chase, seeking a climate wherein he can regain his health, but instead he usually falls into the hands of charlatans and quacks, who soon relieve him of his accumulated earnings, for he is an easy victim for all sure cures and returns to his friends discouraged and gives up the fight, and the end is not far off.

I believe that the climate of Ohio can be so utilized that as many patients will recover here as in any other spot in the United States. Whenever a physician advises a patient to change climate, he at once admits his inability to treat this disease, the same as does the medical man who sends his patient to a surgeon. The time is coming when each county or city will have a sanitorium where these patients can be given a few months' treatment.

We say "next" and we have before us a tubercular. What will we do with him? We have not a sanitorium in which to treat him and we will not send him away from home and friends, so we decide to treat him at home.

Entire control of the patient at all times is the first great essential to success, and herein is the advantage of sanitarium treatment over private treatment. Any physician who attempts to treat these cases should have a systematic plan of treatment which can be adapted to suit the case, and never in any case prescribe drugs as has been the custom of but a few years ago, and have the patient return when his bottle is empty.

I do not mean by this that medicine has not a place in the treatment of consumption, but we have no drug at preent which exerts any influence or curative properties on the disease, and it must be treated by the indirect rather than by the direct method.

There are always times when some medicine judiciously prescribed will be of assistance in the fight, but only when prescribed for some specific symptom and never as a routine. I have seen a number of patients who had been taking patent medicine containing large amounts of alcohol, in whom I am certain their cases were hastened to an unfavorable termination by the accumulation of alcohol and its lessening their power to fight. No patient should be permitted to use alcohol in any form, or tobacco in any quantity, for their effects are detrimental to the system and do prevent nature's work in curing this disease. If the patient has a rise of temperature to one hundred degrees or more, he should be confined to bed or kept quiet until it becomes normal. I make it an invariable rule that no patient with fever be permitted to take any active exercise whatever.

From April until December all tuberculars in this climate should, if possible, live in a tent. During the winter months they can with safety live in our houses if properly arranged. I care not what plan they adopt, whether they sleep on the porch; with their heads out of the window; in a shack or simply open the windows; but they must have pure, fresh air day and night and every breath must be a breath of pure, fresh air. They must not avoid draughts, but learn to live in a draught. No patient ever takes cold in a draught if his body is properly clothed.

The heart in tuberculosis is a study unto itself. It is the principal guide in diagnosis, prognosis and treatment. A large per cent of tuberculars have a small, weak, dilated heart, with weak rapid pulse and defective first heart sound. When we consider the heart we can readily see the importance of rest, fresh air and over-feeding in these cases, and we can also realize how dangerous it is to permit these cases to take active exercise or instruct them, as is so often done, to rough it.

Give me a tubercular with a good heart and I do not care about the advanced condition of his lung. I know he will improve. But on the other hand, take a tubercular with a tachycardia, a weak, dilated heart, and no difference how slight his lung lesion, you have a serious case and will probably meet with disappointment. Digitalis and hydrotherapy are useful in tuberculosis on account of their beneficial action on the heart.

The feeding of these patients is the greatest problem of all in the whole course of the disease. To tell them to eat all the good, rich food they can is simply wasting your breath, for they will then eat as they please. They must have a diet list which contains the estimated amount of fats, albumens and carbohydrates to generate the requisite number of heat units which will over-nourish the body and show a substantial gain in weight, as 90 per cent of our cases are under weight when first seen, and the first sign of improvement is a gain in weight. The foods which produce the greatest number of heat units, and consequently the greatest gain in weight to the patient, are eggs, raw or soft boiled; bread and butter, large amounts of milk and cream, cheese, bacon and cold meats containing great amounts of fat, vegetables or the raw vegetble juice. The beef steak diet, which is yet popular with a few physicians, is a flat failure.

Many of these patients are faulty eaters, and have been so all their lives. The majority eating too rapidly "tachyphagia," and a few too slowly "bradyphagia," and a great many will not eat for fear of causing distress, "sitophobia." They must be taught how and when to eat, as well as what to eat. Time will not permit further discussion of food, but I can not recall in my practice a single case of pulmonary tuberculosis in a patient whose diet had been mostly of animal foods. As to the direct or specific treatment, there is very little to say. About everything in the pharmacopeia has been given, but with no specific action, and all sure cures have been found wanting. Dr. Tyson recently said "Consumption is a specific inflammation, and we may some day discover a specific remedy for it." We all hope this will come true, but when we have such specifics as fresh air, good food

and hydrotherapy, which will cure a large per cent of these cases in all stages, it seems folly to wait for "something to turn up."

When we find that the disease is arrested, that is the bacilli have disappeared from the sputum, the patient is about his normal weight; pulse and temperature normal and digestion good, the patient will believe that he is well, and the real battle is on. We must convince this patient that the rest of his life must be a life devoted to his health, and if he ever returns to his old habits of warm rooms, card tables, cigars and alcohol, avoids draughts or remains in any building where the air is impure, or of greater importance than all the above, if he ever lives in a house where a tuberecular has lived or died, or returns to the same house wherein he became infected with and cultured the disease, his chances are good for a reinfection, which is always more serious than the original one.

In closing, I would emphasize the necessity of relying not only upon fresh air, but also upon a physician's methodical treatment.

GALL STONES AND THEIR SURGICAL TREATMENT. By B. G. A. Moynihan, M. S. (Lond.) F. R. C. S. Senior Assistant Surgeon, Leeds General Infirmary, England. Cloth, $5 00 net. Second Edition, revised and enlarged. Publishers, W. B. Saunders & Company, Philadelphia and London. 1905.

This work contains a full account of the origin and causation of gall stones and of the pathologic changes and clinical manifestations to which they give rise. Especial attention has been given to the detailed description of the early symptoms in cholelithiasis, so as to enable a diagnosis to be made in the stage in which surgical treatment can be most safely adopted. The author has expressed his views with admirable clearness and he supports them by a large number of clinical examples. The illustrations, a number of which are in color, form a special feature of the work. Mr. Moynihan's wide experience in treating cholelithiasis specially fits him to write a book on this subject. He voices the sentiment of many prominent surgeons of the present time, that in the future surgical treatment will be adopted more frequently and in an earlier stage of gall stone disease than has hitherto been customary.

CHRONIC ECZEMA.*

BY JOHN V. SHOEMAKER, M. D., LL.D., PHILADELPHIA, PA. Professor of Materia Medica, Therapeutics, Clinical Medicine and Diseases of the Skin in Medico Chirurgical College and

Hospital of Philadelphia.

Gentlemen: This patient deserves a great deal of study and observation before we attempt to make a diagnosis. He is 19 years old, nativity American, and is a machinist by trade. He has had the ordinary diseases of childhood, and two years ago, while he and his brother were traveling in California, they both had scabies, but claims to have been entirely cured. One year ago he first noticed small vessicles appear on the flexor surfaces of both his legs. Soon the trouble involved the entire legs to his knees, after which time it gradually spread up the thighs, and now it involves the buttocks as well. The lesions presented here are erythema, papules, swelling scales, incrustation and marked infiltration of the skin. The subjective sysmptoms are intolerable itching and burning sensation. The objective symptoms besides those already mentioned are anemia, the tongue is heavily coated and fissured, the breath offensive, and the glands of the groins are slightly enlarged. This undoubtedly is a case of chronic eczema. It is often hard to separate acute, subacute and chronic varieties from each other, because there is no sharp line of difference. However, in this case we have a history of long standing, with swelling of the parts and a hard, infiltrated skin. The patient also gives a history of relapses, and you can plainly see from your seats that the secondary changes are predominating over the primary lesions; especially is this true of the flexor surfaces of the joints. In chronic eczema the parts usually more freely involved are those more richly supplied with sebaceous gland and follicles, as is seen in this patient. Of course, the changes are also largely influenced by the form and methods

*Clinical Lecture at the Medico-Chirurgical College Hospital.