boldly set open, and be kept open at the top all night. If they are to be closed of necessity, a free chimney-draught must be procured, and an Arnott's valve is always an advantage. The bed should be free of curtains, but a single screen may be placed so as to ward off any direct draught from the door or window. Warmth of body is best secured by woolen bedclothes; but, if the temperature of the air is below 60° Fahr., it will, with advantage, be raised to that pitch by a fire in the open grate. Gas should on no pretense be burned through the night in this bedroom, and as few other lights as possible, for the patient requires all the air that is to be had, and must not be carelessly robbed of it. Above all things, the consumptive person should be the sole occupant of his own bed and bedroom. To place such a one for several hours close to another person, however healthy, is injurious to both, but especially to the sick. No ties of relationship, and no mistaken kindness, should cause this rule of isolation ever to be broken.

It has been stated already that the room of the sufferer should be large. It should include, whenever practicable, at least fifteen hundred cubic feet of breathing-space, under all plans of ventilation. If more space can be had, all the better. If less only is obtainable, then the ventilation must be the more carefully attended to.

When the patient has left his room in the morning-and he should do so early-the windows and doors should be set open, and a current of air be allowed to flow through it during the whole of the day. If the air of the apartment be at a temperature below 60° Fahr., or loaded with moisture, the fire should be lighted two hours before bedtime.

Consumptive patients frequently ask, especially in winter-time, the value of what are called respirators; and I have known some poor people purchase things of this description at what was to them considerable cost. The use of mufflers, which are, in fact, respirators, has been known for ages; and Dr. Hales, more than a century ago, recommended a scientifically made muffler for persons obliged to enter into places where noxious gases were given off. Dr. Beddoes, too, as Dr. Arnott shows, pointed out, in the year 1802, that a few folds of gauze held over the mouth and nose made the air warm and moist for respiration, and that such mufflers were, therefore, useful to consumptive and asthmatic persons. The object of the muffler or respirator is this: it retains the heat thrown out in the expired air, and gives up this heat to the cold air that enters in inspiration. In cold, dry weather, the muffler is very useful, and should be worn by all phthisical patients when out-of-doors; but when the air is moist and cold it sometimes is complained of as embarrassing the respiration. It should then be thrown aside. Any patient may easily make one of these mufflers for himself, for the cost of a few pence, out of a piece of fine wire gauze, cut oval so as to cover the mouth and nose and fixed in the center of a small Shetland shawl, so that it may be tied on like an ordinary comforter, with the gauze in the center for breathing through. The metal

gauze, plated or silvered to prevent rust, will last for several months, and in summer-time can be removed from the shawl and laid aside; but the shawl is often useful in all seasons.

RULE II. Active Exercise is an Essential Element in the Treatment of Consumptives.-The conditions for obtaining a due supply of air imply in some measure the necessity for exercise. But there are varieties of exercise. Drs. Rush, Jackson, and Parrish, are in favor of riding on horseback, but this is a thing not practically to be carried out in the majority of cases, and, as I think, not absolutely necessary. Walking is the more natural exercise; it brings into movement every part of the body, more or less, and, leading to brisker circulation in every part, causes a more active nutrition generally. Of late years I have very much recommended tricycling to consumptive patients, and often with great benefit. In many instances it is better than walking exercise, giving more perfect change of air and scene with less fatigue.

The extent to which exercise should be carried will vary with the stage of the disease, and temporary accidents-such, for instance, as an attack of hæmoptysis-may, for the moment, stop it altogether. But, when exercise is advisable, the general rule is to recommend that it be carried out systematically, cautiously, and courageously, and that each exercise should be continued until a gentle feeling of fatigue is felt through the whole muscular system. Violent and unequal exertion of the upper muscles of the body is unadvisable. When restored from the fatigue of one exercise, another should be undertaken, and during the day this can not be too often repeated. If the day be wet, then the exercise should be effected by walking in a large room, or by engaging in some game, such as skittles, billiards, or tennis.

If, in his waking hours, the consumptive patient can keep himself occupied pretty freely in muscular labor, he secures the best sudorific for his sleeping hours that can possibly be supplied; for as the force of life is always expended in producing motion or action, so, to use the words of Dr. Metcalfe, "the proximate cause of sleep is an expenditure of the substance and vital energy of the brain, nerves, and voluntary muscles, beyond what they receive when awake; and the specific office of sleep is the restoration of what has been wasted by exercise." Cough is very much less frequent in the course of the night in him who has been subjected to exercise in the day; while sleep, when it falls, is more profound, more prolonged, and more refreshing.

In summer-time, when the temperature of the day is high, the morning and the evening time are the best adapted for the periods of out-door exertion. In the other seasons, midday is preferable, as a general rule.

I have been asked, often, whether dancing is good exercise for children and young persons of a consumptive taint. There can be no doubt that it is so when properly conducted. When dancing is carried

on, however, it must be done in a very large room, freely ventilated, and scrupulously free from dust; for, the more exercise the body takes, the more air it requires, and the less of incumbrances in the way of mechanical obstacles to a free respiration. In damp days, when walking out-of-doors is impossible, the consumptive child may thus have three hours' dancing with advantage; not in stuck-up bowing and scraping, finnicking, polite quadrillism, but in good active dances, that make every limb feel pleasant fatigue.

In the performance of muscular exercise let the consumptive never encumber himself, nor check the free movements of his body, by strappings, loads of clothes, carrying of weights, and the like. These are but tasks; they lead to unequal exertion in special sets of muscles, and to an inequality of expenditure of power which ought to be avoided.

A last consideration on the value of muscular exercise is, that it is eminently useful in keeping the respiratory muscles in a state of active nutrition. For, if to the loss of capaciousness in the lungs to receive air there is added a daily increasing failure in the muscles by which the acts of inspiration and expiration are carried on, it is clear that a double evil is at work. Now, this double evil is most actively presented in consumption. As the respiratory muscles, together with the other muscles, lose their tone, so do the general symptoms of exhaustion increase in severity, sometimes without very marked change in the pathological condition of the lungs. In sequence, day by day, as the nutrition of these muscles decreases, and as they fail in tonic contractile power, they gain in excitability; so that the irregular spasmodic contractions to which they are subjected in the act of coughing are produced by the merest excitement, and the cough is more frequent as it becomes more feeble.

RULE III. A Uniform Climate is an Important Element in the Treatment of Consumptives.-Consumptive patients are constantly asking questions as to the value of a change of climate. The poorest applicants for relief are anxious on this point, and are often ready at once to contemplate emigration, if the merest hope is given to them that such a course would prove beneficial. In considering climate, the fact should be remembered that the main point to be obtained is to se. lect such a part of the earth's surface as presents the nearest approach to an equality of temperature. Different writers of eminence have given the most contrary opinions on climate and consumption. Some have recommended a warm climate, others the polar regions. Both parties have spoken from experience, and they are, in some measure, both right; for a climate equally cold and a climate equally hot are each much more favorable than one in which there are constant variations, and where the thermometer in the course of the year ranges many degrees from freezing-point up to 100° Fahr. or higher. Speaking of 153,098 deaths from consumption occurring between the years 1841 and 1851, the Irish Census Commissioners observe :

"As might naturally be expected, the seasons exercised a very marked influence upon the deaths from consumption. During the mild months of autumn, succeeding the warm season of summer, the deaths attributed to consumption amounted to only 23,010; with the cold of winter the mortality from this cause increased, so as to present a return of 38,956; but with the harsh, trying weather of spring it rose to 51,334, and in summer fell again to 39,798."

This statement represents a very important truth. It is certainly best for the patient if the temperature, while equal, be also temperate; but a mean temperature of 35° on one side, or 75° on the other, is preferable to one varying constantly, to-day at 60° Fahr., to-morrow at 40°, and a few days later at 80°.

From the experience gained in taking charge of a large number of consumptive patients it becomes a remarkable and highly-instructive task to learn the influence of climatic changes on the symptoms of the disease. I can usually predict, almost with certainty, the history I am to bear from the consumptives who are coming before me. If for some days there has been uniformity of temperature, and the weather has been mild and dry, so that an airing each day out-ofdoors has been effected, the visit is quite a cheery one; all seems better; the medicines are said to agree. The cough is less troublesome, the body is warmer, and hope, diffusing an inward sunshine, lights up each face with brightness and activity. In frosty days, too, when the air is dry and the temperature continues even, the symptoms are often equally favorable; but during periods, so common in this country in the spring and in the beginning of winter, when the atmospheric variations are sudden, marked, and often repeated in the course of a few weeks, the general aspect of affairs is widely different. I have heard on these occasions almost every patient complaining; the symptoms are all exaggerated, the mind discontented. There is a general request for a change in the medicine. Something is asked for that will soothe, for the nights are passed indifferently. It is useless to comply always with these demands, since the exaggerated train of complaints has a general and common cause; but now and then the modification of symptoms is so great as to call for a modification of treatment. During these variations of season, deaths from consumption are most prevalent.

Thus an equable temperature is of great moment, and should always be sought after by the phthisical sufferer. If he can not remove from his own locality, and if the variations in it are considerable, he must take the best precautions at his command. In-doors it is not difficult to sustain a pretty even temperature, varying from 55° to 60° Fahr. Out-of-doors, something must be done by attention to clothing, and by the use of the respirator. The most marked variations, however, occur in the night, and hence the importance of keeping up an equality of warmth in the bedroom, in the manner already described.

The reasons why consumptives feel the effects of climatic changes so much are sufficiently obvious. The effects of such variations are felt, indeed, in the best health; for the body is in some measure both a barometer and a thermometer; at all events, it is subject to the same influences, the lungs being in all cases the parts most affected. With the temperature moderately high and the air dry, the physiology of respiration is carried on easily and well. The amount of oxygen taken in is ample; the expiration of water, carbonic acid, and ammonia is free; the pulmonic circuit of the blood is unimpeded; the exhalation of water from the skin is unchecked; and the radiation of heat from the body is moderate. Let these atmospheric conditions suddenly change for those in which the temperature is 35° Fahr., or less, and in which the air is charged with watery vapor, and the conditions of life are materially modified. The supply of oxygen taken into the lungs is less; the process of absorption of such oxygen by the blood is less; the expired products are lessened; the pulmonic circulation is impeded; the watery exhalation from the skin is, in part, suppressed; the radiation of heat from the body is much more rapid; and, as a result of all, the whole man, body and mind, is enfeebled in force and in vitality. This is the course of things in a healthy man during atmospheric variations. It is left with the reader to trace out the exaggerated evil of these changes in those who, at the most favorable times, are existing with the lungs reduced in capaciousness and the respiratory muscles in power.

I shall recommend no particular place as a resort for consumptives; for I wish not to enter into disputation on this point. But here is the formula for an hypothetical Atlantis for consumptives: It should be near the sea-coast, and sheltered from easterly winds; the soil should be dry; the drinking-water pure; the mean temperature about 60°, with a range of not more than ten or fifteen degrees on either side. It is not easy to fix any degree of humidity; but extremes of dryness or of moisture are alike injurious. It is of importance in selecting a locality that the scenery should be enticing, so that the patient may be the more encouraged to spend his time out-of-doors in walking or riding exercise. A town where the residences are isolated and scattered about, and where drainage and cleanliness are attended to, is much preferable to one where the houses are closely packed, however small its population may be.

In speaking thus of the value of an equal climate, I am guided chiefly by the facts daily presented to me in relation to climatic variations on patients living in these islands. Some authors, however, infer from mortality returns, gathered from various quarters of the world, that variations of climate do not materially affect the disease, but that it is uniformly more fatal in cities than in the country. In England the excess in cities is equal to twenty-five per cent.

The facts are not opposed to the value of climatic uniformity. On