possibly can, in five substantial meals daily, and great importance is attached to regularly graduated exercise in the extensive grounds, Dr. Brehmer, its founder, and long its chief physician, insisting on the importance of the up-grade of the incline on starting, and the down-grade for the return, Dr. Dettweiller, of Falkenstein, urging the opposite view, that the start should be down hill and the return on the rise! On another question authorities differ. While some expatiate on the beneficial 'scavenging' effect of free exposure of the person to strong winds, Brehmer asserts, on the contrary, 'wind is a veritable poison for the consumptive.'

At Falkenstein, near Homburg, forced feeding is also a leading feature in the treatment, but is not insisted on so much as at Goerbersdorf, and more rest in the open air than exercise is demanded. In both sanatoria, practically unlimited milk is supplied from their own dairies. It is important to note that in neither of these institutions is it claimed that in all cases these two methods alone suffice for treatment. On the contrary, in his recent work describing the German consumptive sanatoria, Dr. von Jaruntowsky,' formerly for five years assistant to Dr. Brehmer at Goerbersdorf, in his recent most valuable work on 'Sanatoria for Consumptives,' after referring to Aeration and Feeding (the Hygienic-Dietetic Method), as the best for general treatment, says: 'Passing now to the special or symptomatic treatment, like every other disease characterised by dangerous symptoms, so also consumption, with its numerous and often unaccountable symptoms, requires strict clinical treatment. And to this end the sanatorium with its various appliances offers the best means.' Accordingly we find a large proportion of the patients in the sanatoria, refractory to the healing influences of fresh air, rest, and diet alone, placed under the usual drugs adapted to relieve their symptoms-fever, night sweats, cough, hæmorrhage, dyspepsia, &c. In the characteristic fever commencing with chill, 'the patient may have to be sent to bed early in a well-warmed room with closed windows.' 'In the case of fever occurring suddenly after catching cold, the patient should be sent to bed immediately and made to sweat freely, and kept for some days in a well-ventilated room, wine and phenacetin being used at the same time;' again, one must make more use of antipyretics if fresh air, ice, and wine do not act sufficiently,' and 'patients in the last stages of disease had much better remain in bed in a well-ventilated room.' I think these quotations from the recently published work of an author of such repute and special knowledge at once dispose of the absurd idea that fresh air alone will cure consumption. The therapeutic influence of exposure to fresh air, like that of climate, is slow in operation, and the intensity of symptoms especially in the frequent pyrexial states of

1 Translated by Dr. C. Clifford Beale, of the Victoria Park Consumptive Hospital.

the disease cannot wait, but must be treated on general medical principles. The efficacy of open-air life as a remedy in consumption is as old as the father of medicine, Hippocrates, himself, and recommended by him to be obtained by resort to climates where outdoor life was more possible. Celsus and also Aretaus strongly recommended the open-air life at sea. Pliny sent two of his consumptive freedmen to the mountains for the benefit of the sunshine and the odour of the pine forests, which Galen, the great Roman physician, also advised, with abundance of milk. Indeed, there never was in the history of medicine any time that these beneficial or rather curative influences were not appreciated, although certainly not to the extent they have more recently attained since the nature of consumption has been more fully understood. In later times the teaching, among many others, of Professor Hughes Bennett of Edinburgh, of Dr. Henry Bennett of London and Mentone, of Dr. C. B. Williams of London, and of that original thinker the late Dr. MacCormac of Belfast, was all strongly in favour of the hygienic treatment of consumption. Dr. Brehmer undoubtedly has the merit of first systematising and combining the open-air treatment with enforced diet, and showing how much general treatment, carried out on rational principles, could accomplish. His establishment at Goerbersdorf was founded in 1854, and has been followed by many other similar institutions, more or less modifying the parent teaching, both in Germany and elsewhere. But up till quite recently no attempt has been made on the Continent to provide like resorts for the necessitous. In England, on the other hand, this position is reversed. No private sanatoria have existed until quite lately, and then only of the most limited and domestic character; but consumptive hospitals for the poor and needy have existed for long periods, and to them very probably is due the remarkable decrease in deaths from phthisis that has taken place in England since a date corresponding to their establishment, to which attention has been drawn by Continental authorities. Among the principal Consumptive Hospitals are:-Brompton, founded in 1841, 321 beds; Victoria Park in 1848, 164 beds; North London in 1860, 75 beds; the City Road Hospital in 1863, 75 beds; and the Royal National Hospital, Ventnor, in 1869, 138 beds. The latter differs essentially from the other English hospitals in advantages of climate, locality, and in the structural arrangements having been originally designed for the purpose of obtaining the utmost possible exposure to open air and sunshine as a fundamental principle in the treatment. In all respects it compares favourably with any of the Continental sanatoria, notably Falkenstein, which suffers to a great extent from faulty structural arrangements in its earlier buildings, which involve and indeed explain the necessity for annexes designed for freer and more direct ventilation. The medical staffs of these several hospitals above

named, will yield to none in technical education, competence, and devotion to their particular speciality, and they endeavour, with all the resources at their disposal, to evolve and carry out a rational eclectic system of treatment, including all that their knowledge, experience, and study of other methods enable them to select. This difference in the class of institutions for the treatment of consumption in the two countries is due really to the differences of national character and habits. The well-to-do Englishman will not, in his own country at least, submit to the discipline which is imperative in these sanatoria-exclusive, reserved, insular, he resents the restraints of such an environment, and few only can reconcile themselves to the régime. This is the reason that in England, with medicinal waters many as potent as any of their class on the Continent, the regimen and restraints necessary in diet and habits for their healing powers being realised have never been submitted to as they are on the Continent, where nevertheless English people congregate annually in increasing numbers. The Germans, on the other hand, seem to adapt themselves naturally to the sanatoria life with all its restraints and self-denial, and at the same time it is to be remembered that the country is too poor yet to spend munificent sums in building and maintaining public hospitals on the English scale, for the relief of the consumptive poor.

I

Comparisons in vague terms have been made between the results. of treatment in Continental sanatoria and hospitals for tuberculosis in this country. The statistical method is of course the appropriate one to decide this question, but to be exact the modes of designating and classifying the various categories of cases as regards their stage of disease would require to be identical. This not being so, only approximate results can be derived from the figures available. have before me the statistics of most of the Continental sanatoria, but I shall select only those of three, Falkenstein, Goerbersdorf, and Reiboldsgrün, as they are fuller and more complete, to compare with those of the Royal National Hospital at Ventnor, where the details of every case, with a graphic diagram of the pulmonary condition, have been carefully recorded in no less than 16,951 cases since 1870. The difference in the medical state, as regards stage of disease, of the patients attending this hospital is very marked and. very unfavourable to the comparison-hardly 1 per cent. of the patients admitted were in the 1st stage, whereas at Goerbersdorf they amounted to 27-62 per cent. Again, the physical condition, also, of the patients on admission is very different-seeking as they do the benefits of the charity after a long struggle with poverty and disease-compared with the well-to-do who resort to the foreign Sanatoria. Then again, as regards classification, those designated 'Cured,' or 'Nearly Cured' in the sanatoria correspond practically to the 'Restored' and 'Improved ' categories of the Royal National Hospital.

These figures speak for themselves, and show conclusively that the results of the eclectic treatment at that hospital, which con-sists in the freest exposure to fresh air and sunshine, a judiciously adapted diet, together with such therapeutic aids as the symptomsof each case may from time to time demand, compare most favourably with the other institutions under consideration.

It may be noted in connection with the question of diet that no less than 76.99 per cent. of the patients at the Royal National Hospital gained weight without any forced feeding, but as the result of careful attention to general health with a simple, ample, and suitable dietary. In 1896 out of a total of 676 cases no less than 524 gained, of which the average gain was 6 lbs. 3.97 ozs., while 32 of these gained over 1 stone. In 1898, 583 out of 711 patients in ten weeks gained on an average over 7 lbs. each, of which number 56 patients gained over 1 stone each; and last year 576 out of a total of 717 gained on an average 6 lbs. 8.2 ozs., 38 patients over 14 lbs., one scaling no lessthan 28 lbs. The very meagre details available from Nordrach show that 90 per cent. of the cases were not cured as stated by Mr. Gibson in last month's Review, but that 30 per cent. only belonged to that category, the remaining 65 per cent. merely figuring as 'Ameliorations.' With respect to gaining weight as the result of forced feeding, on which that gentleman lays so much stress as one of the leading features of treatment at Nordrach, it is notorious that many patients break down under the ordeal, and the weight gained under pressure is often as rapidly lost, only a seriously damaged digestive apparatus being the result. The statistics of weight at the Royal National Hospital prove that forced feeding is absolutely unnecessary; it is unnatural, therefore unphysiological; it is utterly wasteful, and is in the highest degree injurious if not dangerous in acute stages of the disease. Mr. Gibson's experience at Nordrach would have been as valuable as it is interesting had not the perhaps pardonable enthusiasm of a grateful beneficiary obscured the memory and given rein to his imagination. He had, as the result of sound medical advice, evidently well advanced on the road to recovery, in that, for three months before he left Ireland, he was able to dispose

of 'more than half a gallon of milk daily' as an item in his diet. At Nordrach he was also equal to the strain of forced diet, returning exactly in the condition of an athlete in training. This now enables him to dispense with umbrellas and greatcoats, and with impunity to get ducked to the skin twice a day, and sit in his wet clothes until they dry; but, quite apart from mere considerations of comfort and economy, the practice is surely not to be recommended to the general public, who for the most part are very rarely in 'condition' to run such a risk. Mr. Gibson says: Here are the features of the cure: nourishment, rest, and fresh air. Of the three the over-feeding is by far the most important, for it is conceivable that a cure might be effected by this means alone, which could never be accomplished by fresh air and rest only.' Surely, if this is the case, why take the temperature four times a day? Why require to receive a visit from the doctor three times a day? Why, if over-feeding alone suffices, should it be necessary to be ordered to bed, to lie on a couch, to sit outside, or to go for a long or a short walk'? Why, indeed, should it be necessary to go to Nordrach or from one's home at all? 'Training as a chemist' does not seem to qualify any one to speak authoritatively, much less dictatorially, on the subject of a disease that demands training very different from that of the chemist. He certainly is not justified in saying 'that from his own case he knows more about this disease than most scientists could possibly know by theory.' 'Most scientists' do not 'know by theory.' Scientific medical men do make use of theory, but as one only of the recognised modes of directing practical studies. People stricken with acute consumption do not consult theoretical scientists-perhaps Mr. Gibson has had this unusual experience. And again, he is not the only man who has had the sad opportunity of knowing his own case; many medical men, the present writer himself, being among the number. One of the most romantic incidents in medical biography is the experience of two (one of them certainly the greatest of specialists in consumption) whose names have already been mentioned -Professor Hughes Bennett and Dr. Henry Bennett. The latter, in the full tide of professional prosperity in another branch of medicine, was stricken with acute phthisis. He hurried to Edinburgh and received his sentence from Professor Bennett, to give up all in town and retire to the Riviera, which he did permanently, and it is well known with what success. But, with the irony of fate, thirty years later, Hughes Bennett, now himself a victim to pulmonary tuberculosis, went to join his whilom patient in Mentone.

Mr. Gibson's emphatic affirmation, that consumption is not a fatal disease, is quite unnecessary, as even theoretical scientists' have always held that opinion. Carswell, the greatest scientific physician of his time, says: 'Pathological anatomy has perhaps never afforded stronger evidence of the curability of a disease than in the case of