The site of the lesion of tuberculosis has no bearing on the dietetic indications but may interfere with the fulfillment of these indications or present special difficulties.

In tuberrculosis with open lesions of the respiratory passages or otherwise lending to the presence of bacilli in the mouth and pharynx, pains should be taken to prevent the swallowing of sputum and other discharges and the mouth and pharynx should be cleansed with hydrogen peroxid, boric acid, borax and similar mild antiseptics before meals.

Certain tuberculous foci of the larynx, fauces, tonsils etc., cause dysphagia and may require local anaesthetics before meals or even gavage. As a rule, if swallowing is exceptionally painful, the use of the tube is also intolerable. In such extreme cases, the prognosis is usually so bad as to render it unwise and cruel to urge feeding too strongly.

Tuberculosis of the stomach itself is very rare and either does not interfere particularly with feeding by the mouth or the case is so hopeless that starvation may he regarded as a form of euthanasia.

Tuberculosis of the intestine is important in a double way. From the stand point of etiology and prophylaxis, it should he remembered that tuberculosis from infected ingesta, especially milk, is relatively more frequent in infants and children than in adults. Some authors have gone so far as to claim that most tuberculosis, even when involving the respiratory passages, is of ingestive rather than inspiratory etiology. While animal experiments have shown that it is possible for tubercle bacilli to be absorbed from the intestine, without producing a local lesion and subsequently to produce lesions elsewhere, there is no substantial evidence against (he respiratory route in tuberculosis and it is certainly far-fetched to hold that pulmonary tuberculosis in (he adult is due to intestinal infection that has lain dormant since childhood. At the same time, the importance of excluding tuberculous sputum, food etc., from the ingesta is obvious.

An established intestinal tuberculosis almost invariably implies intestinal ulceration, with the possibilities of perforation or of cicatrization and obstipation. Hence the diet must be appropriate to these lesions and to any surgical intervention that may be necessary.

Tuberculosis of the meninges may cause paralysis or convulsions which interfere with deglutition, the dietetic management being as for similar conditions of other cause.

Otherwise, tuberculous lesions do not usually cause any direct disturbance of digestion or call for special management.

Tuberculosis, being neither self-limited nor semelincident, and any specific antitoxic or antibacterial action being supported only by theoretic conclusions from animal experiments, the treatment of the disease is limited, at present, to measures directly and exogenically antagonistic to the bacilli (such measures being unsatisfactory) and to measures which increase the vitality and resistance of the cells of the invaded organism.

Hence, in tuberculosis, diet becomes of relatively high importance. There is a general indication to feed abundantly, both with food which replaces waste and that which furnishes energy.

Mere increase of weight in tuberculosis is not indicated by any theoretic conception of the nature of the disease and, empirically, is not a guarantee of favorable progress.

In seeking a basis of special diet in tuberculosis, we have two valuable scientific facts, though both rest largely on empiricism:

1. Gouty patients or those corresponding to the former conception of the uric acid diathesis do not usually contract tuberculosis.

2. Pulmonary tuberculosis is shown by actual experiment to be literally a consumption, there being a greater degree of oxidation in the blood or tissues than normal, so that the ratio of eliminated carbon dioxid to inspired oxygen, is increased. There is also, on the average, more wasting of fat than would be expected from the general features of the infection.

Hence, there is an indication to increase prot-eids and also purin-containing foods up to the limit of tolerance. Urea has been used in the treatment but there is very little theoretic or practical support of this practice. Liver, kidney, thymus, perhaps even spleen should be used to a moderate degree, subject to the patients appetite, and various nuclein preparations should be administered.

Both fats and carbohydrates should be used freely but the former, especially, should not be crowded to the point of disturb-ing digestion or nauseating the patient.

Contrary to general opinion, the writer holds that there is no special virtue in cod liver oil itself and it is at least not established that any of the waste products of hepatic catabolism in the fish have any special action against tuberculosis. On the contrary, hepatic waste, in general, is relatively highly toxic and it embarrasses the emunctories.

While it is true that the biliary salts favor the absorption of oils and fats, there is no evidence that these salts are deficient in tuberculosis and, if there is any special reason for administering them, they may be better given in pure form.

In children especially, a tolerance for cod liver oil, often consists essentially in a growing appetite for the liquor with which it is so often combined.

Generally speaking, butter, cream, Mayonnaise, salt pork, ham, bacon, cocoa, butternuts etc., are more available as fatty foods than cod liver oil and 100 to 150 grams of fat daily should be given.

Remember that while pure petrolatum (purpetrol, not the ordinary commercial forms) may be indicated as a laxative or in combination with bismuth etc., as an internal emollient, no form of mineral oil is capable of assimilation, advertisements of certain proprietary preparations notwithstanding.

Carbohydrates in the form of starchy foods, good candy, chocolate etc., should be used liberally.

Remember that bread, including various other breadstuffs, is the staff of life and that butter has been called its golden head. This combination is especially to be desired in tuberculosis.

It has been claimed that the immunity of sheep to tuberculosis is due to the fact that their special fat acts in some way injuriously to the tubercle bacillus. At any rate, the inunction of lanolin to the amount of 30 - 50 grams a day is feasible and harmless.

It is also possible that the resistance of goats to tuberculosis may depend upon some special principle that enters the milk and which is conspicuous by its absence in cow's milk. Hence, there is a general indication, upon which too much hope should not be based, for using goat's milk in tuberculosis.

Barring special lesions and exceptional conditions, tul>ercu-lous patients may be considered in two categories, so far as dietetic and hygienic treatment are concerned: Those having a pneumonic or other rather acute febrile condition and those whose temperature does not vary much from the normal and who are able to be about. The former should be kept in bed and dieted as for other fevers, except that the strict attention to local conditions as in typhoid is not required. The latter, on the contrary should be kept mostly in the open air and should take light though never fatiguing exercise and should have the liberal diet already described.

Never stuff a tuberculous patient, either by administering unreasonably large quantities of food, or too frequent meals (three, four or possibly five, are the right numbers) or by giving freak preparations of nourishment.

Do not expect miracles of some climate different from that to which the patient is accustomed. Indeed, if the home climate is fairly dry and not too inclement, it is unnecessary to incur the expense, trouble and nostalgia of a removal. If the patient does seek another climate, he should be impressed with the necessity of treatment and freedom from hard work, mental or physical. A patient in a hopeless stage should not be sent to a distant place.

Owing to the practical impossibility of segregating the patient if he eats at the table with the family, his meals should be served separately and the general methods of disinfection should be applied, as discussed in another place.