CONTRIBUTIONS TO THE TREATMENT OF 
PULMONARY PHTHISIS. 
(Read before the N. 0. Medical and Surgical Association, May 5th, 1877.) 
BY DR. W. GLEITSMANN. 
Physician in Charge of the Mountain Sanitarium for Pulmonary Diseases, Ashe?8 
ville, N. C.; Corresponding Member of the New Orleans 
Medical and Surgical Association, etc. 
From s<Tiie New Orleaus Medical and Surgical Journal,” July, 1877. CONTRIBUTIONS TO THE TREATMENT OF 
PULMONARY PHTHISIS. 
(Bead before the N. O. Medical and Surgical Association, May 5th, 1877.) 
DK. W. GLEITSMANN, 
Physician in Charge of the Mountain Sanitarium for Pulmonary Diseases, Ashe- 
ville, N. 0.; Corresponding Member of the New Orleans 
Medical and Surgical Association, etc. 
The object of this paper is not to enumerate all the remedies 
used in the treatment of Phthisis, only those which my own expe- 
rience and that of others have shown to be of value to phthisical 
patients. 
When we consider the vast number of invalids who leave 
their homes for health, we naturally ask: What conditions should 
determine them in their choice of a health resort? It may be 
comparatively easy to advise in a single case, yet even then we 
may doubt if the patient might not improve more rapidly under 
different medical, hygienic, or climatic treatment; but when we 
must decide where to send a number of invalids, the question 
becomes complicated. We need not go to the old world, to Da- 
vos (Switzerland), buried in the snow five months of the year, to 
the Kiviera, to Cairo, in order to see invalids wintering under 
the most extreme climatic conditions—we find them scattered in 
our own country through almost every degree of latitude and 
longitude, in California, Colorado, and the western territories, 
Florida, and the Southern States, Minnesota, and the Adirondack 
Mountains. Each region claims peculiar advantages, and the 
busy practitioner, who has not the time or does not care to seek 
the truth through the abundant phraseology of the publications 2 
of different health resorts, is often amiss when called upon to 
make a proper selection. A climatic association, as proposed by 
Dr. Chas. Dennison,* would to a great extent overcome this 
difficulty, but at present we are not so far advanced as to say 
positively that a certain climate is suited to a special class of 
consumptives. There are other essentials to the improvement 
of invalids besides climate, and these are frequently lost sight 
of. To draw attention to some of these, and to the relative 
value of certain climatic factors, is the object of the present 
sketch. 
That consumption, at least certain forms of it, can be cured, 
is to-day scarcely doubted by any advanced physician. We even 
see cures in the most heterogenous climates, and sometimes under 
the most anti-hygienic conditions. Though we may see a con- 
sumptive improve in spite of improper treatment, of deficient, 
bad nourishment, of unhealthy accommodations, we would never- 
theless hesitate to recommend a patient to live under the same 
circumstances. Dr. Brehmer, in his book on Chronic Consump- 
tion, cites a very instructive case. A large landowner called on 
Dr. Stokes, ot London. Having examined him, Dr. S. consulted 
with his family physician, and they decided that nothing could 
be done for him, and advised him to go home. A year and a 
half afterwards a healthy-looking man, weighing at least 12 
stones, entered the doctor’s office with a very sarcastic expres- 
sion, and asked him if he recognized him. The doctor said that 
he did not. Then the gentleman told him that he was the same 
man pronounced incurable 18 months before. The most minute 
examination failed to reveal any symptoms of the disease. Ques- 
tioning him, the doctor found that his patient, thinking that he 
must die, had lived as when in perfect health, eating and drink- 
ing of everything on the table, and taking his milk-punch regu- 
larly, generally seven glasses a day. He occupied himself duck 
shooting whenever he felt strong enough. When the doctor 
said, You must have wet your feet very frequently, he replied : 
I did not take much care of my feet, for I often waded through 
the water up to my hips four or five hours, following up the 
birds on a fine winter’s day. 
It is therefore of the greatest importance to learn, not where 
or how some patients may have been cured, but where and how 
' The Best Welfare of Invalids, by Charles Dennison, M.D., Denver, Col. 1875. 3 
they are most likely to be cured. The requirements of places 
wli eh offer patients a chance for improvement or recovery must 
be manifold, and are not of so simple a character as might be 
expected from the great number of places which advertise them- 
selves as health resorts. Iu enumerating climatic conditions, 
we find as the main factors of climate: temperature, barometric 
pressure, humidity of the atmosphere, and mostly dependent 
from these three a number of others, as for iustance, ozone, elec- 
tricity, insolation, wind, rain, purity of the atmosphere, etc. 
Great stress is laid on equability of temperature. Although 
we must acknowledge that places with high, and especially sud- 
den daily ranges are not suitable localities for consumptives, 
there is nevertheless a certain degree of range desirable and 
wholesome. A daily range of 20 to 25 degrees often takes place, 
and no physician would advise patients to stay in the house 
because the morning or evening temperature is 25Q lower than 
the temperature at noon. A light overcoat fully equalizes 
the difference, and patient and physician are satisfied and not 
afraid of the ominous “taking cold.” Why do we not think and 
act in the same way when the difference, instead of falling upon 
one day, takes place on two succeeding days'? We are not afraid 
of a daily range of, for instance, 25°, but when the following day 
is cooler, patients are apt to stay in the house on account of the 
“great change.” Can a difference of temperature which is con- 
sidered harmless if occurring within 12 or 14 hours, be injurious 
when the interval is 24 hours? Does not a light coat prevent 
the possible ill effect here just as well as in the first instance? 
If we exercise care in dressing ourselves, ranges like the above 
cannot injure us. 
A similar misconception exists in regard to the influence of 
cold air and night air on consumptives. Iceland and the coun- 
try round Orenburg enjoy immunity from phthisis, and both 
have very cold climates. The mean annual temperature of the 
first is 40°, of the second 37.7°; the mean of the coldest month 
is 28 4° and 7 5° respectively. Every year patients winter in 
very cold regions with benefit; and in Europe it is quite popular 
to send them in winter no less than in summer to health resorts 
in elevated regions, the temperature of which is colder than that 
of the lowlands in the same latitude or of the Southern resorts. 
The conviction is general in Europe, that a consumptive needs 
something more than relief of symptoms and prevention of fresh 4 
injury. ITis treatment must be active; his functions must be 
properly stimulated, he must acquire power of resistance, which 
warm air, because enervating, cannot give, but which is gained 
in the cool air of elevated regions—points which are more fully 
discussed in another essay of mine.* Yery few people consider 
that in Southern resorts east of the Mississippi the thermometer 
frequently falls below the freezing point, that there are occa- 
sional snow storms, that these climatic changes are keenly felt 
by invalids, enervated by the prevalent warmth of these sec- 
tions. But where the air is constantly cooler, and the skin is 
less inclined to perspire, changes are borne more easily and 
with less discomfort, because the system is more vigorous, the 
skin is more active in its functions, and the patient therefore is 
less inclined to take cold. 
Night air is dreaded very much by many patients, and when 
we ask them, why1? we are often answered, “it is too damp to be 
out.” But we see the same patients unhesitatingly sit in the 
open air ou a sheltered verandah during day time when the 
hygrometer shows great humidity, or even when rain is falling. 
Day and night air are perfectly homogenous, and differonlyin tem- 
perature—sometimes in condensation of vapor of the atmosphere, 
caused by decrease of temperature. Statistics have not so far 
shown that occupations, which compel their followers to work 
during the night (in the open air), are more injurious than the 
same when followed during the day. Accepting this view, we 
ought not to object, indeed rather advise patients, to leave a 
window either wholly or partly open during still nights, especi- 
ally when we consider how essential pure air is for invalids, and 
how quickly the air becomes contaminated in a close room. 
Absolutely pure air is composed of oxygen 20.96 parts, nitro- 
gen 79 00 parts, and carbonic acid 0.04 parts. An analysis of 
Pettenkofer (Munich) states that the quantity of carbonic acid 
in a dwelling in the morning is 0.054; the same increases gradu- 
ally to 0.061, and so on up to 0.087. In a sleeping room during 
the night, with windows closed, it is 0.23, with windows partly 
open 0.082. A grown person excretes by way of respiration and 
perspiration, within 24 hours, about 20 cubic feet of carbonic 
acid and 2£ lbs. of water. We ought therefore to bring in at 
* Altitude and Climate in tire Treatment of Pulmonary Phthisis. Baltimore, 
1875. 5 
least 600 cubic feet fresh air every hour for each person, if we do 
not want to accumulate more than the maximum of carbonic 
acid compatible with health. Headache, want of appetite, fatigue 
in the morning, are often attributed to dyspepsia or liver com- 
plaints, when they ought to be considered symptoms of intoxica- 
tion from carbonic acid by sleeping in closed rooms. Already in 
1855, McCormack (England) recommended consumptives to 
sleep with open windows; and lately, Eohden (Germany) urged 
the same. Of course this measure has to be applied “cum grano 
salis,” and we would do very wrong to let consumptives indis- 
criminately, and without regard to the weather and their condi- 
tion, have their windows open every night. Here, as well as in 
every instance in the treatment of consumptives, it is necessary 
to individualize. 
The beneficial influence of elevated regions with low barome- 
trie pressure is now acknowledged by the majority of physicians, 
and even the opponents of this theory cannot help appreciating 
the favorable results obtained by this treatment. The number 
of resorts which are situated at elevations from 1500 to 4000 
feet, is increasing in Europe every year. We are justified in as- 
suming that the good effect of altitude is lost, or at least is not 
perceptible to the patient, if the elevation is less than 2000 feet. 
The claim that phthisis decreases in high elevation, has gained 
strong corroboration by two recent publications. At the meet- 
ing of the Society of Natural Scientists of Switzerland, in 1863, 
a committee was appointed to investigate the occurrence of 
phthisis throughout the country, in its different relations to age, 
sex. occupation, elevation of places, etc. After several delibera- 
tions, it was agreed to extend the time ot observations over 5 
years, from 1865 to 1869, and now the result appeared in a report 
made by the Actuary, Dr. Emil Miiller.* The part of the resume 
at the end of the report, which relates to the influence of eleva- 
tion on phthisis, presents the following points: 
Decrease of Phthisis in Switzerland beyond doubt follows in- 
crease of elevation. 
Phthisis occurs even in the most elevated places, although it 
is very rare. 
Low regions average to have twice as much phthisis as the 
* Die Verbreitung der Lungeu schwindsucht in der Schweiz von Emil Muller, 
Winterthur, 1876. 6 
highest; after deducting cases acquired abroad, considerably 
more. 
The decrease of phthisis is not in strict proportion to the in- 
crease of elevation, and these variations taking place are mainly 
due to social conditions of the people, i. e., whether they follow 
farming, manufacturing, or both. 
The second work is by Jourdauet,* who practiced four years 
and a half in Mexico, and observed only six cases of consumption 
amongst 30,000 visits to patients. The conclusions he arrived 
at are as follows: 
1. Consumption in Mexico is extremely rare at an elevation 
over 2000 metres (about 6560 feet). 
2. There is an almost absolute immunity among the better 
classes. 
3. Disposition to consumption, acquired by young people some- 
where else, generally disappears as soon as they remove to the 
mountainous regions. 
4. Complete cure was frequently observed in patients who 
contracted their disease at other places (France). 
The humidity of the air can be determined by different instru- 
ments. Saussure’s Hygrometer indicates the absolute quantity 
of vapor contained in the air; Miihry’s Micro-atmometer measures 
directly the quantity of water evaporated, whilst Leslie’s and 
August’s Psythrometei or Yaporimeter indicates the humidity 
by the difference between two thermometers, the bulb of one of 
which is exposed (dry bulb) the bulb of the other is surrounded 
by a wick immersed in water (wet bulb). The latter instrument, 
which is most used, enables the observer to calculate most of the 
different factors which show the humidity of the air. viz: 
Relative humidity, i. e., the ratio of the quantity of vapor actu- 
ally contained in the air to the quantity it could contain if fully 
saturated. 
Absolute humidity, i. e., the weight of aqueous vapor in a 
given quantity of air; in this country the weight of vapor in 
grains in one cubic foot of air, in Europe generally in grammes 
in one cubic meter of air. 
Dew-point, i, e., the point of condensation of vapor, or the tern 
perature at which the air begins to part with the moisture, which 
it cannot hold at a lower temperature. 
* Influence <Je ]a pression de 1’ airsur la vie de 1’ homme d’ altitude et 
climats de montagne. Par D. Jourdanet. Paris, 1875. 7 
Elastic force of vapor, i. e., the pressure of the whole vapor in 
the atmosphere over the place of observation. It is expressed in 
inches ot mercury of the barometric column, and is equal to the 
observed barometric pressure, diminished by the pressure of dry 
air. 
It is not necessary to know all the four factors enumerated in 
order to determine the humidity of the climate of a certain place, 
but I cannot approve of the way which is generally adopted of 
comparing localities by means of relative humidity alone. It 
makes a great deal of difference, if the lungs inhale an atmos- 
phere containing 2.59 grammes of an aqueous vapor in one cubic 
meter (the means of amount of vapor January, 1870, at Davos, 
Switzerland), or one containing 7.34 grammes in a cubic meter 
(the means of January at Cannes, France), the relative humidity 
being the same for both places, viz., 86 per cent.* The merit of 
drawing attention to the importance of the absolute humidity is 
due to Dr. Heury B. Baker, the eminent statistician of Michigan. 
I quote from the fourth annual report of the Secretary of the 
State for the year 1870, page 294, the following: 
“The temperature of the air passing out of the air passages of 
human beings is believed to be fixed, or nearly so, the tempera- 
ture shown by a thermometer under the tongue being about 98° 
Fahr., it is probable that the temperature of the expired air does 
not vary greatly from this, and as those passages are naturally 
supplied with moisture, the quantity of vapor in a given quantity 
of air exhaled from the lungs must be nearly uniform throughout 
all temperatures. The capacity of air for moisture being different 
when cold from its capacity when warm, the quantity of vapor 
entering the air passages must be different at different tempera- 
tures, supposing the air to contain all it can in every case; conse- 
quently the relative humidity is not sufficient for our purposes 
of comparison, as it only expresses the percentage of saturation 
at the temperatures existing when the observations were made. 
As indicated in the last report, we want to know for each month 
the relative quantity of moisture abstracted from the human 
air passages in excess of that inhaled; we should therefore ascer- 
tain the relative quantity of vapor in each cubic foot of air in- 
haled in each month.” 
* Klimatologische Notizen neber den Winter un Hochgebirge, by Arthur Wm. 
Waters, F.G.S. London, 1S71. 8 
When we give to the absolute humidity the importance it 
deserves, we can then without difficulty understand, why places 
with high relative but low absolute humidity show all the pro- 
perties of a very dry climate, as do, for instance, the lofty alpine 
health resorts in Switzerland. Biermann, a well-known writer 
about Climatology in Europe, states as the three main factors 
constituting climate, “temperature, barometric pressure, and 
absolute humidity,” and subordinates the relative humidity as a 
secondary factor to the latter. The following table, which for 
want of data could only be extended over nine mouths, will show 
that a place with a higher relative humidity can have lower 
absolute humidity. The data of relative humidity referring to 
Aiken are taken from a recent publication of Dr. W. H. Ged- 
dings, in the Charleston Medical and Surgical Journal, entitled, 
“Aiken as a Health Station.” The calculation of absolute hu- 
midity is based on Table XII, by James Glaisher, page 103, B, 
Meteorological and Physical Table, by Arnold Guyot, Washing- 
ton, 1859, with omission of the decimals in the temperature. 
Time of Observation. 
Asheville, 
N. C. 
Aiken, S. C. 
Tempera- 
ture.* 
Relative 
Humidity. 
Absolute 
Humidity. 
Tempera- 
ture.t 
Relative 
Humidity. 
Absolute 
Humidity. 
August, 1875 
70.9 
81 7 
6.53 
77-4 
79.5 
7.85 
September, “ 
63.9 
79.8 
5.15 
72.5 
69.5 
5.90 
October, “ 
53.1 
64 
3.01 
62 
63 2 
3.95 
November, *• 
43.3 
72 3 
2.46 
52.2 
71.2 
3.24 
December, “ 
37.3 
74.5 
2.07 
45.6 
68.9 
2.50 
January, 1876 
37 3 
61.6 
1.72 
47 
61.8 
2.39 
February. ‘' 
38.9 
62 
1.79 
48 2 
64. .3 
2.57 
March, “ 
44.8 
56 
1.97 
53.2 
51.8 
2.44 
April, “ 
54.1 
58.. 1 
2.82 
62 1 
55. .8 
3.48 
Means. 
49.2 
67.7 
3.05 
57.8 
65.1 
3.81 
Table. 
We see that Asheville, with an average relative humidity of 
G7.7 per cent., shows 3.05 absolute humidity, whilst Aiken, with 
a somewhat lower relative humidity of 65.1 per cent., shows 3.81 
absolute humidity. 
Rain originates from increased condensation of aqueous 
* Not knowing the means of temperature at Aiken, we have taken the monthly 
means of a series of years—of 8 years for Asheville, of 11 for Aiken. 
f In Dr. Geddings’ above publication, by mistake the relative humidity of 
Asheville was taken for the three months, May, June, July, 1876, instead of 
1875, which gives Asheville a higher percentage, as the year 1876 was more 
moist than 1875, and which accounts foi the difference of the figures obtained 
by Dr. Geddings and myself. 9 
vapor, the vesicles of which flow together and fall as 
drops of water. These drops increase in size as they fall, 
because the aqueous vapor of the air, through which they 
pass, condenses and unites with them. Therefore a rain-gauge 
located high above ground indicates less rain than one stuck in 
the ground. Rain is generally a very unwelcome guest to inva- 
lids, and rainy days are not only the most dreary for them, but 
many, nay, the majority, are afraid of direct injury from the 
rain. They do not consider that it is the rain which washes the 
air out and frees it from the carbonate of ammonia, which accu- 
mulates in larger quantity in the air when it does not rain for a 
long time. The rain absorbs this gas and couducts it to the 
soil, for which it serves as manure. The air coutains after a 
rain more oxygen and less carbonic acid, which latter is absorbed 
by the rain. The rain plays a very important part in nature by 
conducting to the ground all the substances, which when inhaled, 
are injurious to health and plant the germs of diseases of the 
respiratory organs. It would be desirable if the rain would fall 
always at night, in order not to interfere with the daily exercise 
of invalids. But it does not hurt them to be outdoors during a 
rain on a sheltered verandah, or even to walk out with an 
umbrella if they wear good boots. The fear of being out in the 
open air during a rain is greatly less in Europe, where very con- 
scientious patients can be seen taking their exercise with um- 
brellas. . > 
Ozone is oxygen in active form, aud oxygenizes organic and 
inorganic substances with much greater energy than common 
oxygen. It is therefore of the greatest importance as a powerful 
disinfectant of the obnoxious gases originating from the decom- 
position and putrefaction of animals and plants. It can artifici- 
ally be produced by exposing bitter almond oil to the rays of the 
sun, or by bringing phosphorus into a bottle with water at 86° 
F. and shaking it. In nature lightning is a generator of ozone, 
but its main originator is the chlorophyll of the plants, which, 
under the influence of the rays of the sun, parts with the carbonic 
acid formed during the night and exhales the ozone. 
After contemplation of some of the maiu factors of climate 
and their relative value to the invalid, a few words may suffice 
to enumerate some points, outside of climate aud drugs, which 
have to be considered in the treatment of consumptives. 
The entire change of habits a patient undergoes when living 10 
in a health resort, has undoubtedly a great deal to do with his 
improvement. But the influence of this change has been greatly 
overrated by some writers, who attributed to it more import- 
ance than to the climatic influence. The improvement derived 
from aif mere change without resorting to a proper climatic sta- 
tion, is either only slight or at least only temporary; and wre 
even see physicians, who adopt the above theory, send the 
greater number of their patients to health resorts of reputation. 
The value of certain climatic factors in treating invalids cannot 
well be denied, and the results obtained sustain their im- 
portance. 
The unlimited use of fresh air is by far the chief desideratum 
for a consumptive. This is a point the value of which is greatly 
underrated by physicians, and which has to be repeated continu- 
ally to consumptives. It we could make a patient in the city 
breathe pure country air several hours every day; if besides, 
wrn could put him under proper hygienic conditions, free him 
from mental cares—wre could sometimes save valuable lives, or 
at least retard the progress of the disease. In speaking about 
night air, the contamination of the air by accumulation of car- 
bonic acid in closed rooms is already mentioned. But an equally 
deadly enemy of the consumptive is the dust in its finest forms, 
which is always in a room, even if kept scrupulously clean with 
all the windows open. To convince ourselves of the great quan- 
tity of this finest dust, it is not sufficient to look at a ray of the 
sun shining into a room, but it is necessary to darken the room 
completely except a very small opening, and I doubt if many 
can be found who would approach the ray of light with their 
mouth open without disgust. The same experiment can be made 
with strong electric light. The time a patient is spending in a 
room is lost, and worse than lost. I mentioned here only dust 
as contaminating the air in a room, but there are a good many 
other injurious elements in our dwellings helping to deteriorate 
the air, as for instance, the decrease of oxygen, the excrements 
of respiration (carbonic acid and aqueous vapor), the excrements 
of perspiration, the products of illumination, the formation of 
carbonic oxide (results of gaslight, stoves), accidental vapors 
(tobacco smoke, kitchen vapor, etc.), the warming into motion of 
the whole conglomerate—each enough to drive a consumptive 
out of doors, w ho is in earnest to do the best he can for his 
health. 11 
Exercise is another essential for phthisical patients, especially 
as it assists to overcome the deficient expansion of the chest, 
and to bring air into parts of the lungs which were more or less 
inactive. To achieve this end, ordinary walking is not sufficient, 
but the patient must take deep inspirations, stop when his breath 
shortens, fully recover it, then go on until the breath shortens 
again, never allowing himself to become even partially “blown.” 
In this connection, it may be permitted me to say a few words 
about the manner of breathing, which I extract from Memeyer’s 
Atmiatry, and to which too little attention is paid as yet. We 
pay much and often painful attention to our food-diet, but how 
many are there who observe a respiratory-diet, which is equally 
if not more important than the first. One of the reasons of this 
neglect is the secrecy with which respiration takes place. Many 
acts are necessary for nourishment, the procuring of food, its 
preparation, mastiscation, digestion; the excrements are disa- 
greeable to our senses—nothing of all this with the respiration. 
We breathe unconsciously, and if the air becomes bad in conse- 
quence of accumulation ot respiratory excrements, it does not 
become perceptible to our senses. We distinguish three modes 
of breathing; shoulder respiration, the most important; costal 
respiration, depending upon the elasticity ot the ribs; abdominal 
respiration, the most extensive, as the descent of the diaphragm 
sets about three-fourths of the lung into activity. The apices 
are the least ventilated parts of the lungs, as the shoulder res- 
piration requires a certain position of the body and a certain 
amount of labor—unlike abdominal respiration, which is possible 
in all positions. Besides a proper position, some few more points 
interfere with full shoulder respiration: the scapula with its 
appendices, the extremities, rests like a roof on the top of the 
lung, and has to be raised by will in order to comply with the 
object in view. The apices have not those supplementary spaces 
at the side and the base of the lung suited to receive the inflated 
parts. Further, the bronchus of the upper lobe does not directly 
descend as in the lower lobe, but runs upward in a curved direc- 
tion and divides very early into a multitude of bronchial tubes, 
so that the inspiratory stream of air has to run around many 
curves and corners, till* it reaches its destination—the alveoli. 
The apices of the lung are therefore best adapted to serve as a 
reservoir of residual air, which stagnates and is seldom and im- 
perfectly renewed—a fact which plays an important part in the 12 
etiology of tbe primary seat of the disease, which, as well known, 
is in the majority of cases the apices. Full breathing is as 
essential to the lungs as eating to the stomach, and we delight 
to see the new-born child exert it to the fullest extent during 
the act of crying. All nomadic tribes are naturally full breathers, 
whilst we are accustomed to a sitting life and only occasionally, 
when bent over too long in oue position, erect ourselves and take 
involuntarily a deep, full breath. Artificial positions assist in 
setting certain parts ot the lung into activity, and ought to be 
recommended after careful selection to the patient. For the 
sake of illustration, examples of two positions may be mentioned: 
if we desire a patient to breathe more with one side, for instance 
the left, lower the right shoulder, let the right arm hang down, 
and raise the left arm and breathe deep. To promote shoulder 
respiration, let an attendant compress the false ribs of the 
patient, and have him cross his hands over his head and breathe 
deep. 
The use of cold water in its different applications ought not to 
be neglected in the treatment of invalids, as their skin is inactive 
and prone to perspiration. Cultivation of the skin counteracts 
the disposition to catching cold, and cold water applications act 
very favorably against an accompanying fever. 
The relief of unpleasant or dangerous symptoms, especially 
careful observation of the functions of digestion and assimila- 
tion, are of course to be kept constantly in view. 
It would unduly extend this article it all the climatic factors 
aud all the hygienic measures w'ere discussed. We saw that a 
difference in certain elements of climate does not materially affect 
the value of health resorts, but that others are essential and 
must not be lost sight ot, if we would place a patient under the 
most favorable conditions for improvement. In the class of 
hygienic measures belong further, good accommodations, nutri- 
tious, wTell-cooked food, diversion of mind, pleasant social rela- 
tions, and a rational physician, well experienced in the treat- 
ment of consumptives. This quotation from the late F. Nie- 
meyer will always be in point: “The consumptive must live 
under the constant supervision of a strict, conscientious physi- 
siciau, if favorable results are to be obtained.” It is not a single 
remedy which is a panacea against phthisis, but it is the cautious 
and continuous application of a great number of remedies, pro- 
perly selected for the individual case, which promises results. 
Patients generally know very little of what does them good or 13 
what hurts them. They have to be taught, and this is often a 
most difficult task. It requires a careful study of and an untir- 
ing attention to all the surroundings of a patient, if we would 
have him to use all the proper hygienic and other remedies in 
the right way. The physician in daily practice cannot exert 
the necessary supervision upon which alone depends the welfare 
of a consumptive. A supervision of this kind, if used with dis- 
cretion and adapted to the individual case, is never objected to 
by patients; on the contrary, as soon as they gain confidence in 
the physician, they like it and depend upon it. The experience 
of nearly two years has taught me the truth of this statement 
sufficiently, and the benefit received from it lias been for a long- 
time acknowledged in Europe. The objection to the aggrega- 
tion of invalids, often heard against an institution, which, right 
or wrong, can be raised against any hotel or boarding-house, 
where consumptives congregate, does not hold good in practice, 
and invariably I have seen patients who hesitated to visit my 
Sanitarium on this account become converted to exactly the 
opposite view: they heartily appreciate the value of being in the 
institution. No patient considers his case the worst, and each 
enjoys to see others improve, and derives from that hope for 
himself. Besides, there are always a large proportion of well 
persons in such an institution, relatives and friends of the 
patient. One of the strongest points in favor of a medical insti- 
tution and its preference to any other residence for consumptives, 
rests on the fact that the interests of the proprietor and physician 
are the same. The physician, whose first and main interest is to 
help the patient, will not hesitate to contradict and forbid, 
without fear, many things which a landlord will allow or even 
favor for the sake of pleasing or amusing his guests. A phy- 
sician will give his patients all that he possibly can, as his repu- 
tation is based on the improved condition in which his patients 
return; a landlord will only do what will sustain the reputation 
of his house. The advantages of a medical institution are best 
illustrated by the actions of the stockholders of the Curehouse 
at Davos, who always boasted that their patients enjoyed more 
liberty, and could follow their own inclinations and notions more 
than those in a medical establishment. According to a letter I 
received recently, preparations are being made to change the 
Curehouse into a medical institution. I hope to be able before 
long to convince the profession by my results, of the advantages 
of a medical institution for consumptives.