the year 1875, I endeavored to draw some conclusions respecting
climatic treatment from the facts contained in the histories. Temporary
changes of climate entered into the treatment in 74 cases. The
histories were interrogated with reference to the number of cases in
which recovery took place, the number in which the disease ceased to be
progressive without recovery, and the number in which the disease
progressed slowly, with reference to the apparent influence exerted by
climate. The changes of climate in the 74 cases were various. In a
considerable number the patients traveled in Europe, visiting different
places. The foreign resorts in which they sojourned for greater or less
periods were Nice, Algiers, Mentone, Egypt, Nassau, Lima, Rio Janeiro,
Cuba, and the West India islands. In this country the different resorts
were in Minnesota, California, New Mexico, Florida, Georgia, South
Carolina, Louisiana, Virginia, Kentucky, the District of Columbia,
Michigan, and the Adirondacks. Colorado as a place of resort had not
excited much attention prior to my making abstracts of my histories for
analytical study, and for this reason it does not appear in the
foregoing list. I have notes of not a few cases in which the latter
climate was resorted to. It is at once evident that 74 cases
distributed over so many places of resort cannot furnish adequate data
for judging of the relative advantages of different climates.
Nevertheless, the analysis of these cases led to an important
conclusion as respects, in general, the usefulness of a temporary
change of climate. Of the 74 cases, 9 ended in recovery, 13 were in the
list of cases of arrested or non-progressive phthisis, and 5 were in
the list of cases in which the disease was slowly progressive. In 33
cases the disease ended fatally, and in 14 cases neither the duration
nor the termination of the disease appears in the histories. Moreover,
of the 33 fatal cases, in 23 the histories afforded evidence of more or
less benefit from the changes of climate.[26] From these facts it
seemed warrantable to deduce, as a positive conclusion, that in a
considerable proportion of cases a {428} change of climate has a
favorable influence on phthisis. It follows also, as a corollary, that
a favorable influence is exerted by a variety of climates. Indeed, it
would seem, judging from these facts, that the favorable influence
pertains to the change rather than to the particular climate selected.
If this be true, it follows that the agencies by which a favorable
influence is exerted relate to accessory or incidental circumstances
more than to purely climatic conditions.
[Footnote 26: For further details vide _Phthisis, in a Series of
Clinical Studies_.]
It is an absurd supposition that any climate exerts a specific
influence in arresting phthisis. This statement is not in the least
inconsistent with the fact that certain climatic conditions are much
more favorable than others for an arrest of the disease. Dryness,
equability, and purity of the atmosphere are essential elements of a
favorable climate. Within late years a high altitude (4000 to 8000 feet
above the ocean-level) has been deemed by many of much importance.
Aside from the purity of the air incident thereto, the rarefaction is
supposed to have a salutary effect by increasing the expansion of the
lungs.[27] Few at the present time regard a tropical temperature as
advantageous. The choice is usually regarded as lying between a cold
and a warm climate, each having favorable elements aside from
temperature. There is abundant testimony in behalf of each.
Circumstances pertaining to cases individually must determine which to
choose. A patient who in health has found cold weather more favorable
to vigor and well-being than warm weather will be likely to find a cold
climate more beneficial than a warm climate, and vice versâ. In order
to derive benefit from a cold climate a patient must have preserved
sufficient vigor to endure out-of-door life in such a climate.
Confinement much of the time within doors must deprive patients of the
benefit to be hoped for from a cold climate. For obvious reasons a cold
climate is better suited to men than to women. With reference to the
superior excellence of particular health-resorts, caution is to be
exercised in weighing not only testimony either for or against their
superiority, but the value of reported cases. Putting aside the chances
of error in diagnosis, it is to be considered that among those who
elect a particular place of resort an arrest of the disease or
improvement to a greater or less extent would probably have taken place
had any one of many places been selected, and perhaps if no change had
been made. On the other hand, in a certain proportion of cases the
disease will be progressive anywhere. A limited number of cases must
not be relied upon to establish the relative advantages of particular
places, especially if there be not data enough to judge of the
condition of the patient in each case as regards the amount of the
pulmonary affection, the temperature, pulse, and other symptoms. A few
cases which have been selected to illustrate either the favorable or
unfavorable influence of a particular climate are not entitled to any
weight in the formation of an opinion. To gather clinical facts
sufficient to determine by analytical study the actual advantage
severally of different climates is a work attended by so many
difficulties that it must be long before it can be accomplished.
Meanwhile, in discriminating between different places of resort the
physician is to be governed by rational considerations. In reality,
custom and fashion have much to do in this matter. Places which were
formerly in vogue as health-resorts have now fallen into disrepute. It
is almost inevitable that sooner or {429} later this will be the fate
of any place which becomes so popular as to attract very largely
phthisical patients, owing to the aggregation of the instances in which
no benefit could have been expected from climatic treatment.
[Footnote 27: On this topic the reader is referred to an article by C.
Theodore Williams, entitled "The Treatment of Phthisis by Residence at
High Altitudes," in the _Transactions of the International Medical
Congress_, London, 1881; also to a work entitled _Rocky Mountain
Health-Resorts, an Analytical Study of High Altitudes in Relation to
the Arrest of Chronic Pulmonary Disease_, by Charles Denison, M.D., 2d
ed., 1880.
There is much reason in the suggestion that the immunity from phthisis
in situations which are sparsely settled may be due not so much to
climatic influences as to the fact that these situations are free from
non-climatic causes contributing to the prevalence of the
disease--namely, in-door occupations, overcrowded dwellings, etc.]
There is reason to believe that the benefit derived from climatic
treatment is often in a great measure due to accessory circumstances.
As already intimated, this seems to be a fair inference from the number
of instances of arrest of the disease, of cessation of its progress,
and of notable improvement in a collection of cases in which many and
varied climates had been resorted to. Under the name accessory are
embraced a variety of circumstances--in fact, everything not pertaining
purely to climatic agencies. The opportunity of living in the open air
and freedom from the cares of business, together with relaxation and
mental diversion, are in the category of accessory circumstances. These
contribute largely in some cases to the benefit derived from change of
climate. Patients at a health-resort are apt to carry out hygienic
regulations more faithfully than when at home. In contrast to the
accessory circumstances which are favorable there are those which have
an unfavorable effect, such as home-sickness, ennui from lack of usual
occupations, anxiety lest affairs should suffer for want of personal
supervision, interruption of fixed habits, and the want of home
comforts. These in some cases may go far toward counteracting the
benefit from climatic influences.
All these accessory circumstances, as bearing upon individual cases,
are to be taken into account in deciding the question as to the
importance of climatic treatment. Of course a change of climate is
important, other things being equal, in proportion as the climate in
which the patient resides is humid, variable, and the atmosphere
impure. So far as purely climatic influences are concerned, it may be
important only that the patient escape the more trying seasons of the
year--namely, the spring and the hot summer months. A malarial climate
should certainly be exchanged, if practicable, for another during the
season when there is danger of being infected with the malarial miasm.
To avoid this cause of disease, as well as the changes of temperature,
etc. incident to the spring and summer months, it may not be necessary
to go very far from home. It is probably better not to go to a distant
climate for a few weeks, in order that the double acclimatation caused
by going and returning within such a brief period may be avoided.
It is of essential importance to take fully into account the condition
of the patient as regards the pulmonary affection and the general
symptoms before advising or sanctioning a change of climate which
involves long journeys and separation at a distance from home and
friends. There is more reason to expect benefit from a change the
stronger the evidence against an intrinsic tendency of the disease to
progress actively. Whenever the temperature and circulation denote
activity of progress the propriety of a change is doubtful. Whenever
there is great emaciation with muscular feebleness there is little
ground to expect material benefit from any climate. The experiment is
allowable at an advanced period of the disease only with a view to
satisfy the wishes of the patient and the friends, having a full
understanding with the latter in respect of the danger of dying away
from home. It should be added that sometimes in cases which offer no
ground for the expectation of any essential benefit journeys or voyages
are well borne, and life is apparently prolonged by a change from an
inclement to a genial climate.
Distance is a point to be considered in the selection of places of
resort. It is often an objection to crossing the ocean that
communication with relatives or friends is attended with delay and
difficulty. The voyages, as a rule, are not objectionable. Our own
country embraces almost every possible variety of climate, and
therefore, so far as purely climatic influences are concerned, it is
not necessary to resort to foreign countries. The latter, however, have
for many the advantage of being made more attractive by novelty and
{430} historical associations. Moreover, there are often better
arrangements for comfort and enjoyment. The accessory advantages are
always to be considered with reference to the particular tastes and
needs in individual cases. Good food in abundance and well cooked,
large and well-ventilated rooms, facilities for walking, riding, and
driving, opportunities for hunting, fishing, and other out-of-door
sports, ample provisions for in-door exercise in bowling, etc.,
agreeable society,--these are among the accessory advantages without
which often the best climatic influences will prove inoperative. To
these is to be added available judicious medical advice.[28]
[Footnote 28: For details concerning the health-resorts of the Riviera,
Hyères, Cannes, Nice, Mentone, and others which are much esteemed in
Europe, the reader is referred to a work entitled _The Riviera_, by
Edward I. Sparks, London, 1879.]
A mistake often made by those who find benefit from a change of climate
is to continue the change for too short a period. The benefit speedily
obtained may be speedily lost when the patient is again placed under
the climatic and other circumstances attending the development of the
disease. It is to be borne in mind that the benefit from a change of
climate does not depend on any special remedial agency, but on a
combination of favorable circumstances, and that the salutary
influences connected with climate are exerted not so much directly upon
the lungs as upon the general system. It follows that the beneficial
effect may be manifested more by increase of appetite, better
digestion, greater endurance of muscular exercise, and especially gain
in weight, than by immediate improvement in the pulmonary symptoms.
Many patients cannot afford the loss of time and the expense of
lengthened absence, and therefore are unable to make trial of change of
climate. These may be consoled by the fact that not a few cases of
phthisis do well without any climatic treatment. In some of the most
striking of the instances of arrest of the disease which have come
under my observation change of climate did not enter into the
treatment. Important as is this fact, it does not conflict with the
belief that additional chances of arrest and the prospect of more or
less improvement are often secured by climatic treatment. It is a wise
precaution for patients to reside permanently in a climate in which an
arrest of the disease has taken place. Of course this is not always
practicable. Its importance is attested by reason and experience, and
it is the duty of the physician, according to his discretion, to
suggest it. The many obstacles which are often in the way of its
adoption are sufficiently obvious.
Sanitaria for phthisical patients at health-resorts are doubtless
serviceable in many cases, because hygienic measures are enforced which
would not under other circumstances be thoroughly carried out. An
offset to this advantage is the depressing effect upon some minds of
association with other patients. Owing to this moral effect it is
sometimes judicious to advise patients not to go to places which, for
the nonce, are especially popular, in order that they may not have
before their eyes cases exemplifying all the phases of the disease, and
be led to talk over symptoms with other patients affected with
phthisis. As regards sanitaria, those in which the chief object is to
enforce measures of hygiene are perhaps most likely to be serviceable.
If these measures be secondary to some system of medication, there is
room for distrust.
It is hardly necessary to say that the treatment of patients in such
institutions should be under the charge of competent physicians who
have not originated or adopted any peculiar notions respecting the
pathology and therapeutics of the disease. As a matter of course, there
cannot and should not be any restriction in either originating or
adopting ideas and methods of practice, however much they may be at
variance with commonly-received opinions; but a physician who
appreciates his obligation to his patients will hardly feel willing
that they should be made subjects for testing pathological and
therapeutical novelties in behalf of which his own belief is not
committed.
{431} Dietetic and Regiminal Treatment.--The dietetic treatment
resolves itself into a few simple principles. It may be assumed that as
much assimilation of aliment as is possible is desirable. No one
probably will contend for the propriety of any restriction of diet with
a view to limiting the amount of the nutritive constituents of the
blood. The difficulty in this part of the treatment lies in the
impairment or loss of appetite and in lack of digestive or assimilative
ability. It is useless to consider whether such or such articles of
food are suitable or not for phthisical patients. All wholesome
articles which can be taken with any relish and digested are suitable.
Nothing could be more ill advised than to direct kinds of nutriment
which a patient does not like, and to enjoin avoidance of those which
the patient's appetite would dictate. Pains should be taken to
ascertain the articles of diet most acceptable or against which there
is the least repugnance, and to excite the appetite by variety and
culinary attractions. It is important not to judge too hastily of the
ability to digest the food which can be ingested. The evidences of
indigestion are nausea, vomiting, flatulence, acidity, and diarrhoea:
whenever these symptoms are wanting it is fair to assume digestive
ability. Nor should evidence of indigestion deter at once from
continuing articles which appear to have occasioned it. The processes
of digestion are so apt to be disturbed by extrinsic accidental
circumstances that a meal which will occasion indigestion to-day may
not do so to-morrow. In short, so far as regulation of the diet is
concerned the patient is to be encouraged to take all kinds of
wholesome food according to appetite and taste, giving to each and all
a fair trial as regards digestibility. Fully aware that these views may
not commend themselves to the approval of many who think that the diet
should be regulated on scientific principles rather than by the
instincts of the patient, I do not any the less adhere to them,
believing that they are based on experience and common sense. As
regards the liability, where the instincts are followed, to the
over-ingestion of food and to the ingestion of food indigestible from
its quality or modes of preparation, it is far better to incur whatever
inconvenience may therefrom arise than the evils of inadequate
nourishment. In short, the dietetic instructions to a phthisical
patient may be summed up as follows: Eat of wholesome articles of food
whatever the appetite may dictate; endeavor to maintain and develop
appetite and relish for food by the excitement of variety in kind and
in preparation; eat whenever hungry; satisfy the appetite; eat without
any expectation of harm; do not hastily attribute an indigestion to any
particular articles of diet; incur the risk of over-feeding rather than
of the greater evil of under-feeding.
Anorexia in a degree which I have characterized as invincible--that is,
an almost complete inability to take food--is one of the most
discouraging of symptoms in cases of phthisis. Of course if the symptom
continue the duration of life is simply a question of time and
tolerance. Milk is an invaluable form of food when appetite is
completely lost. The advantage sometimes of substituting for simple
cow's milk buttermilk, koumiss, or milk made sour by fermentation with
yeast is due wholly to these being taken more readily and more easily
digested. The same is true of the substitution for the milk of the cow
that of other animals--the goat, the ass, and the mare. Eggs may be
given in a liquid form with milk or other fluids. Very little reliance
is to be placed on the various meat-extracts (Liebig's, Valentine's,
and others) as representing any considerable amount of nutriment. Meats
artificially digested--that is, in the form of peptones, as in Leube's
meat solution--form a valuable addition to beef-tea. Rectal
alimentation may be resorted to. A. H. Smith has reported marked
benefit from defibrinated blood as a form of rectal diet.[29] A French
writer, Debove, has lately reported notable benefit from forced
alimentation, food being injected through a tube introduced into {432}
the stomach.[30] If in any way food can be introduced, in spite of the
anorexia, and assimilated, there may be room to hope that a return of
appetite will be among the beneficial effects. Cod-liver oil and
alcoholics will be considered in connection with the medicinal
treatment.
[Footnote 29: Vide _N.Y. Med. Record_, 1881, No. xix.]
[Footnote 30: Vide _Bullétin générale Report_, Paris, 1881. Another
French writer more recently in the same journal, Desnos, has pointed
out a source of danger in forced alimentation--namely, the occurrence
of violent acts of vomiting, during which portions of food ejected from
the stomach are inhaled. The danger is from asphyxia and pneumonic
inflammation excited by the presence of particles of food within the
smaller bronchi. In order to avoid this source of danger, food should
be introduced slowly and not in too large a quantity at a time.
Intolerance of the presence of the tube within the stomach is an
obstacle which may be overcome by use, but in some cases it is
insuperable (vide article in _Philadelphia Med. Times_, March, 1882).]
The regiminal treatment embraces changes relating to out-of-door life,
exercise, occupation, clothing, etc.
Of all the changes in this category, those relating to out-of-door life
and exercise are of greatest importance. In-door life and sedentary
habits, if not factors in an acquired cachexia, undoubtedly favor it.
This is shown by the place which these hold in the etiology and by
their agency in the arrest of the disease. With respect to the latter
point, the result of my analysis of recorded cases has much
significance. In 44 cases change of habits from those more or less
sedentary and confining within doors to those involving out-of-door
life and activity entered into the treatment. In all but 4 of these
cases the hygienic treatment consisted chiefly or exclusively of the
change of habits mentioned. Of the 4 excepted cases, in 1 the patient
passed several months in Europe; in 1 the patient passed a summer in
Minnesota; in 1 the patient made several voyages to Europe; and in 1
the patient travelled in Europe. Of these 44 cases, 15 are in the list
of cases of unknown duration and termination. Deducting these, the
remaining number is 29. Now, of these 29 cases, 11 are in the list of
cases ending in recovery; 7 are in the list of cases in which the
disease was arrested or became non-progressive; and 3 are in the list
of cases of slowly-progressive phthisis. Thus, only 8 out of the 29
cases were not included among those in which the course of the disease
was favorable in the three aspects just named, and in more than
one-third of the cases recovery took place. Of the 8 fatal cases, in
all save 1 case the change of habits appeared to be beneficial. The
benefit was marked in 2 of the cases, there being in 1 of them no
evidence of progress of the disease for several months.[31] Moreover,
the majority of the histories of the 15 cases of uncertain duration and
termination show more or less improvement. In 7 of the 11 cases ending
in recovery the change in habits constituted all the treatment. Making
the fullest allowances for an intrinsic tendency in the disease to end
in recovery, and in some instances purely from self-limitation, the
foregoing facts afford ample proof that changes of habits from those
more or less sedentary and confining within doors to those involving
out-of-door life and activity have considerable agency in the arrest of
phthisis and exert a favorable influence upon the disease when it is
not arrested. There is reason to believe that the favorable influence
is greater than any other class of hygienic measures, and it is
probable that to this source much of the benefit derived from change of
climate is to be referred.
[Footnote 31: For details of the changes of habits in these cases vide
_Phthisis, in a Series of Clinical Studies_.]
The particular changes to be made in order to secure as much
out-of-door life as practicable with a certain amount of exercise must
of course vary in different cases. Clerks, school-teachers, mechanics
whose business requires in-door life, etc., should, if possible, adopt
some other occupation securing the desired objects. Students,
clergymen, and men of leisure should systematically devote a fair
proportion of time to exercise in the open air, and as far as {433}
practicable the exercise should involve recreation. It is needless to
say that the importance of change is as applicable to women as to men.
Caution is sometimes necessary not to carry muscular exercise to an
injurious extreme. If carried to the extent of producing great fatigue
or exhaustion, it is debilitating instead of invigorating. Exercise
within doors, although much less useful than when taken in the open
air, is nevertheless useful. Gymnastic exercises may be recommended
when other measures which are to be preferred are not available. They
are inferior to rowing, horseback riding, hunting, etc. An increased
expansion of the chest is apparently a desirable effect of exercise.
Forced efforts of expiration to overcome a mechanical resistance, the
lungs being fully inflated, constituted a method of treatment formerly
in vogue, and I have met with instances in which it seemed to have been
useful. In taking exercise patients are apt to imagine that in order to
avoid catching cold they should go out of doors only when the weather
is in all respects favorable. Precautions in this regard are often
carried so far as to interfere materially with the amount of life in
the open air which is desirable. It should be understood that
phthisical patients are no more--and perhaps less--liable to catch cold
than persons in health, and that a cold, as a rule, does not affect the
progress of the tuberculous disease. These excessive precautions have
arisen from the error of considering phthisis as a sequel of
bronchitis. There is no ground for the great scrupulousness with which
phthisical patients avoid the night air, although out-of-door life in
the daytime is to be preferred.