Of course we know that the cost of feeding the consumptive is much above that figure; nevertheless, not counting the cost of medicines and administration, the Government expends $36.50 once each year, to say the least, for the subsistence alone of the consumptive case.

As previously pointed out, the actual number of consumptive persons represented by the number of cases (531) would hardly be 300. Taking that number, the cost of their transportation would be $10,230, and the cost of feeding them in hospitals would be $10,950.

Five months in the hospital, as an average for these cases, seems quite high, but if we turn to the tables we shall find that, taking all classes of diseases, the average number of days in hospital is over thirty. It can hardly be doubted that the consumptive is with us five times as long.

As previously stated, the actual number of persons represented by the number of cases (531) would not be above 300, for we know that the consumptive goes in and out of our hospitals a number of times each year, thus confusing the reports and at least doubling the number of

cases.

COST OF TRANSPORTATION.

But following the records strictly, let us again take the year 1895 as an average year, and see what it will actually cost to transport these men to designated points. (The railroad fare here given by districts is in round numbers and, approximately correct.)

For stations by districts to points in western Texas or New Mexico, based on annual report, 1895:

Of course some one may explain that this does not answer the question strictly from an economical standpoint, for, while the consumptive receives five months of hospital treatment, at the sanitarium or home he would be a charge for a whole year, thus running his expenses for subsistence, on the same basis, to $81.25 for the year; or a total cost of $43,143.75, for the total number of patients, viz, 531. Granted, but the answer, roughly speaking, aside from other economical questions which could be presented, is that the patient at the sanitarium would cease to be a charge probably in two years, while the patients at our stations are at least three times that long, making the eventual cost more.

It

will also be pointed out that the patient will have to be subsisted at the sanitarium just as well as at the hospital. Very true, but anyone must know that such a place properly cared for would be practically selfsustaining for subsistence, while the patients at the sanitarium will cost very little for medicines and attendance. Furthermore, we know that the consumptive when not being treated at the hospital is, nevertheless, a constant care and expense to the Service, because of the treatment furnished at the dispensaries. Now that we can clear out our hospitals and transport the consumptive to designated points and pos sibly save money thereby, let us pursue the question further. Where shall this designated point be? What climate is best? What altitude is most suitable?

For our present purpose this question need not be discussed, or, if it is to be considered, the article bearing on this subject by P. A. Surg. W. D. Bratton (deceased) in the annual report of 1895, page 150, furnishes very good data.

For the present let the good to be gained be presented in as clear a light as possible from the data at hand and the details become unimportant. Suppose, now, to start the arrangement, that Congress appropriated $50,000 for the necessary building, stocking the land, and putting on water for irrigation. That seems a small sum, and yet much can be done with it. I am assuming, of course, that the neces sary Government land can be set aside for the purpose. With this amount to begin with, and a small appropriation annually, such a place can be made an ideal home, and will in a short time become practically self-sustaining.

The land should be suitable for farming purposes. This would be advantageous in lowering the cost of the ration, for on such a place all the fruit, vegetables, eggs, poultry, milk, and butter could be produced, while the light work required of the convalescent patient would benefit him and lower the cost of administration.

RELIEF OF HOSPITALS FROM OVERCROWDING.

Now, we must not look at such a home too narrowly for facts of economy, but rather to the indirect saving to our hospitals. To obviate overcrowding by consumptives and chronics it has been necessary from time to time to build new hospitals or annexes to care for these cases. If we remove these cases, no further expenditures will be necessary, so long as American shipping does not increase. The buildings needed for such homes will, for scientific reasons, be inexpensive and simple, for the remote benefit to be gained by the isolation of consumptives is only problematical along the line of economy or in saving life. Yet if we allow ourselves to theorize, it seems that eventually we could reduce these cases to the minimum, remove from our hospitals foci of infection to other cases, and perhaps bring about some real reform in the care of seamen afloat.

WILL THE SAILOR GO TO A SANITARIUM?

Now we shall have to consider the question from the sailor's standpoint. Will he go to such a place after it is built for him? If he refuses to go there, what are we to do about it? Does the Government save money by his refusing to go, and if so, why? If he does go, will he stay and will he not return to sailing sooner or later and again become a charge? Will he not often use his transportation and never report for treatment? Will the negro go?

Probably not more than half of our cases will go in the early stages when there is a chance to cure them. The average sailor can not be made to see the gravity and importance of the disease at first, and he will put off and procrastinate until he is in the last stage; but that, however, is no more than he does to us at the station, and if he is sent away even in the chronic stage, he ceases to be a source of infection to others and the cost of maintenance is lowered. If he refuses to accept the conditions offered, which, of course, are the best, then we have the solution in a desirable manner, and that is to refuse absolutely to treat any case of tubercle of the lungs in hospital. We certainly can find many good reasons for this course of procedure, and as they will readily suggest themselves to our minds, it is unnecessary to tabulate them. That it would be right to act in such a manner and refuse them hospital treatment can not be questioned.

That we dispose of the consumptive and clear out our hospitals in this way, with a great saving of money, can be readily seen. I believe that most of the patients will remain under treatment at the sanitarium until discharged. But if the patient leaves without permission, he is effectually debarred from hospital treatment, and as he disobeyed orders, he can not be returned to the sanitarium. That many of the patients will use their transportation with never an intention to report at the sanitarium for treatment, I do not doubt; but even then money has been saved, for his transportation has not cost more than would his subsistence in hospital. The negro would never go to such a place away from his friends and relations. He would look upon such a place with suspicion, as all his superstition would be aroused, and the fear that he would die and serve a necropsy would be more than he could endure. However, that is only an incident in the peculiar nature of the negro race, and does not in any way deserve consideration. Even in our hospitals the negro leaves, if he can, so soon as he becomes hopelessly sick. This is solely to avoid necropsies; nothing else.

If we had such sanitariums, the Navy and Revenue-Cutter services would probably take advantage of it for their officers and men, many of whom contract the disease annually.

CONCLUSIONS.

The mortality of the consumptive sailor as shown by the annual reports is 21.4 per cent. The actual mortality if it were possible to

obtain correct data would probably be 40 per cent. The eventual mortality is probably 100 per cent.

The results obtained to-day are no better than were obtained twenty years ago, if we are to rely on statistics, i. e., relative mortality 1873 to 1877, 21.5 per cent; relative mortality now, 1890 to 1895, 23 per cent. The results obtained to-day are not better than were obtained ten years ago, i. e., mortality from 1880 to 1885, 22.9 per cent; now, 23 per cent.

The improvements made in our hospitals have not lowered the mortality. The present methods of treatment have not lowered the mortality, but probably have attenuated the cases. There are probably more cases now than ten years ago. Our hospitals are foci of infection, dangerous to officers, attendants, and patients suffering from other diseases. Granting the most liberal allowance for faulty conclusions from the data at hand, it is quite probable that the Government can build sanitariums for these men, transport them to these places, and take care of them to a termination of the illness, for the amount that would be expended in their care at hospitals. All consumptives will do better with considerable altitude and dryness. The sanitarium is the ideal method of administration for these cases. At the sanitarium these cases can be closely studied, and all kinds of treatment tried. Taking that, then, to be a fact, the eventual outcome would, from a medical standpoint, be an ideal one.

FEMORAL HERNIA-BASSINI'S OPERATION-RECOVERY.

By P. A. Surg. J. B. STONER.

J. C. (white); aged 30 years; nativity, New York; admitted to the United States Marine Hospital, Chicago, Ill., January 29, 1898, for operation for radical cure of hernia. He was previously in this hospital for a protracted diarrhoea from December 7, 1897, to January 28, 1898. Has a femoral hernia, right side, size of a goose egg, irreducible. Says it was sustained twelve years ago in a jumping contest; that it has gradually enlarged to its present dimensions, and is now accompanied by paroxysms of pain which is increased at work; has never worn a truss. Operation under chloraform anesthesia. Usual antiseptic precautions. Incision made parallel with Poupart's ligament (Bassini) over the fundus of tumor, and the tissues carefully divided down to the sac. The sac was then opened and a finger introduced to the edge of constriction (Gimbernat's ligament) when a hernia knife was passed along the finger and the constricting fibers nicked. A portion of adherent omentum was tied off and removed and the hernia reduced. The sac was found to be closely adherent, and in freeing it for high ligation it was accidentally excised before a ligature could be applied. Silk sutures were then inserted by a curved needle, so as to unite Poupart's ligament with the pectineal fascia, the first being placed near the spine of the pubes, the second half a centimeter externally, and the third about a centimeter from the femoral vein. These sutures were left untied until two others had been passed first through the edge of the falciform fascia, then the pectineal fascia, the lower suture entering just above the saphenous vein. The upper and lower sutures were then tied and the skin incision closed without drainage.

February 17.-Examination shows union by first intention. Stitches removed and dressings reapplied.

February 25.—No impulse on coughing. Result satisfactory. Temperature never rose above a fraction of a degree, except one day, when it was 38° C.

NOTE.-This patient has been heard from some seven months after the operation, and the result has so far been satisfactory in every respect, although the man has been engaged in hard work since the date of his leaving the hospital.

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