f0>i S: %'''<&■>/%%■.■ MMNM frtMJHMNtiN|ttBM>Mtf«iaMmNM(p *^C^w (Eolumbta 1Itttu?rsttg Ut tty? (Hitg of Nwti fork (£all?#£ of pjyatrtatiH ano imrgrmts 4&?fnmtt library ■* v, ? ' < ,^\ v s. K - PRICE, 50 CEMX HOME CLIMATIC TREATMENT Pulmonary Consumption ON THE BASIS OF MODERN DOCTRINES. By J. HILGARD TYNDALE, M. D., Member N. Y. County Medical Society; late physician in charge of Rocky Mountain Sanitarium for Consumptives at Manitou, Colorado; author of " Present Status of the Pathol- ogy of Consumption and Tuberculosis," and of " Influence of Altitude on Consumptives." BERMINGHAM & CO., Publishers, 1260 & 1262 Broadway. 1882. Copyrighted — 1882. By Bermingham & Co. :\v\ Printed by SAMUEL L. LYONS, 109 Mercer St., New York. THIS VOLUME IS DEDICATED TO Prof. ALFRED L. LOOMIS, Of New York City, as a tribute to his earnest endeavors in promoting our knowledge of the pathology of pulmonary consumption. Digitized by the Internet Archive in 2010 with funding from Open. Knowledge Commons http://www.archive.org/detaiis/homeclimatictreaOOtynd PREFACE The object of this little work is to present to the profession in a readable and easily assimilable form the most approved methods and lines of treatment of consumption, which I have endeavored to present strictly upon the basis of modern doc- trines. The opening chapter on pathology is to convey only a terse review of the leading factors which go to make up that clinical picture which we call pulmonary consumption. In the chapter on home treatment, my endeavor has been to free the subject from all cumbersome material, and retain only such features as have stood the test of time. While thus sketching the present status of the treatment of pulmonary consumption, it is my earnest desire to draw attention to what seems to me the future path to be pursued in thera- peutics, namely : To endeavor to bring nutrition to the highest point attainable, and retain it there long enough to enable us to pursue a systematic course of antiseptic treat?nent of the general co7idition, laboring wider chronic septicemia, as well as of the local lesion. Such a system, carefully planned in all its details, I have been carrying out for some time. As yet my statistics are in their infancy, but as the system is care- fully elaborated and founded on a rational basis, I feel con- fident of the future. " Climatic treatment" aims to set up a standard of factors requisite for an ideal climate. The claims of any locality or health-station are in part measured by this standard, in part by statistical results, as gathered from a variety of sources, all of which are duly credited. I am now at work collecting all meteorological data obtainable for the various States and sec- tions of our country, in connection with the reports of the U. S. Signal Service and the Coast and Geodetic Survey, in order to stimulate further investigation into the all important subject of suitable climates for various forms and phases of phthisis. Another factor which has decided me to publish the fol- lowing letters (originally addressed to a friend in greater part), has been a desire to collect and summarize the much scattered material relating to the therapeutics of consumption, to preserve what is worth preserving, and present it in such a shape as to bring order out of chaos. CONTENTS Pathology on Consumption, - 9 Of Treatment in General, - - . - -22 Home Treatment, - - - - - - 26 Climatic Treatment, - - - - - -91 General Conclusions, - - - - - 165 PATHOLOGY OF CONSUMPTION. The term "consumption" comprises all progressively destructive processes of the respiratory organs which do not occur successively and rapidly in the train of acute inflam- mations of the lung. Pulmonary phthisis is not a morbid unity therefore; it stands as the collective expression, the highest potency of a number of more or less chronic inflammatory processes of the lung, which, having failed of restitution to the normal condition at an early period, lead in their further course to proliferation and shrinkage of connective tissue with or with- out pigmentation and bronchiectasis, to calcification or to progressive destruction of their cheesily degenerated infiltra- tion and the formation of ulcerating cavities in the substance of the lung; at times to the formation and rapid dissemination of tubercle, either independently or in connection with the preceding conditions. Thus consumption may result from unusually protracted acute inflammation of lung tissue, or the process may assume a lingering form from the outset. In either case the form and course of the disease are governed entirely by the con- stitution of the person affected. In other words, the amount of living matter (protoplasm) which each individual brings to his case will determine the future form of lunq; trouble. JO TREATMENT OF CONSUMPTION. This important fact teaches us that, since each individual in his composition is a law unto himself, so strict individualiza- tion is the most important factor in and the surest road to the correct diagnosis and prognosis as well as to the treat- ment of pulmonary consumption. The following extract from my forthcoming publication, " Present Status of the Pathology of Pulmonary Consump- tion,"' will give you the pathological condition in different language: "A low state of vitality may exist from infancy through hereditary influences, or may be acquired by various perni- cious accidents of our career. By a ' low state of vitality ' we understand a certain general condition of the system, which manifests itself by the reproduction of living matter of low grade and ready tendency to necrobiosis, which pro- ducts are the only demonstrable evidence of said general condition. By ' living matter' I mean, in accordance with Prof. Heitzmann's teachings, all protoplasm from the finest granule to the full-fledged corpuscle. In impaired vitality living matter is defective as to quantity, a feature which we can recognize microscopically, and as to quality, a feature which we cannot recognize, and which change is most prob- ably histo-chemical; but as yet we do not know this. When this production of sparse living matter, with little tendency to development into normal connective tissue and epithelium, is hereditary, we speak of these products and of the person afflicted as scrofulous, and say they are vulnerable. When it is acquired in a previously healthy person by lin- gering sickness or frequent repetition of abuses to the vari- ous organs, they likewise become vulnerable. PATHOLOGY OF CONSUMPTION'. ] I Vulnerability manifests itself in a more or less constant irritability of the pulmonary and gastric mucuous mem- branes, which irritation is readily answered by proliferation of sound or indifferent elements, (also called inflammatory corpuscles. ) These corpuscles in the healthy nature of things should : First, not multiply so numerously ; 2d, develop slowly into tissues of the connective tissue series and epithelium dis- tinctly nucleated. Instead of this they multiply rapidly and crowd upon one another and develop into imperfect, readily broken down connective tissue, still less perfect epithelium and in large part remain as inflammatory corpuscles. Pulmonary disturbance in the vulnerable manifests itself, so far as the innervation is concerned, in irritability of the mucous m3mbrane ; so far as the vascular apparatus is con- cerned, not in active arterial determination, but in venous stagnation with a tendency to clogging up of the fine ramifi- cations of the capillaries. The tissues enclosed within the river delta of a capillary net, find themselves cut off from nutrition ; hence their death by anaemia, anaemic necrosis. The products of this behavior of the vascular system may be properly said to be of the lowest forms of inflammation, and consist of : Weak connective tissue, inflammatory cor- puscles and pre-existing normal epithelial- and connective tissue, now undergoing anaemic necrosis. The first product differs from healthy connective tissue in its tendency to pro- liferate rapidly and imperfectly, and frequently as rapidly to break down ; the round corpuscles may undergo shrinkage and are then called cheese; the previously healthy tissue, cut 12 TREATMENT OF CONSUMPTION. off from the nutrient supply, makes an attempt to regain the juvenile condition, but shrinks before accomplishing it (an- aemic necrosis) and is then known as tubercle. All these products may shrink, or they may become re- moistened by serum and with it form pus. The existence of several or all of these elements in the lung, their subsequent fate and the symptoms which accom- pany every stage of their fate, form a clinical picture which we are agreed to style pulmonary phthisis, consumption, pneumo-phthisis. A short review of acute and chronic conditions of the lung, relating to their tendency to pass into consumption, may not be out of place here. i. Acute inflammatory conditions : Laryngeal, tracheal and bronchial catarrhs (laryngitis, tra- cheitis, bronchitis), In persons with plenty of living mat- ter, absolute restitutio ad integrum. In individuals with sparse living matter, so-called scrofulous individuals, and such who, though previously healthy, have had their amount of living matter reduced by lingering disease, the likelihood is hyperplasia and subsequent contraction of connective tissue in loco. Extension of this process to the lesser bronchi and the parenchyma of the lung, will depend upon the future general condition of the patient and never becomes dif- fused. Localized cheesy centres may form from shrinkage of formative elements (inflammatory corpuscles), which have developed at a time when a slight acute catarrh was super- added to the already existing condition. When once the connective tissue is in a state of proliferation, we have more PATHOLOGY OF CONSUMPTION. 1 3 or less localized peribronchitis ; in which case the continued qualitative and quantitative secretory changes in the mucous membrane are only secondary. Chronic bronchitis, in the sense in which it has been spo- ken of in the past, is therefore a misnomer. Mere superfi- cial catarrh of the bronchial mucous membrane cannot exist indefinitely, without proliferation and contraction of the underlying connective tissue — one form of peribron- chitis. Catarrhal pneumonia or capillary bronchitis gives rise in persons with reduced living matter to proliferation and con- traction of bronchial and interalveolar connective tissue; in other words, to catarrho-fibroid phthisis. The occurrence of cheesy nodes of any notable dimensions is rare. Fresh catarrhs may produce them. Croupous pnetwionia. Inasmuch as only individuals with plenty of living matter and fibrine can be affected by croupous conditions (including croupous bronchitis), the patient who recovers gets rid of the fibrinous exudation and leaves no remnant for cheesy degeneration. Untoward circumstances, which reduce the amount of living matter, may result in a continuous infiltration of the submucous connective tissue and continued shedding of epithelium — the condition known as desquamative pneumonia. The result of this is a more or less widespread cirrhosis. Desquamative pneumonia, the condition accompanying in- fectious diseases of scrofulous persons en the one hand and following as a sequel to other acute inflammations of the lung on the other, in cases where the disease has lasted for more than a limited period. This continued infiltration 14 TREATMENT OF CONSUMPTION. and desquamation is the fruitful source of cheesy foci and of cirrhosis both. It is likewise in this class of cases that the sudden and fatal occurrence of purulent peribronchitis is an important factor. 2. Primarily chronic conditions: Interstitial pneumonia aud peribronchitis simplex in its lo- calized or diffused forms are nothing more nor less than fibroid phthisis in its various shapes and manifestations, 3. In tuberculosis we are dealing with those products of inflammation, or rather of necrosis, which are caused by mul- tiple embolism or by thrombosis from venous stagnation. In the processes recited above we have had the results of active arterial determination (as in croupous and catarrhal pneumonia), and those of venous stagnation in part, as seen in desquamative processes and connective tissue prolifer- ation. The formation of tubercle is largely dependent upon more or less continued capillary stagnation and thrombosis or upon multiple embolism. The conditions favorable to the development of tubercule are often dependent upon the presence of a cheesy focus. Cheesy foci are chiefly to be found in scrofulous persons, such as have sparse living matter from infancy, or else they may be developed in the course of lingering disease or deprivation. Now tubercle may be, and often is strictly localized, not only in certain portions of the lung, but in other organs, with a predilection for serous membranes. In so far then as tubercule actually exists, and continues to exist without material change or without doing any harm, we may speak of chronic tuberculosis. But it must be remembered that in this condition, and while not undergoing softening, it is not PATHOLOGY OF CONSUMPTION. I 5 an active agent of destruction, and therefore not a dominant element in pulmonary consumption. In the occurrence of acute tuberculosis the whole nature of the case changes. General dissemination of tubercle takes place, when ttys more or less long- existing chronic condition suddenly develops, by self-infection, into a rapid course of destruction, and for this reason only do we speak of it as acute tuberculosis. So you readily perceive that in regard to tubercle, its presence may be local or become general, thus leaving us to deal with different degrees of intensity. Remember, then, that tubercle in certain quantity, and not concentrated as to locality, may exist, shrink, or disappear without symp- toms; that its becoming diffused is only another degree of intensity, and that this diffusion, with its accompanying manifestations, is the disease known as acute tuberculosis. As regards the simultaneous presence of the three chief elements of consumption, I may say that one necessitates the presence of the other. In cirrhotic conditions, any new crop of inflammatory or indifferent elements may be converted into cheese by shrinkage. Where a cheesy focus exists, whether it be an original centre of inflammatory elements or shrunken pus corpuscles in a cavity, there also will be found a greater or less conden- sation of connective tissue in the periphery, endeavoring to form a capsule. Again where cheesy foci exist, localized tuberculosis is apt to follow. Scrofulous persons are those in whom we look for cheesy lymph — glands and inspissated superficial abscesses. Where the chances for absorption are as favora- 1 6 TREATMENT OF CONSUMPTION, ble as they are in the lymphatic system, there will be found the greatest danger for the general dissemination of tubercle. This then is in accord with Rindfleisch who holds that scrofulous persons only can be affected by tuberculosis. If he had spoken of persons who primarily or secondarily suffer from an insufficiency of living matter, I would quite agree with him. When cirrhosis of the lung is diffused, overshadowing, as it were, other conditions, we speak for convenience sake of fibroid phthisis. As it is most frequently the sequel to catarrhal conditions and forms their second stage, I propose for the same the appellation of catarrho-ftbroid phthisis. When a portion or the whole lobe of a lung is infiltrated by sluggish inflammatory products, which have undergone water-abstraction and shrinkage, we speak of caseous phth- isis, chronic cheesy pneumonia. When the presence of tubercle is manifested to a c on- siderable extent in the lungs, by persistent catarrh of the bronchi, irreducible fever and great irritability of the mu- cous membranes, we speak of tubercular phthisis or acute tuberculosis, according to the severity, of the case. But please to remember, that these differences in nomen- clature are only justified by the fact that one or the other of these conditions decidedly predominates. The history of the case gives us the most important clue, next to the physical signs. From both history and present condition, as manifested by percussion and auscultation, we may be able to distinguish which of these three factors has been the starting point of the trouble. Local proliferation of connective tissue and induration as PATHOLOGY OF CONSUMPTION. 1 7 a sequel to a previously superficial catarrh or as a primarily independent proliferation of connective tissue. Cheesy deposit, either in a cheesy gland dating from in- fancy or cheesy remnants in the wake of an acute trouble. Local tuberculosis, either in the immediate neighborhood of and caused by a cheesy focus, or having its origin in some purulent source ; as yet, however, strictly localized. Once, however, any process has passed its initial stages, it rarely remains unmixed with the others, one often seeming to be lost in the other. Every one is familiar with the great frequency of con- sumption, as shown by statistics. No space can here be given to statistical matter, much of which is the result of local conditions and the percentage of accident. The frequency of pulmonary consumption is not difficult to understand when the following facts are kept before the mind : First, the exposed position of the organ, leaving an easy approach to pathological insults. Second, consumption, more than any other disease, is the outcome, the climax, of such general conditions of life as have strayed from the normal, physiological laws of exist- ence. Third, there is the peculiar structure of the lung; an enor- mous web and conglomeration of canals, supported by a comparatively feeble scaffolding, containing blood, lymph, and gases. In part these channels have almost structureless thin walls, and the lympathics have a free opening upon the surface. Take then a copious emigration of corpuscles, consequent upon irritation meeting with no resistance, the difficult expulsion of desquamated epithelium from funnel- TREATMENT OF CONSUMPTION. shaped alveoli, which have moreover no inherent contractile power, and add to this, stagnation in the capillaries, and all factors for a common and stubborn disease are given. In speaking of treatment, of the cure of pulmonary con- sumption, let it not be forgotten that medicine is not, and does not claim to be, one of the exact sciences. There are now, always have been, and always will be, a large number of well-meaning individuals in the medical profession, whose chief aim and desire it is to bring that branch of medicine which we call therapeutics, into such tangible form that it may be grasped and held unto as a permanent, never-chang- ing guide. The apparent inconsistency between theory and practice, of well-ground knowledge as opposed to the oft- occurring necessity of rapid action, is a puzzle to the laity as well as to many practitioners. The fault lies in the practi- tioner himself. Here is a science which, while resting upon positive foundations, is in its deeply-rooted principles an undefinable art. Certain well-defined and well-tried facts and principles are inculcated into the mind by teaching and demonstration. This acquired knowledge, however, must be supplemented by individual intuition, by that tact and ready appreciation of the needs of each separate case as it presents itself, which alone is the road to success in treat- ment, whether it be in general practice or in the exercise of a specialty. The chief factor in correct comprehension and successful treatment is the individual capacity for giving to each of the three factors of therapeutic conclusion: Fixed laws, em- piricism, and hypothesis their due in each case. The safest PATHOLOGY OF CONSUMPTION. 1 9 road to successful treatment, therefore, is a sort of intuitive fusion of these factors into a harmonious whole, and this is especially and particularly true of the treatment of pulmon- ary consumption. A few wdds in reference to hereditary taint in consump- tion. The actual disease as such is not transmitted to the offspring. What is really transmitted, is a more or less fre- quently manifested tendency of the lung to answer every irritation from without or within by the proliferation of patho- logical products. Further than this we do not know, and never will know as long as we cannot penetrate the mysteries of generation. Why the note issued by the parents should not become due before the later years of a child's life, is not easily ex- plained. My theory in regard to this matter is as follows: without touching upon the question of inoculability of tubercle, or its transmission by mother's milk, I will say that a child nursed by a consumptive mother does not receive such nourishment as is required for healthy growth. If, on the other hand, it is brought to the period of dentition by the milk of a healthy wet-nurse, or good milk from domestic animals, other things being equal, the blood and tissues of a child should be in a healthy condition. Under ordinarily favorable conditions of life the growth of a child progresses evenly until the so-called ' ' age of puberty " is reached. This period is marked by rapid and often unproportionate growth on the one hand, and a call is made upon nature on the other, additional to that of self-development, to wit: repro- duction of the species. It is not much to be wondered at when at such a time the sustaining powers are unequal to 20 TREATMENT OF CONSUMPTION. the double task. Nor when any hitch in the performance of the functions of the body vents itself upon that organ whose powers of resistance are hereditarily below the normal. I am satisfied that an exact knowledge of the physiologi- cal eccentricities of the individual disposed to consumption, and the possibility of balancing, and keeping in balance dur- ing life the exactings of the body and the capacity for per- forming the same, would result in keeping the tendency to consumption in a latent condition and enable us in many cases to cause its total disappearance. Of course this tendency, this disposition must have an anatomical basis, consisting in an insufficient construction of the respiratory apparatus, not, however, capable of demon- stration previous to the appearance of pathological products. If it could be measured, it would most likely be found in the comparatively insufficient development and capacity of the vascula 1 ' system as against the lung, or vice versa. Certain it is, that the longevity of a person disposed to consumption is altogether dependent upon a favorable con- stellation of the conditions of life, which again are governed by pecuniary and other surroundings, and are largely the re- sult of accident. So much for inheritance and disposition. On the other hand we have acquired consumption, the laws governing which do not differ materially from the hereditary, once it is well acquired. The causation, as you may readily infer, must be more acute, more drastic, because the original power of resistance is greater. Generally speaking, we may say that all exciting causes and conditions tend primarily to thoroughly disturb the in- PATHOLOGY OF CONSUMPTION, 2 I terchange of tissue in the body and this leads to disturb- ances, which may be dwelled upon under these heads : i. Impoverishing of the blood, known under the gene- ral name of anaemia. As it would be going out of our way too far to go more deeply into this matter, it suffices to state that the blood may be impoverished as to quantity as well as to quality, or both. 2. A decrease in the secretion of the juices necessary for digestion, as a natural sequence of anaemia. Hence imper- fect nourishment of muscles and nerves, and of the former, more especially the heart, thus impeding its propulsive force and rendering it flabby. 3. Surcharging of the tissue fluids with used-up material, such as has served its time and should have been mustered out before. This is the prime source of fever, the refuse being cast off septic matter, if we may so call it. 4. Disturbance, unbalancing of the innervation of vari- ous organs, manifesting itself notably in irritation of the pul- monary and gastric mucous membranes. The completion of this string of occurrences constitutes what I term the " fatal circle, "and marks the absolute, sink- ing beneath the physiological line. By a careful retrospect in a well-developed case of con- sumption, you will mostly be able to put your finger on the climax, from whence the scales dipped over toward destruc- tion. . OF TREATMENT IN GENERAL. Comprehension of the pathological processes in consump- tion and of the treatment based upon such knowledge, has passed through many stages and trials, and even at this day, we cannot speak of an established line of treatment. The management of a phthisical case will ever be a matter of strict individualization. Consumption is curable. In proof of this, we not only point to the results of autopsies, where the shrunken, contracted connective tissue processes point to the original seat of disease, but also to the complete conval- escence of undoubted phthisical subjects. The prime object of all plans of treatment must be based upon an effort to cause a break in the above-named fatal cir- cle, where this exists. The best efforts and skill of the physician will often have to be put forth to determine the proper measures and the proper time for the same. Consumptives may be treated at home or by sending them to such climates as have been shown by experience to have benefited a greater or lesser number of cases. In either case, neither local treatment nor the mere change of climate is to be considered as an all-sufficient therapeutical measure. For in connection with both local home and climatic treat- ment, attention to the general co?idition is the great sine qua non in pulmonary phthisis. OF TREATMENT IN GENERAL. 23 It may be well to mention here that this is not a histori- cal review, nor a statistical compilation, and hence what has been done since the days of Hippocrates will be passed over in respectful silence, in order to give space and time to the discussion of the therapeutical measures of the present day. The therapeutics of consumption of the present day rests as nearly as possible upon a physiological basis, though by no means a perfect one. Now, as formerly, a demand makes itself felt for the direct removal of the local disturbance in the lung by some definite remedy. This craving should be shelved, because the manifest disturbance of the lung is dependent upon and in connection with a number of pathological processes in various other organs. The gradual restitution of these seve- ral organs to their normal functions is the primary condition for local restitution. All rational treatment, therefore, should be based upon the re-establishment of bodily functions and not attention to symptoms, as they present themselves from time to time. The unfavorable factors, which we are not able directly to combat, are the peculiar habitus of the patient (the sum total of his growth), the continued accessibility of the lung to hurtful influences of all kinds and the impossibility of giving rest to the organ. What we have to and are able to cope with chiefly, are the decreasing, the lessening of the noxious influences on the one hand, and of the ever present feebleness and depression of the circulation on the other. The latter is the great desideratum, not only for the pur- pose of re-establishing the necessary propulsive force for 24 TREATMENT OF CONSUMPTION. sending blood to the periphery, but to stimulate absorption of effete products. These two requirements have been pretty distinctly recognized at all periods and the efforts to act more or less directly upon the lung in recent years have resulted as fol- lows : i. Overloading the circulation with lime and kindred salts, with a view of causing tubercle to undergo calcareous degeneration. . No scientific facts justify us in assuming any such proposition. The salt, accompanied by the wish that it may make the lung its permanent abode, will be lost in the general mass. If, indeed, muscle would be appro- priated by muscle, brain by brain, &c. , the most likely place of deposit for the lime salts would be the bones. 2. The use of mineral waters, of which more hereafter. Whenever they are used with the intention of furnishing the fluid parts of the body with liquid sufficient to moisten and encourage the absorption of infiltration, such an attempt is visionary, but not practicable. 3. Transfusion of blood and milk. The hypotheses upon which these trials are based are deserving of some respect, as endeavoring to directly enrich the blood by introduction of its own species, or of that which would as nearly as possible represent chyle. But neither transfusion has met with any- thing but temporary success, for reasons which will be dwelt upon further on. Direct assault upon a cavity or an infiltration through the thoracic walls with the hypodermic needle, using disinfectants such as carbolic acid, or absorbents such as iodine. In its proper place and at the proper time this treatment has a fu- OF TREATMENT IN GENERAL. 25 ture (thus far unattained), and will be spoken of in the chapter on home treatment. 5. Better results were at one time claimed for the inhala- tion of compressed or diluted air by the portable apparatus. This method will be spoken of as one of the closed methods. As regards remedies for increasing the heart's action and sustaining it at a given point, no such have been discovered. A depressing reaction will follow the prolonged use of all heart stimulants. *"The various cures for pulmonary consumption that are constantly brought forward, are founded on entire ignor- ance of the laws of general pathology. Those who are ac- quainted with these laws, know well how utterly impossible it is for any one of the remedies proposed, for the inhalation of any medicinal substance, or of any amount of compressed air, or for any degree of forced inspiration, to cure a disease such as I have described, one of defective and of lowered in- nervation and vitality. " Nothing but an appeal to the laws that regulate the development and preservation of life can have that result. An intelligent application of those laws, as demonstrated by physiology, with the assistance of climate and rational thera- peutics, may, however, be made, most unquestionably, the means of saving very many lives." * J. H. Bennett —Pulmonary Consumption — 1879. HOME TREATMENT Under the head of "Home Treatment " we will consider all rational therapeutical measures instituted to cure or arrest pulmonary consumption, which can be made use of without resorting to banishment from home, without resource to change of climate. In order to avoid confusion, I will first present to your view what may be properly termed "closed methods," by which are meant lines of treatment more or less one-sided and exclusive, but with a history of partial successes. Then will follow the "home treatment" proper, beginning with the general condition and the re-establishment and uphold- ing of offending functions; the local treatment of the various forms of consumption, such as catarrho- fibroid, cheesy and tubercular, with their manifestations in the shape of cavity, condensation, &c. ; lastly, symptomatic treatment, the un- avoidable treatment of urgent and distressing symptoms. The most prominent, as also the most recent of closed methods, is the inhalation of compressed and diluted air by port- able apparatus. The theory is a plausible one, being based upon the successes attained by rarefied air at certain alti- tudes. Close observations were made, certain conditions of the lung relegated to condensed, others to rarefied air. There HOME TREATMENT. 2J was inhalation of compressed air with exhalation into com- mon atmospheric air, the same with exhalation into diluted air; and inhalation of diluted air with exhalation into atmos- pheric air. The late Waldenburg and his followers worked out the details for separate lines of treatment for various lung troubles. Effects upon respiration, pulse, and heart's action, as well as the general condition, were noted. In- halation of compressed air was supposed to have certain direct effects upon the alveoli of the lungs, upon the con- tractility of the pulmonary capillaries, while diluted air pro- duced in part the opposite effects. The literature upon this subject is very extensive. Inhalation on this principle is carried on by means of Waldenburg's apparatus and its various modifications, as well as in closed chambers. The portable apparatus consists either of one or two cyl- inders containing water up to a certain mark, with a second cylinder closely fitting into it and hanging upon pulleys. Weights laid on top increase the pressure upon the air with- in. A twenty-pound weight is equal to an increase of one- sixtieth (the most frequently used); thirty pounds for one- fortieth, and so on. There is no use in going any further into this subject, because it has had its day ; which is owing to the fact that it rested upon false premises. I except only symptomatic em- physema and asthma, as conditions in which temporary relief is afforded. For all other conditions the inhalation by ap- paratus of condensed or rarefied air, of steam or of nitrogen are of value only as limited pulmonary gymnastics. An appa- ratus has this advantage over enforced deep breathing in the 2 8 TREATMENT OF CONSUMPTION. open air, that it fixes the attention of the patient and in- creases his faith in the efficacy of well-regulated in and expi- rations. And as such I would not condemn them. Left to hi sown will to empty and refill his chest in the open air, the patient will soon relapse into indifference and breathe super- ficially. Even big children must have toys to play with. But it is as a closed and distinct method of treatment that it is to be condemned. In my opinion the gymnastics are of circulatory and functional value only to the non-infil- trated portion of the lung. Another closed method is what is known as the " Salisbury method. " This is an English invention and signifies no more nor less than the restitution of the general condition, and through it of the shattered lung, by an exclusive diet of meat. It is possible that a meat diet to the exclusion of other nutriment may act favorably by giving rest to the diges- tive apparatus other than the stomach, and a certain degree of improved nutrition be attained in a comparatively short time. But successes claimed on the score of this treatment admit of explanation on general principles and on the strength of the auxiliary treatment. Besides, the idea of an exclusive diet for consumptives is a superannuated one. Mixed diet is the accepted plan, to the utter exclusion of vegetarians, milk feeders and other dyspeptic misan- thropes. The last of these specific-seeking methods is the at one time much vaunted treatment of pulmonary consumption by the hypophosphites of lime and soda. A few years ago the cases cited and cures claimed by Dr. J. F. Churchill of Paris made quite a stir in the medical profession. Without HOME TREATMENT. 2 going into the question of successes from this plan of treat- ment, I must say that the rationale of Churchill's method was largely misunderstood and misrepresented. It has been taken for granted, that he sought to overload the system with lime salts ; that it was intended to furnish fuel for the organ- ism in order to save from waste the existing normal tissues. The rationale of the administration of the hypophosphites of lime and soda consisted essentially in an endeavor to fur- nish the nutritive functions with a substance, which Churchill claimed was lacking in phthisis ; that the introduction of phosphorus in readily assimilated shape would arrest the dia- thesis, thus leaving the physician to deal with an ordinary ulcerating surface or infiltration, not differing from those resulting from inflammatory processes in a previously healthy person. Churchill claims that by the administration of hy- pophosphites the economy is brought back to its normal con- dition, from which all the organic disorders have sprung. You will at once observe that this assumption of a resti- tution to the normal condition is based upon equally assumed premises, namely that phosphorus was the one element which was lacking in the system. In order, however, to give you all the light possible upon this subject, I condense Dr. Churchill's own conclusions, as given by Dr. de Bremon of this city : * First. — There exists in the system, as a constituent ele- ment of nervous matter, blood, the muscular organs and of the albuminoid compounds in general, a phosphorous ele- ment not yet chemically isolated, and which element is dis- * Phthisis Pulmonalis and its treatment by hypophosphites, by L. de Bremon, M. D., 1880. 30 TREATMENT OF CONSUMPTION. tinct from the previously known phosphatic element. Second. — This phosphatic element is one of the substan- ces of our economy which has a great affinity for oxygen. Its probable function is not only to be oxidized itself, but also to promote combustion, and perhaps to initiate organic meta- morphoses in other substances. Third. — Diminution of this phosphorous element in the system, whether as the result of its exhaustion (its being used up), or of a failure of reproduction, is one of the essential conditions of the tuberculous diathesis. Fourth. — The immediate effect of the diminution of this phosphorous element is to diminish the degree of oxidation, necessary for tissue in process of transformation. This has the effect of rendering such living matter unfit to fulfill its function in the system, while at the same time other matter is retarded from being eliminated in an excremental form. Fifth. — The deposit of this abnormal matter under the form of protein substances, incompletely developed and of. variable composition, constitutes the different pathological products known under the name of tubercle, and which are the anatomical characteristics of pulmonary phthisis. This latter proposition will show you, that the whole method, both in its pathology and therapeutics, is based upon histo chemical assumptions, taking no cognizance of histological (microscopical) pathology. In justice to Dr. Churchill and his followers it behooves me to add : - Many practitioners, who have given the hypo- phosphites a trial, have made two mistakes. First — The salts of lime and soda may be alternated, ac- cording to the physiogenic or pathogenic symptoms produced HOME TREATMENT. 3 I by either, but they should never be mixed. Second — The doses recommended for general use are too large, surpassing three times the doses given by Churchill as a general limit. Broadly speaking, fullness and color of the face will indi- cate the physiogenic effects, and epistaxis the commencing phase of the pathogenic phenomena. As antipyretics, or better as antiseptics, since the fever of phthisis is a septic one, the salicylates and benzoates are not without use. This is especially true of salicylate of soda and the benzoates of soda and magnesia. They will be spoken of again further on. We pass now to the consideration of home treatment proper: of the treatment of consumption at home on certain principles which, by no means perfect, have at least the merit of having stood the test of time thus far. This line, or these lines, of treatment are based upon experience thus far attained, partly by indications pointed out by fixed physio- logical laws, in part by empiricism, and, last and least, upon reasonable hypothesis. The constant objective point to the careful observer should be the general condition of the patient. In the ma- jority of cases, in the so-called first stages, the " fatal circle " has not yet been established, and yet the general health is decidedly failing. The great indication, then, is the re- establishment and upholding of offending functions. In hereditarily predisposed cases, the chief offending func- tion is usually the circulation — the heart and its distributing channels. Muscle and nerve are the two tissues of highest development. Imperfection in the development of nervous 32 TREATMENT OF CONSUMPTION. centre is not always capable of detection or demonstration. But in the case of muscle, the size, consistency, and color are points to judge by. In the case of the heart, its develop- ment may have been imperfect at birth, or, what is oftener found to be the case, its growth does not keep pace with the development of the body. Thus we find in rapidly growing young people a heart, the size of which fails to cor- respond to the requirements of the dimensions of the person: the consistency of which is flabby, its color pale, and, as a consequence of the whole, its propulsive power not up to the normal standard. As stated on a previous page, no remedy exists which will persistently keep up the action of the heart or strengthen its muscular fibre. This must be brought about through nour- ishing the muscular tissue by the digestive road, and more especially by exercise. The realization of the replenishment of the vital fluids by food being a slow one, often too slow to keep pace with the destructive process, has led to the direct introduction of blood into the vessels, to be transmitted to the heart, and from thence to the tissues. We have before stated that the results of this proceeding have not justified the method. It would probably make no difference as to whether the blood was defibrinated and warmed, or passed directly from the arm of a well person to that of the patient ; no difference as to whether it is introduced into a vein and carried primarily to the heart, or into an artery and taken directly to the tissues; nor do I believe that any quantity, be it small or great, need be fixed upon as the proper one, as long as it is done with sufficient care and slowness. HOME TREATMENT. ^ The trouble seems to lie in the flabbiness of the heart itself. The muscular weakness of the heart is not able to cope with the quantity of blood already on hand, much less with the augmented quantity. The result is not permanently increased propulsive power, but an attempt thereat, followed by depression and decreased contractility, with consequent stagnation in the capillaries and in vessels of lesser calibre. The above facts hold true also as regards the transfusion of milk. Food, whether liquid or solid, must be introduced into some portion of the alimentary canal, and join the blood by the natural routes in order to be of any use as nu- triment. The bluod and tissues of the body, and with them the heart, must first be strengthened by foe d. When by judi- dicious feeding and exercise the heart can be depended upon as to propulsive power and rhythm, the gradual introduction of human blood by transfusion may be resorted to with less risk and a far greater possibility of success. Neither others nor myself have had any experience as to this proceeding, when practiced as suggested, but I should think it feasible. Food: What constitutes proper food for consumption is a well settled question. A mixed diet is the correct thing. Nitrogenous materials and hydro-carbons should equally be given; likewise fluid as well as solid food. Broadly speaking, there are only three kinds of solid food: Meats, vegetables (including fruits), and bread substances (all-flour- yielding substances and their products). Certain rules should be observed with regard to the pre- scribing or recommending of food. First.— -Let the patient state his likes and dislikes, what 34 TREATMENT OF CONSUMPTION. agrees and what disagrees with him; do not force him to eat things which may happen to agree with you or your friends. Second. — But this choice of the patients must not be limited to one kind of food. There exists frequently a dis- like for meat and a preference for the starchy substances. If he insists upon a positive dislike for meat or some other form of nutriment, his digestive apparatus should be made to cor- respond to the normal condition, of which more directly. Third. — It is often best, no doubt, to recommend the patient to eat light meals at more frequent intervals, but this is frequently not feasible and irksome. But the patient must be positively instructed to eat very slowly and to chew his food very finely, even if he has to place a*watch in front of him to time himself, until he has acquired the habit. Exercise : As a remedy for increasing the muscular strength, the propulsive power of the heart, exercise stands uppermost in my opinion. Here also the ability of the patient to undergo exertion is best judged by himself in the beginning. Females often show a great unwillingness to ex- ercise in the open air, and need much encouragement. Ex- ercise on foot is, on the whole, the best of all. The patient must be told to walk slowly, head erect and shoulders thrown back, because an attempt to walk briskly results in his stoop- ing over in front. A constant reminder of the necessity of walking erect, as well as a silent companion, is a cane. As a diversion and reminder the cane may be carried in both hands in front of the body and occasionally passed through the elbows behind the back. After a patient is able to walk about two miles without fatigue, he should undertake to HOME TREATMENT. 35 climb to a limited extent, where vhe nature of the surround- ing country is undulating or hilly. While walking, the patient should as 'frequently as possi- ble (say every ten or fifteen minutes), take deep in — and ex- pirations without straining, from six to eight times in suc- cession ; which act completely empties and refills the lungs. The importance of knowing how to breathe, cannot be overestimated. No line of treatment, at home or by change of climate, should be inaugurated without thorough instruc- tion in lung gymnastics, in the mechanism of breathing. Until you have paid close attention to the subject for a num- ber of years, you will never know how many human beings do not know how to breathe and through which organ to breathe. Respiration, this most important of all functions of life, is by some carried on superficially, by others pervert- edly and contrary to physiological requirements. Breathing is a function, which should be exercised slowly and profoundly, a requirement which can only be fulfilled by breathing through the nose. Breathing through the mouth leads to superficial and often rapid breathing ; still oftener to snapping up of air. Dr. Clinton Wagner says : * "The air, in its passage through the tortuous channels of the nose, is raised to the temperature of the body before it reaches the larynx ; this can easily be demonstrated. On a cold day, let one breathe through his mouth in the open air ; the sensation of cold will at once be felt as far down at least as the larynx, and an irritating cough be induced. No matter how low the temperature may be, the sense o,f cold is * Habitual mouth breathing. By Clinton Wagner, M. D. 36 TREATMENT OF CONSUMPTION. never experienced below the border of the soft palate, so long as breathing is carried on through the nose with closed mouth. Let me remind you again that the function of the lung is a passive one and the result of the combined labors of the other organs, and you will have an idea of how a neglect of this performance may lead, not to local disturbances only, but disturbances affecting the whole organism. This be- cause the introduction of oxygen for burning purposes and the exhalation of carbonic acid, representing in part the effete products; this introduction of air is not "food for the lungs,"' but for the organism at large. With persons moving about in the open air the act of res- piration is in a measur. performed promptly, without cogni- zance being taken of it, as a result of active motion. But for the great majority of city people, whose occupations re- quire them to sit or stand for from eight to sixteen hours a day, it is absolutely requisite that they should accustom themselves to frequent full and deep inspirations. Horseback riding has no particular advantages. Only a limited set of muscles are brought into action, and the heart's action is apt to be subjected to irregular impulses. Carriage riding is beneficial in cases where the patient is not yet strong enough to walk. It is also of service when it is desirable to remain in the open air for a length of time exceeding the time a patient would be able to walk, and is on the whole to be preferred to sitting still without mo- tion. Rowing is not to be recommended, nor any form of gymnastics in which the pectoral muscles are likely to be put upon the stretch. I have seen hemorrhage occur in a HOME TREATMENT. 37 convalescent from such a slight cause as the sudden checking of a a gen'tle horse, while driving. Lung gymnastics proper should be carried on in the open air, while walking or standing still, or in a well ventilated room. The exact limits to which actual gymnastics should be carried on at home or in a gymnasium, often tax the best judgment of the physician. Nearly all gymnasial perform- ances require more or less severe straining of the pectoral muscles and sudden calls upon the heart for increased action. House gymnastics may be carried on by movements of the arms and legs, as well as the body, with or without the use of a long stick or pole ; by the use of light Indian clubs for both of which kinds of exercises a variety of pamphlets are published in several languages, and made easy by illustra- tion. Deep inspirations, always without muscular strain, are the chief point aimed at in connection with the development of the muscles of respiration. There are a few movements preferable to others, on account of their efficacy and simplici- ty and because the patient is not so apt to tire of them. I know of none better than the following : Stand erect, toes out ; while slowly inspiring, raise the hands above your head until the palms meet; then reversing the hands, drop them slowly to the side while expiring. Repeat this six or eight times in succession. In addition to filling the lungs, the movement teaches the patient to respire slowly and pro- foundly. Or let the patient walk into one of the corners of his room, with his arms horizontally extended, and while slowly inspir- ing, endeavor to get his face into the corner as nearly as possible. 3 8 TREATMENT OF^CONSUMPTION. Whatever movements are made, three points must be kept in mind : First — Inspiration must be made slowly and profoundly, ordinary breathing being resorted to for a time after some eight inspirations have been taken. Second — The passage from in — to exspiration should be gradual and not snapping. Third — No muscular tension, which is felt to be a strain, should be indulged in. So much for the various methods by which the heart and circulation and through them our flesh, the muscular system, are to be brought up to the required standard. The next apparatus to claim our attention is the digestive one ; which, while found offending, is often more sinned against than sinning. There are instances of an hereditary insufficiency of the digestive organs, oftenest found in in- fants whose life is thereby shortened and of whom we say that they are "not visible." This tendency is probably never entirely outgrown, and as a consequence we have adults who digest certain kinds of food more readily than they do others. Some relative ine- quality in the development of the organs assisting in diges- tion, either in size or in their blood supply, doubtless exists, factors which as yet we are not able to distinguish. Or one part of the digestive process is carried on satisfactorily, while the other halts and limps ; the stomach may be all right and the bowels sluggish, or vice versa. In either case the balance is destroyed and it is this we are called upon to rectify. By far the most frequent disturbances, however, are ac- quired ones. That patient organ, the stomach, has been abused and insulted and is in rebellion. HOME TREATMENT. 39 Let it be set down as a rule in the pathology of phthisis : Individuals ivho have destroved the balance between their func- tions repeatedly and thereby have been dragged below the physi- ological line, often need only the impulse of an acute gastric catarrh, to develop at once one of the forms of lung trouble which sooner or later assume the common characteristics of 'consumption. It follows, therefore, as an imperative law that all heredi- tarily vulnerable patients, as well as those whose constitution has become shaky by deviations from the normal conditions of life, should be impressed with the fact that every gastric disturbance, however small, must be promptly met and cor- rected. The scope of this work will not allow one to go deeply into the numerous disturbances, which the alimentary canal is liable to, for this would in itself fill a volume. It will be my endeavor to point out the leading facts, and likewise sali- ent points in treatment, as concisely as possible. The condition of the teeth should be looked into, and, if necessary, remedied. Practically, and for our purposes, we may look upon disorders of the stomach in connection- with lowered vitality (as is the case in consumption) as two- fold : First — Lack of vascularity, of proper blood supply, and, in consequence, insufficiency of the gastric juice, both as re- gards quantity and quality of admixture. Second— Lack of innervation, largely dependent and consequent upon the failure of vascularity (gastralgia) and spasmodic contractile action or lessening of sensibility and paresis. In the first instance we have hyper-sensitiveness, and vomiting : in the second, and by far the most frequent, 40 TREATMENT OF CONSUMPTION. dull, heavy feeling ; partial paralysis, with dilatation of the stomach. The result is slow and imperfect digestion, which means fermentation, and the development of gases. The indications, broadly speaking, are then : To replenish the blood, and, partly through it, partly through artificial means, to restore tonicity and contractility to the unstriped muscular fiber of the stomach. The first indication, that of replenishing the blood, is to be met by careful introduction of food into the stomach or rectum, or both. In cases of pure gastralgia, intensity of pain, giving evi- dence of neuralgic trouble, the careful hypodermic injection of morphine (gr. 1-16 — 1-8) over the region of the stomach once, or perhaps twice a day, will prove very successful. The paralytic condition of the stomach is dependent upon its innervation, and this again upon blood supply to the sympathetic centres. While improving the condition of the blood, both as to quantity and quality, we can aid tonici- ty and contractility of the stomach by the administration of nux vomica and its alkaloid, and by the Faradic current. Nux vomica may be used in powder or in the form of the tincture, and is on the whole preferable to strychnia. The latter may be, however, advantageously applied hypodermi- cally over the region of the stomach, in doses not exceeding i-24th of a grain. Good results are obtained by the daily use of the inter- rupted current. Let me give you a few formulas of combinations of the above-mentioned remedies, which have proved useful in my hands : HOME TREATMENT. 4* Lactopeptini Pepsini sacch. ad 3iv. Pulv. nuc. vomic. 3 SS - M.f. pulv. Div. in chart viii. S. 3 times a day after meals. .# Bism. submit, ^i ss. Pepsinae, 3* ss. Strychn. sulph. gr. i. Tinct, cardamom, com p. ^iv. M. S. Teaspoonful 3 times a day in water. Acid, muriat. dil. 3 V - Tinct. nuc. vomic. 3 SS - Infusi gerition. comp. ad §iv. M. S. Teaspoonful in water after meals. Pepsini (Samarsch) q'u\. Glycerini puri ^i. Acid, muriat. dil. 3* ss - Aquae ,5 v. M. S. Tablespoonful in water every 3 or 4 hours. In regulating disordered conditions of the stomach, of course liquid food will have to be resorted to for a few days. As soon, however, as the patient is able to take more or less solid food, the liquid fast should be broken, as the strength often falls off rapidly. Digestion of the food partaken of, 42 TREATMENT OF CONSUMPTION. should be actively aided by pepsine, lactopeptine with nux vomica, and perhaps antacids. Acids are good with or with- out pepsine, and their utility is best determined by the thirst of which the patient may complain. A mercurial purge is never indicated. Whenever a con- dition is somewhat protracted, or having disappeared once, shows a tendency to sudden re-appearance, a golden rule is to be remembered : Change the form of the remedy and alternate by changing the remedies themselves. A wet compress worn over the region of the stomach or over the whole abdomen at night, is very serviceable. A dry one (so-called belly bandage), is an equally excellent pro- phylactic against recurrent catarrhs of the alimentary canal, for those who are subject to them. The liver and other secreting glands need no " touching up," but should be left alone. Constipation of the bowels is an oft occurring drawback to re-establishing the general condition. Never prescribe for constipation before ascertaining whether food is properly di- gested on the one hand, and whether any pathological con- dition of the rectum or the colon exists, which can be ascer- tained by inspection and palpation. I need merely mention fissure of anus, hemorrhoidal knots, atony of the colon and rectum, stricture of rectum, the presence or neighbor- hood of abscess or already-established fistula in ano, fecal impaction, neuralgia of anus or rectum. Enemata, mild laxatives and the Faradic current are all of use in certain conditions. The current is an excellent remedy, where there is sluggishness, a lack of tonicity of the large bowel. HOME TREATMENT. 43 I append such cathartics and remedial measures as never act too drastically. The indication for their use must be left to individual judgment : 1. Tamar Indien — a French confect — chiefly condensed extract of senna leaves. 2. Tropic fruit laxative — an American preparation of similar composition. 3. Karlsbader salt — condensed from the springs at Karls- bad (Sal. therm. Carol, natural.). Teaspoonful in one-half tumbler of warm water upon rising. 4. Artificial Karlsbader salt — a mixture of bicarbonate of soda, chloride of sodium and sulphate of soda. 5. Enemata— best with a fountain syringe. 6. Faradic current — to rectum and abdominal walls. 7. Pulvis liquirit. comp. (German Pharmac). Dose : One teaspoonful. 8. Compound cathartic pills. One or two at bedtime. 9. Glycerine. Tablespoonful with lemon juice. 10. # Aloin Extr. nuc. vomic. Extr. belladonna? aa gr. vi. M.f. pilul. No. xii. S. One to two pills a day. »■ # Podophyllini gr. 1-4 — 1-2. Atropiae gr. 1-80. Pulv. aloes gr. ii. As a pill at night. Extr. colocynth. comp. gr. ii. 44 TREATMENT OF CONSUMPTION. Pulv. rhei gr. i. Extr. belladonnse gr. 1-4. Extr. hyoscyami gr. 1-2. As pill at bedtime. Whenever digestion is sufficiently restored, either food and drink may be relied upon alone or the preparations of iron may be called into aid. In their administration three things must be kept in mind : First — Commence with small doses and increase rapidly. Second Change the form of the remedy about once a week. The saccharated carbonate of iron is a good form to begin with. Third — After giving iron for some time, say two months, allow a week or ten days to pass before beginning again, to avoid any intestinal irritation. Some of the best forms of iron are here appended, and should be administered in accordance with the rules men- tioned above. 1. Ferri carbonas, sacch. with lactopeptine. 2. Ferri carbon, oxyd. with saccharated pepsine. To either of these, subnitrate of bismuth or pulvis nucis vomi- ca? may be added when required. 3. Ferri ' ammonio — citras in infusion of quassia or ca- lumba. 4. Ferri et potass, tart, in infusion of cascarilla or gentian. 5. Ferrum dialysatum — with plenty of water. 6. Ferri sulph. exsiccat. Potass, carb. puri ad ^ni. Mucil. tragacanth. q. s. M.f pilul. No. 60. S. 3 pills 3 times a day. HOME TREATMENT. 45 7. Tinct. ferri percblor. M. x. Liquor, ammon. acet. ^i. As a dose 3 times a day. 8. Tinct. ferri muriat. — from five drops rapidly increased to sixty. Small doses of quinine may be added. Lemon syrup or syrup of wild cherry bark are excellent adjuvants. 9. Ferrum lacticum — a German preparation. Alone or with lactopeptine. 10. Ferrum redactum (iron reduced by hydrogen). In pill form with the coldly prepared extract of cinchona bark. 11. Ferri pyrophosphas — with stimulating expectorant syrups, such as tolu, prunus virgin, or armoracia. 12. Tinct. ferri pomati — a German preparation. Begin with 15 drops to one-half drachm. 13. Mistura ferri composita (U. S. Dispensary) — a mix- ture of sulphate of iron, carbonate of potash, myrrh and spirits of lavender. The two last-named preparations are useful in the chlor- otic condition of females, with whom they generally agree well. This appears to be the proper place to speak of such nutriment and other substances as hold a medium rank be- tween fluid nutriment and actual medicines. Milk has always been held to be more or less indispensable in the treatment of phthisis. It has been insisted upon as the nutriment par excellence in large quantities, but as such has not proved as valuable as was expected. This, I think, admits of an ex- planation. Milk stands at the head of all nutriments while the stomach is unable to cope with solid food. The in- definite continuance of milk as sole article of food, to the 46 TREATMENT OF CONSUMPTION. exclusion of what the stomach is able to bear, reduces the digestive apparatus to its juvenile condition, physiologically speaking. Besides there are a great percentage of patients who can- not digest even fresh cow's milk. In such cases it is well to give it in some other shape, such as milk punch or egg nogg, or it may be given cold. But it will not do to force them to take it against their previous experience. Those who can drink it should drink it slowly, and rather between than with meals. The quantity can only be regulated by the capacity of the individual. From five to six glasses of milk per day I have found to be a good average. It is always of benefit to add a few tablespoonsfuls of lime water to the milk, to guard against acidity. Goat's milk and asses' milk are both superior to cow's milk as an article of food. Buttermilk is a product which meets with my approval for its triple qualities of not easily creating acidity, of quenching thirst, and of containing more or less fatty nutri- ment. Its acidulous taste is very grateful to many patients, and I let them drink it ad libitum, always in small mouth- fuls at a time. Kumyss is another form of milk. The inhabitants of the Kirghis Steppe, in Asia Minor, drink the milk of mares, which is allowed to undergo partial fermentation. It is said to possess intoxicating qualities, but this is probably not true. As a nutriment it is on a par with clabber (the so- called " Molken " of the Germans). In no sense is kumyss a specific. It is a good article of food to alternate with goat's or cow's milk and buttermilk. HOME TREATMENT. 47 Midway between articles of food and actual medicine stands our old friend, cod liver oil This ancient remedy has been both over and underrated many times, has passed through many vicissitudes and changes of fortune, and yet stands its ground, and justly so. Well-clarified cod liver oil is a fatty nutriment par excellence, and in all cases where it is well borne nutrition is rapidly improved. I repeat, where it is well borne! For those with whom it agrees, es- pecially in the cold months, it is a readily assimilated nutri- ment, and by improving the general condition gains us time for local treatment. The capacity for properly assimilating cod liver oil is not so individual as with other things. A few may be able to take it ad libitum; then it is often to the exclusion of other food. Half an ounce four times a day appears to be the maximum dose. A word or two about the form and manner of adminis- tration. Attempts at disguising must not be carried far. If it is not well borne, by beginning with a teaspoonful twice a day, it had better be abandoned. Children take it best, the juvenile condition being favorable to the ready absorption of fat ; old people it rarely agrees with. The best shape to take it in is pure. The stomach should be encouraged to the extent of adding an alkali, but aside from this no advantage will be derived from adding stimulants. But the taste need not remain in the mouth. To this end, fixing the teeth in a slice of lemon immedi- ately after taking will answer. Likewise aromatics, such as a mixture of ol. menth. pip. gtt. i., tinct. aurant. , 15 to 20 drops, on a lump of sugar. The best oil comes from Norway, and Mceller's oil has, 45 TREATMENT OF CONSUMPTION. and deserves to have, the best reputation. Emulsions of cod-liver oil, with or without the hypophosphites, often prove very useful in treating children. As in all other remedies or articles of food, alternation and an occasional complete ces- sation are necessary to insure benefit. Whenever and wherever it is reasonably well borne, the administration of cod-liver oil should form part of the per- manent treatment. During the past few years several articles have been in- troduced as substitutes for cod-liver oil, and I am sorry to say, none of them have my sanction. Glycerine is the sweet principle of oils, and in no manner a substitute. In tablespoon doses, it serves to keep the bowels open, and that is the best I can say for it. Cream will pass. It does not agree with many individ- uals any more than cod-liver oil, but when mixed with milk (say half and half) its assimilation is rendered easier. Its chief use is as an alternate to the oil a principle in prescrib- ing food and remedies which cannot be too often recom- mended. Malt Extract and similar preparations in teaspoonful doses have been lauded to the skies as specific nutriments. They are excellent stomachics, and appear to give tone to the muscular coats to some extent, thus aiding digestion. Malt extract, therefore, may be used as an adjuvant to liquid food, directly after we have restored the stomach to its normal function. It is upon this principle of furnishing the stomach with a substance readily digested and assimilated that are based the treatment by grapes and by clabber, re- spectively known as the " Trauben-Kur v (grape cure) and HOME TREATMENT. 49 the ' ' Molken-Kur " (clabber cure) in Germany. The ra- tionale of this line of treatment is readily understood. Lay- ing aside the popular belief in any specificity in connection with either product, we have two articles of nutriment, which fulfil the three requirements of being easily digestible, of keeping the boivels soluble, and of introducing a vegetable or animal acid into the system. The benefits derived from pur- suing such a plan are incalculable for so-called hemorrhoidal persons, who suffer from stagnation in the portal cir- culation. I have long been of the belief that the vegetable acids are of benefit to nutrition, although hew and why is more than I can say. Of light food, to be taken alone when the stomach is in- capacitated for a short time, or in conjunction with more solid food, the oyster is to be commended. Rectal alimentation will prove very satisfactory, in cases where the stomach is compelled to take a vacation for a greater or lesser length of time. Especially is it to be com- mended, where loss of appetite appears almost insurmounta- ble; by no means a rare occurrence. In so-called third stage cases the stomach is in the same condition as regards vascular supply and innervation as is the heart. Its function is, for the time being, absolutely suspended. Nowhere does my principle of changing the route by which food and medi- cines are administered apply more aptly than in substituting rectal alimentation for that by the stomach until such time as the latter may be relied upon to resume its function. Note, however, that under no circumstances should the stomach be left entirely without at least a small supply of liquid food, for more than the very limited period of a few days. 5 01. crotonis 3 u '-> Tinct. iodinii ^v. In localized pleurisies, which at times occur in various places at once, I have found this application useful in pro- moting absorption. Where no longer any pain is caused by deep inspirations, tincture of iodine or Lugol's solution is to be applied twice a day by painting over the same surface twice each time. A prolonged and steady derivation of the chronic process to some other part, has been mentioned by authors at various periods as likely to have a future. Its value has never been determined by systematic trial, so far as I am able to gather from literature. A seton in the arm (over the deltoid is spoken of in Ziemssen. As part of local treatment we may in future find it useful. * " Can this (a fresh invasion) be prevented by establish- ing an issue on the upper part of the arm, as was customary in former times? How much benefit is to be derived from the use of revulsive measures for the purpose of changing the abnormal course of the nutritive processes, it is impossible to say ; nor are we able at the present day to explain how an artificial suppuration can check internal disorganization, or diminish established morbid discharges, especially suppura- * Ruekle — Pulmonary Consumption— Ziemssen's Cyclopaedia. HOME TREATMENT. 67 tions in internal organs, and yet in all times there has been unbiased testimony to show that this mode of treatment ap- parently modifies the course of morbid processes and par- ticularly those which are of constitutional character or are dependent upon a dyscrasia. " But a seton must neither be in dangerous proximity to the seat of disease itself, as in the thorax, nor in too remote a part of the body. The upper arm would seem to be the suitable place. Again, the extent and character of the inflammation thereby induced will have to be carefully watched, especially the too rapid formation of pus, as well as the possibility of septi- caemia. One of the sovereign adjuvants for causing determina- tion to the skin, as well as for general effect, is the local douche. It may appear contrary to reason at first that cold douche should stand in the same category with warm appli- cations ; yea, even applicable to the same cases. Any one who has at all studied hydro-therapy will know that the effect aimed at is the same by a different method. In one case we invite a flow of blood to surrounding parts to promote ab- sorption ; in the other we bring on a sudden contractility of vessels, soon followed by dilatation and refilling of the same. A local douche cannot of course be confined to any particu- lar part, though it may be made to act more decidedly upon it. We achieve by the douche, therefore, two important things : A strong impulse to the activity of the skin, a?td a general effect upon the whole system. The first stimulates the respiratory function of the skin. The second does much to weaken the strong disposition of the patients to colds and to slight relapses. 68 TREATMENT OF CONSUMPTION*. The subject of douching might have as appropriately been spoken of as part of the general treatment, but its ap- plication is primarily local, and besides, different conditions call for different applications of the douche in form and strength. The literature upon the use and abuse of the douche in its various forms is very extensive, as regard its use in general diseases. In its application to phthisis, its uses have been 'tested and reasonably well defined at the resorts for consump- tives at Gcerbersdorf, Falkenstein and Inselbad, near Pader- born. Before stating the indications for the use of the douche, I feel it imperative upon me to say that nowhere is strict in- dividualization more called for than here, according as an individual may be only a trifle or very far removed from the health line. According to the experiences of Drs. Brehmer and Sokolousky at Gcersbersdorf, and Dettweiler at Falken- stein, the following rule may be laid down in regard to the use of the douche in pulmonary consumption : About thirty-five per cent, of patients are able to bear the douche with benefit to themselves. There are two forms of the douche, the rain (sieve) douche, and the solid stream, which latter may be applied from above as well as from the side — vertically and hori- zontally. Of application to the general surface for the purposes of cleanliness and for promoting capillary action, we have spoken in connection with the treatment of the general con- dition. Experience has shown that if a person is found fit to be douched, according to certain indications as laid down HOME TREATMENT. 69 in the previous chapter, it is better to precede any local ap- plication of the stream by a rain-douche to the general sur- face. This will tend to uniformly increase contractility ot capillaries over the whole surface, after which the local appli- cation can be made without risk. The length of time of each shower should not exceed five seconds. This may be done daily for from four to five weeks before local douching is resorted to. For infiltrations situated in the apex of the lung, the vertical stream is to be applied ; for infiltrations in the lower lobes and pleuritic adhesions with or without effusion, the horizontal one is applicable. In either case let the time be about five seconds in the commencement, and if reaction sets in successfully, for three or four days in succession, the time may be increased by five seconds daily. Thirty seconds (half a minute) is, however, to be the maximum of time. A quick and thorough rubbing down should immediately follow the application of a shower. This is best done by throwing a dry sheet over the patient, drying him off and then rubbing him down with soft crash towels. Wherever it is at all feasible, a brisk walk should follow immediately upon the douche. The application of the douche should not be entered upon unless all surrounding conditions are favorable ; and once begun, all details should be rigidly enforced. Under no circumstances should the carrying out of the douche programme be left to the patient and his friends. They must be attended to by the physician himself or else abandoned. I am quite aware that in a large number of cases in pri- vate practice this is not feasible. In such cases we may with 70 TREATMENT OF CONSUMPTION. great benefit resort to wet sponging or dry friction in the patient's own room, and executed by the patient himself. Consumptives applying for treatment have often gotten out of the habits of cleanliness. From fear of catching cold they have become strangers to the use of water. Hence their vulnerability is manifested in the irritability of the skin, which must be weaned back to the normal condition. It is best, more especially in winter time, to direct dry friction of the thorax, both in front and behind, by means of a crash towel, for about ten days. After that, cold sponging, fol- lowed by the same friction, will be of great benefit. This sponging should be done immediately upon rising in the morning— the best time to relieve the stagnatory congestion of mucous membranes by derivation to the surface. The room to be at a temperature of seventy degrees to seventy- five degrees. Salt (and if possible sea salt) should be dis- solved in the water the night previous, ready for immediate use. I always direct the neck and the thorax, both front and back, to be rapidly slapped with the wet towel (not a sponge) and then leisurely dried with gentle friction. Your attention is lastly directed to two forms of local treatment of cavities and infiltrations which may be looked upon as direct assaults upon the offending portion of the lung itself. I refer to direct injections into the parenchyma itself by means of a needle passed through the thoracic walls into the lung ; and secondly to the inhaling of substances via the larynx and bronchial tubes. The idea of so bringing the diseased lung within reach, as to be able to treat it as any other ulcerating surface, is not a new one. Not only is aspiration or free incision the ac- HOME TREATMENT. 71 cepted treatment in cases of empyema, but cavities in the lung substance have been laid open and treated as open wounds. All of the following history, indications and results L gather from the pamphlet by Prof. Wm. Pepper, of the Uni- versity of Pa. Further contribution to the local treatment of pulmonary cavities. Extracted from the transactions of the American Medical Association. The idea of opening lung cavities by incision through the chest walls, is as old as Bagliori, (possibly older. ) In the present century it was performed by Hastings and Storks. But it is only within the last few years that continued treatment of cav- ities by local application has been seriously entertained and carried out. Operations by Storks and Mosler have shown that lung cavities are quite tolerant of external interference; that they may be cut down upon and opened, canulse, introduced and retained and medicinal agents injected in solution or by spray. Dr. Wm. Pepper was the first to practice (Feb. icS74.)con- tinous injections into cavities and infiltrations by means of delicate canulae and to demonstrate that they may be conduct- ed without severe pain, hemorrhage, traumatic irritation, or interference with internal medication and hygienic measures. The dangers which present themselves in this proceeding are as follows ; First — The imperfect length and strength of the needle, of course an ordinary hypodermic needle will not penetrate into the substance of the lung, not even into a very super- ficial cavity, careful measurements upon the cadaver have proven to me that the proper length of the needle should be 72 TREATMENT OF CONSUMPTION. one and a half inches. To make assurance doubly sure, it is well to have an additional one of two inches in length for deep seated infiltrations and cavities. The needle must be a little thicker than the ordinary hy- podermic, with a very decided bore and well sharpened at the point and on the flat. Second —The resistance of the pleura. This is far greater than imagined by any one who has never tried it. It feels as if you had struck a firm wall. But a decided push will readily overcome this obstacle and the quicker it is done, the better for the patient. Third— Uncertainty as to whether you will properly strike an infiltration, or enter a cavity. Here you can safe- ly be guided by the results of percussion and auscultation on the one hand and by the sensation conveyed to your hand a.ter passing the pleura. Fourth— Sudden and greatly increased action of the heart and in consequence, the expectoration of small quanti- ties of blood. We know that the first effect of the introduc- tion of any foreign substance into the blood vessels or into organs is violent action of the heart. This is temporary and passes over. Fifth — The setting up of a fresh inflammatory process and with it the increased dangers of increased infiltration and more rapid destruction. It is true that we have no exact means of ascertaining what amount of surgical or medical in- terference will produce just inflammation enough for adhesive purposes and just when the scales will dip in the direction of renewed ulceration and sloughing. These risks and the old maxim, that it is preferable to let well enough alone, have HOME TREATMENT. 73 given a check to this sort of local treatment. Now I hold that knowing full well the dangeis to be expected, we are called upon to forestall the same and not to wait until an ac- tive inflammatory process is developed. To this end I have used ice bags over the affected part, a few hours after the injection and continued at intervals for three or four days. The degree of cold is of course to be regulated by the sensations of the patient; the ice may be in a bladder or in a rubber bag. Again the patient may stand the cold for sev- eral hours and a release given him from time to time. Quin- ine in small doses should also be administered for two days. The above analysis of dangers and their prevention is the result of my own limited experience. Dr. Pepper does not attach so much importance to the same, for reasons which will appear shortly. Before making an injection, the skin at the point of puncture should be chilled by ice or ether spray to deaden the sensibility. . The liquids thus far used by Dr. Pepper have been dilute solutions of carbolic acid and iodine. The former, where the destruction of fetor from expectorations was aimed at ; the latter in attempting arrest and cicatrization. The strength of the solutions used are : Carbolic Acid, two per cent. (10 drops— gi); Iodine, Lugol's solution (liquor iodin. comp. ) in proportions of one part to from three to twenty parts of water. At present I am engaged in making trials with the chlorides-aluminum, magnesium, potassium, &c. The amount of liquid injected must be determined by 74 TREATMENT OF CONSUMPTION. the tolerance of each individual, the first injection being from five to ten minims and subsequent ones from twenty to thirty. This accounts for the absence of danger from a too active inflammatory process in Dr. Pepper's cases. The depth into which the needle is to be introduced, de- pends of course upon the thickness of the thoracic walls and the superficial or deep position of the cavity or infiltration. This varies from three-fourths of an inch to two inches. Now when it is shown that these injections are practically free from danger, we turn our attention to the indications which present themselves for their use, and to finding out to what extent these indications are met. The objects desired to be accomplished are : First — Disinfection of the contents of a cavity. Second — Diminution of formation of pus. Third — Relief of cough . Fourth — The favoring of cicatrization and contraction and the prevention of general infection (septicaemia). The results obtained have been as follows : Sputa of an offensive character are readily freed from fetor by injection of carbolic acid, which was found to exert a prompt influence. The amount of expectoration is notably and rapidly di- minished. Cough is very considerably relieved. The paroxysm of cough, excited by the entrance of the liquid into a cavity, is of short duration. Autopsies proved a highly favorable appearance of the living membrane of the cavity, indicative of an arrest of ulcer- ation and a marked tendency to reparative action. In a cer- tain number of cases, not only arrest of progressive disease, HOME TREATMENT. 75 but development of connective tissue, so as to circumscribe the cavity and tend towards its contraction. Finally let me tell you in what class of cases injections are most likely to be of service, according to Dr. Pepper's investi- gations thus far : — Cases of single, superfical and circumscrib- ed cavity with comparatively little surrounding disease, and without implication of the other lung, are best adapted for local treatment by injections. Cases of cavity, with extensive disease of the surrounding lung or of the other lung, hold out no prospect of permanent benefit from local treatment; but nevertheless, much relief may be afforded to certain symptoms, as frequent paroxysmal cough connected with efforts to empty the cavity, or fetid expectoration. In cases of extensive consolidation of lung tissue, there is no good to be expected from injections into the diseased area. In cases where there is circumscribed partial consolidation as in the first stage of catarrhal phthisis; which persists obstin- ately and tends to spread despite the use of other measures (hygienic care, change of climate, internal medication, etc.), or, where the most important of these favorable influences cannot be secured, injections of medicated liquids into the diseased tissue may be tried with propriety. The subject of inhalation has ever been one of more or less absorbing interest to the profession, as well as to the laity. Inhalation of remedies for diseases of the inhaling appar- atus appears very plausible to the public, and hence quackery has disported itself in connection therewith and assisted in bringing this method of treatment into disrepute with the regular profession, and in great part justly so. 76 TREATMENT OF CONSUMPTION. Before entering upon the trial of a remedy by any route, we are to determine first, -whether the remedy is applicable to the condition existing within the diseased organ, and second- ly, whether or not the aforesaid remedy will reach the seat of disease by the route proposed. Now what are the facts in regard to the possibility of remedies reaching the lesser bron- chi, bronchioli and air-vesicles of the lung. Atomized substances, &c, reach the bronchioli and air-cells. This was demonstrated in the experiments of Dr. Tappeiner, ofMerau, of Schottelius, of Clark, Fox and Sanderson, to settle the question of inoculability of tubercle. With this latter question we are not now concerned. For our purposes it suffices to know that atomized substances, fluid and solid, such as tuberculous expectoration, mixed with water, and powdered cinnaber, reaches the air-cells. It is further to our purpose to know that as regards the conditions under which such inhalations were made by dogs, they were those of con- tinued inhalation in a closed chamber and of very powerful and forced inspiration. It is clear therefore, that the success of inhalation in gen- eral depends upon the force of the propelling power, the pro- fundity of the inspirations and above all upon continued inhalation. We know that gases pass through by inter- change. In the case of atomized fluids and solids, (vapors and fine powders) it is somewhat different. They are not as diffusible as gases; there is no interchange between inspiration and expiration; on the contrary, the expiratory force is rather a hindrance to their admission. Then again they have to pass the narrow entrance of the larynx, the numerous bifurcations of the bronchial tubes from the tracbea down, and at each turn meet HOME TREATMENT. 77 with some resistance, which does not increase their chance of reaching the final destination. In view of all facts bearing upon the case, are any advan- tages to be derived from the inhalation of medicinal substan- ces ? Part of this question has been answered in speak- ing of inhaling compressed and rarefied air. It has been shown that its effects are those of pulmonary gymnastics in conjunction with the full and well fixed attention of the patient. The same holds true of inhaling atomic substances, with the additional factor of the patients certain faith in remedial power of a remedy thus directly administered. Deception is not to be countenanced in the Practice of Medicine. Still the mental condition of a patient is a factor, with which we are bound to deal. Buoyancy of spirits and a firm belief in his ability to get well, are aids not to be despised. A part of the atomized substance no doubt reaches the surface of a cavity; into the neighboring inflammatory fields or into an in- filtration it cannot enter. A direct influence upon the heal- ing process cannot be claimed for any substance introduced by inhalation, because it would require almost incessant inhalation to accomplish what in the end would yield but small results; on the other hand, pulmonary gymnastics must be kept well within bounds and never exaggerated. Is the ordinary inhalation of remedial substances, then, useful only as pulmonary gymnastics? No, not altogether so. In the coarser tubes we find some use for their local action. In bronchiectatic dilatations the bronchial walls are rigid and hence have lost much of their propulsive power. Pus that has accumulated becomes inspissated and mucus becomes tough ; both from water abstraction. The same may take 78 TREATMENT OF CONSUMPTION. place in the bronchial tubes and in the folds and pockets of the larynx, causing continued irritation. Now the two points which we are able to cover, are to re-supply the inspissated material with moisture to render it more easy of expectoration ; and to relieve and partly subdue irritatio?i. The inhalation of steam, pure or impregnated, may, as we have seen, prove too much of an effort for the respiratory muscles. In addition to this it has a tendency to increase irritation, in the beginning at least, This is a drawback which renders deep inspirations in the inhaling of the medicated substances almost futile. As an aid in rendering tough expectorations more soluble, the inhalation of common salt is as good as anything I know. The object being to supply the tough mass with moisture and possibly slight disinfection, no one particular remedy is more beneficial than others. Appetite and digestion of the patient are too precious, to be placed in jeopardy by filling the buccal cavity with a bad tasting substance. Twice a day is sufficient for such inhalations. This seems to me the proper place to speak once more of the inhalation of the benzoate of soda as practiced only a short time ago by several authorities abroad. With them, it must be understood, inhalation served to combine absorption into the general circulation with local effect upon the diseased portion of the lung. Or again, inhalation would be combined with internal administration, a line of treatment which is rational and in accordance with the plan advocated by me of changing the remedy or form of the remedy, and likewise alternate as to the HOME TREATMENT. 79 route of introduction, or to combine two routes at once. Always however keeping the management of the general condition and of the digestive function in the foreground. The following doses and modes of administration were some months since published in the " Medical Record," Letzerich recommends for internal administration the benzo- ate of sodium : Sodae benzoat. 3* v - Aquae destill. Aquae menth. pip. aa. ^i ss. Syr. cort. aurant. 3" ss - M. S. Tablespoonful every hour, for adults. Klebs advises the inhalation of ^n ss. per dayat two or three sittings, conjointly with the benzoate of magnesia inter- nally, in doses varying from ^i to ^ ii per day. Schueller uses §i to §ii benz. soda per day, taken by the mouth in doses of 3 SS to 3*- Kroczak employs inhalations of a 5 per cent aqueous solution. Others have used and recommended a 2 per cent, watery solution, the sittings lasting at times over an hour. The dose administered by inhalation is 3 SS at starting, with a gradual increase up to and above ^ l ss daily. Two to three inhalations are practiced each day, the sit- tings in some instances lasting two hours (counting pauses for rest). The minimum dose appears to be about 10 grains; the maximum ^ss and even ^i. Lastly a word or two concerning apparatuses for inhalation and insufflation. 8o TREATMENT OF CONSUMPTION'. Apparatuses for the introduction of atomized substances are of various kinds ; Steam atomizers of various shapes and patterns. Atomizer by compressed air with self acting cut-off. Hand apparatuses with one and two rubber bulbs. For insufflation; Warner's insufflator: a curved hard rubber bulb for thumb compression. The remedies used to allay irritation by inhalation will be spoken of together with other forms of administration in connection with the treatment of cough as a symptom. One form of inhalation has lately been re-introduced which appears to promise more favorable results than hereto- fore attained. I have reference to direct local medication of the lung by continuous inhalation of an antiseptic atmosphere, brought doivn to a practical shape. Before giving the details and results as furnished by Dr. Pepper, let me say that while my objections to long con- tinued or continuous breathing of any substance or form of air are based upon tiring out the respiratory muscles and the heart, this method enables the patient to breathe continually at his ordinary rate. This because the apparatus is attached to the mouth of the patient, worn day and night, thus enabling him to "respire an atmosphere charged quite strongly with alterative or disinfectant vapors". * " Two or three years ago, Dr. W. Roberts, of Manchester, England, described a simple portable "respirator inhaler," in the form of a metal box, perforated in front and behind, and filled loosely with layers of tow on which the inhalation liquid was poured. This inhaler fits over the mouth and is * Pepper— Local treatment of Pul. Cavities, pp ( 4 to 6. HOME TREATMENT. 1 fixed over the ears like an ordinary respirator. A much more convienient form of apparatus for continous inhalation has been devised and extensively employed by Dr. H. Curschmann, now of Hamburg. He has used it with great success in cases of putrid expectoration due to chronic bronchitis, and also where there has been destructive disease of the lung accom- panied with offensive sputa. In at least one of his two most remarkable cases I think, however, the physical signs are open to an interpretation different from that which he assigns, and one which renders the recovery of the patient less extra- ordinary. I quote the following report of one of these cases : A man aged 53 who had been ill some months with symptoms of phthisis, was admitted under Dr. Curschmann's care in Nov. 1878, with dullness, bronchial breathing, and medium sized moist rales over the lower half of the right lung poster- iorly. At one point percussion was tympanitic, and ausculta- tion revealed signs of a cavity which was proved to be such by tapping and drawing off some of its fetid contents. The pa- tient expectorated about a litre of most intolerably putrid secretion in twenty-four hours. His evening temperature was 39 C. , his pulse 112, and he suffered from night sweats. He was treated throughout with almost continuous inhalations, first of oil of turpentine, and then of pure carbolic acid. In three weeks, the sputa were quite free from smell, fever and night-sweats had left him, and he only spat up about one-third of the amount he had done on admission. As in the other case referred to above, there was ultimately extraordinary dis- appearance of the abnormal physical signs, and the patient gained twenty pounds in weight during his scarcely six 82 TREATMENT OF CONSUMPTION. months stay in the hospital. Except a little morphine for the cough at the first, he took no medicine internally, no hypophosphites, no iron, no cod liver oil. In both cases the successful result can be attributed to nothing except to anti- septic treatment — for such it is — by inhalation. Since obtaining a supply of Curschmann's respirators from Berlin. * I have used continuous inhalation in a certain number of cases. There can be no doubt of its efficacy in destroying the putrid odor of the sputa in some cases of dilated bronchi or pulmonary cavity. It certainly exerts a modifying effect n the bronchial mucous membrane, and may be of material service in the treatment of obstinate bronchitis. I have seen unmistakable benefit from its use in cases of empyema dis- charging putrid pus through a pulmonary fistula. In cases of extensively diffused chronic catarrhal pneumonia, I have some interesting evidence pointing to the benefit that may possibly be derived from the continuous inhalation of suit- able vapors. In cases of true pulmonary cavities, however, apart from the disinfection of their contents, it seems to be unsettled how far the condition of the walls can be modified even by this method of inhalation. It appears to be a subject deserving of thorough and pro- longed investigation, and I am now engaged in carrying out observations on a number of suitable cases. The mode of using these respirators is very simple. The space between the wire disks, through which the air is respired, is filled with Iragments of sponge on which the substances used for inhal- * This respirator is figured in the Berliner Klinische Wochenschr, No. 27^879, fig 430 ; and can be obtained from H. Dunzelt, 22 Schaaren-Straase, Berlin. HOME TREATMENT. 83 ation are poured. Those which have so far yielded the most satisfactory results are carbolic acid, creosote, oil of turpen- tine, a mixture of tincture of iodine and compound tincture of benzoin, and thymol. If care be taken to apply a little cosmoline to the skin where the rim of the inhaler touches the face, and to wipe the rim frequently, no local soreness will be produced The vapors of these substances, even when dropped on the sponge undiluted, are tolerated with remark- able ease. Some patients become impatient of the constraint of wearing such a mask continuously, but as a rule, a clear explanation of the object in view, and the permission to leave off the respirator for a few hours each day, will overcome all such difficulties." Symptomatic treatment includes the management of all urgent and distressing symptoms which may arise during the course and at any stage of pulmonary consumption, regard- less of the general or local treatment for the time being. Of such occurrences are cough, night-sweats, hemorrhage, diarrhoea and sudden collapse from failure of the heart's action. In the foregoing pages, mention has been made of the causes of cough; presence of tough masses, ready for expect- oration, with partial loss of propulsive power of the bronchi and peripheral irritation of the superior laryngeal nerve; which irritation may be caused by the presence of tubercle; or an ulcerative process in any part of the respiratory tract. The presence of tough muco-purulent matter is of course as much a cause of irritation as the others, but is mentioned separate- ly, because with it we are enabled to remove and continue to 84 TREATMENT OF CONSUMPTION. remove the cause; whereas in the other cases we merely allay irritation without removing the cause. Percussion and auscultation will enable us at all times to determine which cause is present and whether removal is call- ed for, before an effort is made to allay spasmodic irritation ; or whether irritation is to be soothed at once. It will by no means do to use expectorants and the like indiscriminately. A great deal of harm maybe done by the continued retention of secretions ready for expectoration. It would be equally injudicious to prescribe a stimulating expectorant, when the most careful soothing and suppression of irritation is called for. Let me add that expectorants should be very sparingly, given and only under pressing indications. This applies es- pecially to all expectorants of which opium or its alkaloid are the bases. Stimulating Expectorants, carbonate of ammonia; mur- iate of ammonia; tinctura sanguinariae; liquor ammoniae an- isatus or benzoicus; benzoic acid. The following are convenient formulas used by me : Liquor ammon. anisat. gtt. v-xv. Morph. sulph. gr. 1-8 As a dose three or four times a dav. Acid, benzoic, gr. v. Sulph. aurat. gr. i. As a dose every three hours. Soothing expectorants — To allay an unnecessarily irrita- tive cough, we have recourse to internal administration, in- HOME TREATMENT. 85 halation, insufflation or application to the larynx by a hair- brush. Do not use a sponge-probang. In internal administration, morphine of course takes the front rank for effect. For many reasons it is best to avoid giving it, except in the last stage or at great intervals in other stages, and to use the other anodynes first. Of these, I know none better and more reliable than Chlorodyne -- This is a happy combination of chloroform, morphine and oil of pep- permint, minus the bad aftereffects of opium. From ten to fifteen drops may be given at bedtime, and at long intervals as required. Oxalate of cerium is excellent, and is followed by no bad effects whatever. Merck's preparation has been found to be far superior to others. Five to ten grains put as a dry powder upon the tougue at night will allay irritation beautifully. Or it may be given in the same manner three or four times a day. Sulphuric ether; extract of hyoscyamus and dilute hydrocyanic acid will likewise allay irritation. The following are a few of my favorite formulae : Morph. acet. gr. ii. Acid, hydrocyan. dil. 3 SS - Tinct. sanguinar. 3 n - Syr. pruni virg. Syr. tolutani ad ^ii. M. S. — Teaspoonful every 2 or 3 hours. $C Extr. hyoscyami sice. 3 SS - Aquae amygd. amar. gi. (With morphine if required). M. S. — Twenty drops four times a day. 86 TREATMENT OF CONSUMPTION. Aether, sulph. ^ni. Tintc. hyoscyami. Syr. pruni virg. Syr. tolutani aa ^i. Aquae ad giv. Dose: — From one to three teaspoonfuls. By hypodermic injection to insure rest from irritating cough at night: Morph. sulph. gr. 1-12 — 1-8 with i-i2oth grain of atropine; Pilocarpine, gr. 1-3. Application to lar- ynx by hair-brush: Solution of nitrate of silver (^i — §i); may be used every fourth or fifth day, in order to destroy ex- cessive peripheral sensibility. Though rather a rough pro- ceeding, it proves of benefit frequently when other measures have failed. The following formula? are useful for topical application : Acid, tannic, gr. x in ^ii. of Glycerine, also : Iodinii gr. vi. Potass, iod. gr. xii. Glycerini puri gii. M. S. — Local application (in chronic pharyngitis). Inhalation is useful by combining the allaying of irrita- tion with deodorizing the expectoration. The best remedies for accomplishing these objects are : Oil of turpentine, the bromides of potassium and sodium, salicylic acid, creosote, compound tincture of benzoin. A few drops or ol. terebinth, creosote, or chloroform or all three may be inhaled for convulsive cough with offensive sputa. HOME TREATMENT. 87 01. terebinth, gtt. xv-xx. Exte. opii aquosi gr. i. Aquae ^i. M. A slight peripheral shock, in the shape of little ice pills at night prove grateful. In the absence of other remedies, a teaspoonful of honey allowed to dissolve on the tongue, has stood me in good stead in allaying peripheral irritation. When hemorrhage from the lungs occurs, you will find ac- companying it a rapid heart's action. Indication, therefore : to control the hemorrhage and also the heart's action. The chief of all remedies for this mishap is the fluid extract of ergot. Twenty drops should be administered hypodermically and into the skin covering the chest, as nearly in loco as pos- sible. Ice should be applied without fear or hesitation. To control the heart's action (in part accomplished by ergot) digitalis in tincture, ten to fifteen drops, or infusion (doses of 3 SS — & vu ) The tincture of night-blooming cereus (tinct. cerei Bonplaudii) in five to ten drop doses is said to act well; my experience with it is too limited to war- rant an expression of opinion as yet. In several urgent cases, where cedema threatened and the heart's action was very rapid, I unhesitatingly made a bold hypodermic injection of half a grain of morphine (and once three-fourths of a grain) and carried my point in each case. That this was taking a liberal risk, I am quite aware, but boldness is occasionally requisite. Gallic acid and common salt are old remedies, success- fully used before ergot came into vogue. 00 TREATMENT OF CONSUMPTION. Night-sweats are a troublesome and weakening symptom. In connection with a rational treatment, a little cold cognac at night in the shape of a milk-punch often does ex- cellent service. Two or three tablespoons of first rate brandy or bourbon whiskey mostly answers. Next to this simple remedy stands the hypodermic injec- tion of atropine — gr. 1-80 — at bedtime. Sponging with cool water and alcohol is practiced in cer- tain sanitaria in Europe. A good formula is ; Zinci oxid. gr. xii. Extr. hyoscyami gr. xviii. M. f. pilul. No. vi — S. One at bedtime. The mineral acids : dilute sulphuric, aromatic sulphuric and dilute muriatic acid are ancient remedies. Diarrhoea is often a troublesome symptom in the last stages. A regular gradation of remedies may be used, all of which act beneficially. Rapid change from one to the other is often admissible. The most reliable astringents are : catechu, tannic acid, opium, calumba, kino, argent, nitr. , and enemata of starch with astringents and opium. Claret wine is a good adjuvant, so is an imported cheap Greek wine, called '' Camarite. " What your duty to diagnose is, whether you are deal- ing with a catarrhal condition or an ulcerating surface and act accordingly. Dr. C. T. Williams has recently written in the " Lancet" upon this subject. He adds to the above conditions, waxy degeneration of the bowels. In the catarrhal form he recommends altering the dietary and order- HOME TREATMENT. 89 ing a Few doses of alterative and purgative medicine, with some alkali to reduce the acidity. In the ulcerative form, he recommends three sets of meas- ures : a, rest in bed, with easily assimilable food, such as chicken broth, beef and veal tea, milk gruel, blanc- mange, always combined with liquid pancreatives. Koumiss is also highly recommended. b, Warm applications to the abdomen in the shape of linseed poultices, turpentine stupes, or hot water fomenta- tions, to reduce the pain and produce derivation to the skin. In severe pain, small blisters. c, Internally astringents. The most powerful of min- eral astringents is sulphate of copper in one-quarter or one- half grain doses. Of vegetable acids, tannic acid is the best, in four grain doses. Enemata of lead and opium may have to be resorted to. Astringent enemata are best combined with a pint or a pint and a half of linseed- tea. Dyspncea may arise from such temporary causes as the presence of gases in the stomach and bowels, slight disturb- ance of the innervation of the heart and from a variety of causes during the course of a healing process. Of course the cause is to be removed. The sudden occurence of flatulancy, apart from a generally weakened condition of the digestive organs, is a very troublesome symptom, mostly caused by fermentative processes in the alimentary canal. For patients in whom such temporary accidents are of more or less fre- quent occurence, it is best to have on hand some pulverized charcoal for immediate use, as for instance the following mixture : 90 TREATMENT OF CONSUMPTION. Carbon, animal, ^i ss. Magnes. hydr. 3 V >- Aquae ad ^ V1 - M.S. Tablespoonful as required. From one-half to one ounce of tinct. cinchon. comp. with a little syrup of orange peel answers the same purpose. For immediate relief of threatening dyspnoea, a hypoder- mic injection of morphine is the thing. Of late the fluid extract of Quebracho has attracted con- siderable attention. It is the fluid extract of the cortex of quebracho bianco and is administered in doses of from one- half to one drachm. By increasing depths of inspirations, it relieves dyspnoea and thereby facilitates oxygenation of the blood. One of the drawbacks to the use of quebracho is that, like many other fluid extracts, it is very unreliable. CLIMATIC TREATMENT. The question of a proper climate for consumptives is very important, and yet not one which received careful and proper attention in former times. Patients have been sent to "mild climates" since time immemorial, for reasons which no authority has ever been able to establish. Statistics did not improve under this sys- tem of expatriation. It is only within more recent times, that constant attention is being paid to this subject and not without some encouraging results. Our knowledge of me- teorology is now so far progressed, that thermometrical, barometrical and hygrometrical observations are daily made in most of the civilized countries. True, no ideal climate for all classes of cases has been or ever will be found. Dr. Loomis is right when he says, that in regard to climate, no absolute rules can be laid down. And again "The individual pecularities of each case must decide this question. Experience shows that one individual improves in a warm, moist air : another individual improves in a cold, dry air. Ever}' phthisical patient has a climate adapted to his peculiar diathesis.'' How to find this out, will be spoken of later on. It will also be my endeavor to demonstrate, that we have so far advanced in our know- ledge of the "relative value of various climates, as to be able 92 TREATMENT OF CONSUMPTION. to present certain advanced foot-holds, which will serve as a guide to your judgment. Medicine is not an exact science, that branch of it called therapeutics least of all, and the further we are removed from exact and fixed rules, the more will you be called upon to exercise your judgment in individualizing and in strict atten- tion to detail in conformity with the plan which may be marked out for climatic treatment. Before proceeding to a detailed account of the comparative benefits derived from sea and mountain air, a few words may not be out of place, in regard to pure fresh air in general as a remedial measure. And first let me say, that no air of whatsoever part of our globe, be it on land or water, at the top or at the foot of mountains, in proximity to or in the middle of the ocean, has any specific qualities which tend to cure consumption. This fact cannot be recalled to mind too often." Our pabulum vitae, the air, cannot and does not act di- rectly upon solidified lung tissue, whether this air be diluted or compressed, warm or cold, pure or impure. The same holds true of inhalation of air, that obtains in reference to artificial inhalations. The gates are more or less tightly closed against it by swelled mucous membranes and secretions from the terminal bronchi, by desquamated, partly metamorphosed epithelium filling in the terminal bronchi and alveoli. The enjoyment of a pure, fresh air is a capital remedy, but it needs to be regulated and fitted to each individual case by close supervision, or it may prove as harmful as other remedies wrongly administered. CLIMATIC TREATMENT. 93 Therefore the atmospheric air should be handled thera- peutically like other remedies. For pure air is not stationary and continuous, but requires the occasional interference of severe meteoric changes, and this factor may in a measure be considered a disadvantage. This much is promised, in order to point a moral in con- nection with indiscriminate living in the open air in the way of camping, residing on a farm or "ranching" as it is called in Colorado and in other Western States. Such prim- itive styles of living for one not accustomed to them (I refer especially now to inhabitants of cities and towns) are not productive of any good, for two reasons : First ; because it is undertaken under the mistaken apprehension that this fresh air is " nourishment for the lungs." Second — Because those who camp or ranch do so, under the impression or instruction that their whole mode of life should be revolutionized, turned up side down as it were. The reason why open air is beneficial at all, is chiefly be- cause the patient is at all times completely surrounded by it, But this does not constitute nourishment to the lungs. You can scarcely find a book or pamphlet upon the subject of treatment of consumption, which does not speak of pure air as "nourishment to the lungs," which is mislead- ing. The lungs are nourished by the bronchial arteries, whereas the pulmonary blood-vessels represent the whole body at large. It is through them that oxygen is carried back to the reservoir and from there distributed to nutrient arteries, one set of which are the nourishing vessels of the lungs : the bronchial arteries. On a par with this notion of "nourishment to the lung" 94 TREATMENT OF CONSUMPTION. is that which attributes the probability, of "getting tired out" to the lungs, after severe exercise, such as climbing. The lung does no work in this connection, the muscles do that; it serves as a sort of gas-filter for the reception of oxygen and the casting off of effete products in the shape of carbonic acid. As regards the performance of function in the body, its role is really a passive one. This fact may account for its scarcity of nerve filaments. The function of the lung is the effect of the labor of other organs. The fact of the pulmonary ramifications of blood- vessels being the representatives of the tissues and organs at large, gives us the clue to the benefits derived from the in- halation of pure air. This benefit, as was stated in previous chapters, lies in the strengthening of the propulsive power of the heart, which in turn encourages interchange of tissue and calls the assimilative powers into renewed action. Healing of the local lung trouble comes in as a secondary matter, keeping pace with the general improvement, but not in miscellaneous air and not by unregulated living, as will be shown directly. The second point, the desire of the patient to revolution- ize his whole mode of life, too often ends like other revolu- tions — in complete collapse. No step should be taken, no plan followed, without care- ful instruction from and more or less constant supervision by a strict physician. In the following pages, the exclusive method of treating patients in closed institutions will be lauded only so far as their advantages actually extend, but I do not consider them an absolute sine qua non. But knowing well that the simplest gastric catarrh may CLIMATIC TREATMENT. 95 pave the way to destruction (to speak only of one danger), I hold that more or less constant supervision by a physician is absolutely necessary. But the question will be asked : Is not this fresh air surrounding us at all times, as good as any other air ? No, it is not. Absolutely pure air must have certain other qual- ities besides being plentiful. Pure air requires primarily the absence of impurities in whatever shape, whether of atomized solids, fluids or of gases. That is, generally speaking, there should be an ab- sence of dust, of excess of ?noisture and of noxious vapors. These conditions are only furnished by sea air and moun- tain air. In other words, both sea and mountain air rejoice in the absence of vehicles for harboring and conveying 'noxious influences or animal or vegetable germs or hydro-sulphurous ex- halations. They alone can be truly called antiseptic atmos- pheres. It is another error to suppose that the atmosphere of all sea coasts or islands must be surcharged with moisture. To be of any benefit to the majority of cases of consump- tion, it requires, however, still further additional factors to constitute an approximately ideal breathing medium and these factors will be dwelt upon in their proper place. Any belief, let me repeat, in the specific influences of any kind of air is unscientific. That the belief in the efficacy of warm air has been so long-lived, is partly due to hum-drum methods and partly to the fact that a warm atmosphere permits of remaining out doors and enjoying plenty of it. But this unlimited enjoy- ment is, as I have shown, not sufficient. 96 TREATMENT OF CONSUMPTION". I repeat that neither warm nor cold, moist nor dry air, nor air impregnated with any substance, be the same salt or pine tree exhalations, have either specific effect upon the lungs, nor any such contact whatsoever with the diseased portion, as would benefit the same in the least. Now let this be distinctly understood, that cures effected or benefits accrued in pine regions, in the middle of the ocean, or in the vicinity of the North Pole are not here called in question. But the factor to which such cure is ascribed, is not only called in question, but denounced as out of the question. Warmth, cold, dryness, moisture, artificial impregnations are all influences of 7110s t varied kind, but 0/ equal effect upon the molecular changes in our tissues. In this connection it may not be out of place to speak of the immunity of the inhabitants of certain countries or parts of countries from the scourge of phthisis. To me it has been a standing matter of surprise that this really existing immu- nity of the inhabitants of Iceland, the Faroe Islands, the Orenburg Steppes and other regions has not been properly accounted for before. The reasons thereof are very simple : First — Phthisis is an ubiquitous disease, occurring or lacking entirely independent of climate. Statistical tables are the result of an accidental combination of circumstances, such as overcrowding commingling of races, &c. , and bear no relation whatever to climate. Second — All the tribes heretofore enumerated as exempt, are as far as possible removed from the centres of civilization, live simple and healthy lives, with plenty of out-door exercise and above all, notoriously abstain from commingling with other natives or tribes. Or what amounts to the same thing, nobody goes to Iceland, Spitzbergen or the Steppes. CLIMATIC TREATMENT. 97 Equally as false as the supposition of the existence of specific air for the cure of consumption, is the belief that climate has any hand in the development of pulmonary phthisis, in directly causing this dread disease. Here allow me to stamp it indelibly upon your mind, that no particular Avid of climate either in the torrid, temperate or frigid zone, and no particular country and part of a country in either hemisphere enjoys the privilege of originating consumption, because of its temperature or geographical location. The cases of consumption (which we have no time to en- quire into in these letters) are found in connection with the mistakes and vices of civilization, such as overcrowding in cities, bad food and water, uncleanliness, alcoholic and venereal excesses and the miscegenation of races. It is a noteworthy fact that mulattoes form a large contingent of the scrofulous and consumptive army. But this is independent of their residing in New York, New Orleans, Zanzibar or Halifax. Lastly, now be kind enough to distinguish between cause and the cure of the effect. Because there are no climates which especially cause consumption, that is no reason why there should not be localities where it is likely to get well. Mind, however, that this existing ideal atmos- phere is not the outcome nor representative of the climate of any large section of country but of the general geographical location and local conformation and advantages which include all or the great majority of factors necessary for a pure, fresh and antiseptic air. What these factors are, let me now tell you in the order of their importance : 98 TREATMENT OF CONSUMPTION. In order to give you a clear insight into these ideal fac- tors, I will divide them into " meteorological " (such as are connected with the atmosphere) surrounding our globe, and "terrestrial" (those springing directly from the earth itself). METEOROLOGICAL FACTORS. First — Dryness or the absence of excessive hwnidity. One of the best established facts in the climatotheraphy of con- sumption is that dryness is an almost absolute requisite. It has been statistically proven by Dr. C. T. Williams of Eng- land and stands corroborated. Desirable as absolute dryness is, it is not found anywhere and its presence would annihilate other important factors of the ''ideal atmosphere," since that would preclude such meteoric phenomena as tend to change and purify the air. A certain amount of vapor is always present in the atmosphere. Its source is the surface of water, from whence it rises up into the air. Therefore the greatest amount of moisture is found over large bodies of water. Saturated air at a temperature of 6o° contains 5. 87 grs. of vapor in each cubic foot. Air expands with increas- ing warmth and its capacity for holding moisture is increased by expansion. Always keep in mind however, that because an atmosphere is expanded, as it is at high altitudes, that it does not follow that it contains so much more moisture. It is capable of carrying it, but that does not say that this moisture is present to fill that capability. It is popularly supposed that the presence of vapor in the air adds directly to the heat. This is a mistake. As water is turned into vapor, heat is carried off with it, but this heat remains latent METEOROLOGICAL FACTORS. 99 (sleeping), not capable of producing an additional effect upon the thermometer, or of exciting the sensation of warmth. A moderately moist air is undoubtedly favorable in cer- tain cases, when such moisture comes directly from the sea. The injurious effects of moisture, which we wish to have consumptives avoid, consist of its preventing, by its presence in an over-dose, the taking up of moisture into the air from our bodies ; it hinders uniform water abstraction, the most important element of rapid tissue changes. Of course the quantity of moisture present in the air in any locality depends upon the nearness of sources of moisture and the prevailing direction of the wind. The degree of moisture which we would like to have as one of our factors, is one just sufficient to keep the land from becoming a desert, or, in other words, no moisture brought from large bodies of water near or far, and only a limited rain-fall throughout the year. Second — A certain equability of temperature. The chief point to be desired in this connection is that the mean annual range shall not be too great. I have already told you that even persons of reduced resisting power are capable of meeting lesser changes of temperature. The tolerance of the lung against variously tempered air is much greater than is commonly supposed. Heidenhain has shown that it may amount to a difference of one-hundred degrees. That is, the normal lung can with impunity inhale air all the way from zero to ioo ° Centigr. Not consumptives of course. If the annual range does not exceed 30 fahr. say that it ranges from 45° in the cold- IOO TREATMENT OF CONSUMPTION. est season and 75 ° in the warmest; the mean to lie some- where between 55 and 65 , we may call it equable. According to J. H. Bennett, a temperature ranging from 45° Fahr. at night to 65 in the daytime, is physiologically the most conducive to the well-being and longevity of the human race. Third — Absence of strong and frequent winds. We know that on the whole, winds which tend to keep the air in mo- tion and change it, are beneficial. The desideratum is that these should be short-lived and not known to be of great velocity. Both uninterrupted blowing as well as great velocity exert a powerful influence in reducing the temper- ature of the body, by carrying off its warmth too rapidly. Besides, nothing proves so troublesome to the respiration of consumptive patients or so excites to coughing those who are afflicted with throat trouble, than strong winds. Fourth — Abundance of sunlight, or in other words a de- cided preponderance of clear days in the year over the cloudy and rainy ones. In some sections of country the intensity of the unobstructed sunlight is very great. It mostly goes hand in hand with a preponderance of clear days. Lombard tells us that light stimulates and darkness im- pedes respiration. Assuredly there are diseases, whose re- mote or immediate cause is insufficiency of light. Daylight stimulates the organism to greater nerve activity and greater capacity for reaction. I am satisfied, that light exercises a great chemical effect upon life ; that the histo-chemical changes in our tissues, by which interchange is affected, combinations dissolved and colors created and changed, are due to the influence of sunlight. METEOROLOGICAL FACTORS. IOI Fifth — -Frequent changes in the electric conditions of the atmos- phere. As frequent changes are necessarily dependent upon and in connection with storms, it is desirable that these should be short, sharp and decisive, the same quality which we desire of the factor which is to keep in motion and change the air, namely, the wind. I do not agree with certain enthusiasts, who pretend to be able to demonstrate a direct influence of atmospheric electricity upon the human body. One of the products of active atmospheric electricity is ozone otherwise known as oxygen struck by lightning, elec- trified oxygen. Ozone is a powerful oxidizing disinfectant and as such probably serves to keep the air free from germs through its power of resolving all animal and vegetable putrescent matter into primitive and harmless forms. TERRESTRIAL FACTORS. Presence of a porous soil for the rapid absorption of rain or snow. Sandy or graveley soil will cause most rapid drain- age by absorption. Seventh — Supply of water, pure in quality and plentiful in quantity. Drinking water should be free from animal or vegetable germs, as it should be abundant for drinking and cleansing purposes. Eighth — Presence of extensive pnne forests, sufficient in extent to impregnate the air with terebinthine odors. If there is any value in the continuous inhalation of an antiseptic atmosphere, these odors should be able to cover that require- ment: You will hereafter see, that as regards the absence of 102 TREATMENT OF CONSUMPTION. germs, pine regions are serviceable in lieu of high altitude. These then are the factors which are to be looked for in an "ideal climate." By carefully looking over and consid- ering them you will observe, that all these together, or a majority of them, combine to create opportunities, favorable for a pleasant out-door life, either of work or recreation, or both harmoniously blended. Secondly ; that insisting upon such elements as I have cited, we name the conditions by which alone a pure una,dulteraled and antiseptic air may be obtained for the phthisical patient. And next it becomes clear, that the presence of pure and unadulterated airis due to the com- bined influences of heat, light and electricity, wherever these three imponderable substances have full and uninter- rupted sway. For it is by their combined actions that the atmosphere is kept free from impurities. In addition to the above eight factors which we are desir- ous of finding in nature — nature's factors — it is of course desir- able and often enough indispensable that the patient should be surrounded by conditions similar to those enjoyed at home. If expatriation must take place, let it at least not be isolation. We may therefore speak of desirable "artificial factors" in contradistinction to the above "nature's factors." First — Food of proper quality and quantity. A patient cannot be expected to train his debilitated stomach to illy- cooked victuals, nor to change his American tastes for such as Spanish or Mexican. Many of the most desirable climates abound in indigenous vegetables and fruit ; a great advantage over canned goods. Second — Society is a factor, which not one patient in fifty could do without. Mingling: and conversing with others of TERRESTRIAL FACTORS. 103 the human family is an absolute necessity to keep the mind from becoming dwarfed. Nothing is so exhilerating as social amusements. Of course it is desirable that the patient should be among his countrymen or such as speak his native tongue. Third — Variegated scenery; something for the eye to feast and the mind to dwell upon ; variety in the conformation of the country and an equable proportion of open country, tim- ber land and surfaces of water, however limited. Fourth — Medical advice. This is absolutely a sine qua non. It is not sufficient that the patient should see a con- scientious and vigilant physician every now and then. He should be sufficiently near to such a one to insure prompt attention. A reliable physician will know how to individualize and pay strict attention to detail in treatment. At first glance it may seem to you, as if I had piled up an unnecessary number of requisites. But while I am free to acknowledge that all of Nature's and of arti- ficial factors cannot be combined in any given case, you are to set your judgment to work to find, if not the ideal, the nearest approach to it. To aid you in this, let me give you a fixed maxim : The highest percentage of cures ivill never be reached until cli??iatic and home treatment are harmoniously blended. Personal supervision and treatment must be called in to aid climatic influences. Comparative freedom from impurities, I have told you, is found both in sea, and mountain air. Both sea and mountain air are known to encourage and promote rapid changes of substance, although they differ 104 TREATMENT OF CONSUMPTION. in the modus operandi. Both are subject to irregular vari- ations of the barometer, as they are known to occur rapidly, and of short duration, both at the sea-side and in the mountains. In contradistinction to wide plains, where slow changes of the barometer indicate equally slow and long-lasting rains, the sea-shore and the mountains have rapid changes, with rain of very short duration. These changes, once consid- ered as productive of evil, are now known to be essential to the highest condition of health. There is no doubt that rapid changes of short duration are more favorable for the more important functions of the human body than relative stability. We cannot endure either constant dryness or dampness, and since, therefore, baro- metric changes are necessary, such changes as take place rapidly and having supplied the absolutely necessary amount of moisture only, equally as rapidly return to the normal and usual standard, must be of benefit to invalids. These conditions are shared by sea-shore and mountains, as above stated. The difference in action between sea and mountain air, is now to be considered, of which Dr. Brown says, in sub- stance : Sea air acts rapidly, mountain air slowly; sea air very soon compels a more increased ingestion of food, stimulates di- gestion powerfully, so that the bodily weight is considerably increased in a short time. Mountain air, on the other hand, acts as a more subtle, slow stimulant, exerts its influence beneficially on enfeebled bodily functions, and their naturally increased irritability. Sea air pre-supposes robust assimila- TERRESTRIAL FACTORS. 105 tive functions arid equally robust integrity of the functions of the heart and lungs, however anaemic or otherwise enfeebled a person may be, if only their circulation and nervous system are sufficiently) above par to bear the strong stimulant. Mountain air exercises a calming and indirect, quiet, gentle influence on the atonic and catarrhal condition of mucous membranes, and, however persons may suffer from weakness with in- creased irritability, it will act slowly but surely beneficially, if only the circulation and nervous system are still capable of responding to the gentle and scarcely perceptible influence of moun- tain air. Of course you will understand that no rule or set of rules can be laid down by which you are to determine exactly what class of cases should go to the sea-shore and. what others should go the mountains. A great deal must be left to individualizing and still more to the judgment of the physician, and this will to a certain extent ever remain so. Still experience has given us certain land-marks, which are positive and safe guides, while we have certain other less well established factors, which serve as out-posts, from whence you are justified in making raids by the scientific use of your imagination. You will for instance have seen that sea-air will, so to speak, help those who can help themselves; those whose capacity of resistance has not yet fallen below the physio- logical line. But you will ask ; where is this line ? well, each individual has his own, so that we are often compelled to ascertain his capacity for reaction by actual trial ; when a change may be found to become necessary. Thus a patient having tried sea-air may be compelled to go inland ; but never vice versa. 106 TREATMENT OF CONSUMPTION. There is a certain class of cases which are benefited and often cured by sea air either in the shape of repeated sea voyages, or residence on an island or at the sea coast. I refer to : First — Catarrh of the bronchi in which the finest ramifi- cations are not much involved, Superficial catarrh, the existence of which is not past a limited period, from which fact we have a right to conclude that the connective tissue is not as yet seriously involved in proliferation and the forma- tion of cheesy foci. Especially if such cases have no record of hereditary vulnerability ; in fact where the catarrhal condition is chiefly dependent upon a general break down from hard, mental or physical labor, insufficient food, etc., and the lack of strength and nervous power engendered by the breakdown, still predominates over the local lung trouble. Or to express it still otherwise : where the immediate cause predominates over the local manifestations in the lungs. Second — It happens that previously healthy persons with an abundance of living matter, and with a good family his- tory, pass through a croupous or catarrhal pneumonia and have a remnant left behind, after absorption and expectora- tion have done their best. Such persons may be thoroughly recruited by a sea voyage or an active life on the sea-shore for a time. I have drawn your attention to the factors which should govern the choice of climate, as nearly as possible approach- ing the ideal. They are ; First — Dryness. Second— Equability of temperature. Third — Absence of winds. TERRESTRIAL FACTORS. \OJ Fourth — Abundance of sunshine, Fifth — Frequent electric changes. Sixth — Porous soil, Seventh — Water, pure in quality and plentiful in quantity. Eighth — Pine odors. Likewise have I told you that the presence of the majority of these conditions include in a greater or lesser degree the absence of dust, fog or noxious gases : the carriers of infec- tion. The absence of germs has been mentioned, and I have shown you that this is due to our having found an atmos- phere of great purity, unmixed and unobstructed ; and lastly that this condition of the atmosphere is undoubtedly due to the unobstructed influences of heat, light and electricity. In order to avoid frequent repetition, it is well to tell you here that three of the ideal factors are by far more important than the others and they again in turn are of importance in the following order : Dryness ; equability of temperature ; absence of frequent and strong winds. For convenience sake they will be spoken of as the " greater factors" and the rest as ' ' lesser factors. " If now you will ask, where are we most likely to find an approach to such a climate ? my answer is : In the high in- land plateaus of the various continents, and upon the high seas. Until within a few years, all cases of infiltration or cavity of the lung, which were not destined for a maritime climate were sent south. The general prevailing impression was (for the study of climate had not received any attention) that what the consumptive needed was a mild climate and furthermore that mildness was a monopoly of Southern climes. Even now, this belief is so firmly rooted in the laity, Io8 TREATMENT OF CONSUMPTION. that it will take decades to remove it. A good beginning could and should be made by removing such erroneous impression from the medical mind. Please understand me to mean, however, that southern climes as such are not to be con- demned en masse. It is the old fogy notion of the benefits of mildness which I object to. The climate of any locality is to be measured by the standard-of the ideal climate, which we have set up, not as an absolute requisite (not attainable on this globe of ours), but as a collection of qualities, of which a climate suitable for the majority of the consumptives must have at least a majority. Thus there can be no objection to sending patients south to a warm and equable climate, provided the locality deter- mined upon has not too great a thermometrical range. Here it is necessary to recur to a point previously touched upon. Though the annual thermometrical range may be within reasonable limits, it may happen that the highest or lowest records of the thermometer, exist for an unreasonable length of time in succession. This is especially often to be found at low or only moderate altitudes of southern countries. The highest thermometrical reading may be from 8o° to 85 ° Fahr. in a certain locality and this may continue for a number of weeks and is by no means well borne by the average patient. In higher altitudes the reverse of great diurnal changes ob- tains, which changes though thermometrically, are not sen- sationally great, consequently not harmful to the patient. Another objection to warm climates is the fact, that warmth is of necessity more or less closely linked with moisture in excess ; another unfavorable factor. TERRESTRIAL FACTORS. IO9 Equally as objectionable as this indiscriminate sending of patients South to an enervating and debilitating climate, is the convenient method of advising residence in the south in winter and in northern climes in the summer ; the idea being to keep the phthisical individual free from extremes of heat and cold. A little thought will at once show the fallacy of this notion. Extremes of heat and cold occur in all ordinary climates, North or South, inland, and upon the sea-shore; at least for days at a time. Moreover it is well- known that the division of the year into seasons is an en- tirely arbitrary one. March and April are as much winter months in New York as are January and February. The intermediate seasons of spring and fall exist in part in the Eastern Hemisphere ; much less so in the Western, and they have no connection whatever with the months to which they are credited, (such as March, April and May, as spring months.) The only practically tenable division with refer- ence to seasons, is with cold and warm weather. If the passing of one season into another were in the re- motest degree allied to dates, a change from South to-North and vice versa might present some therapeutical advantages, but the sad fact remains, that seasons fail to accommodate themselves to dates. A patient rinding the heat of a south- ern locality oppressive for weeks in succession, might come North to find the same oppression prevailing in the opposite direction. To the phthisical patient who has not reached the latter stages of the disease and who is not suffering from colliqua- tive symptoms, any change from city to country, from maritime to a contine7ital climate or vice versa will be productive of benefit to him for the time being. IIO TREATMENT FOR CONSUMPTION. This beneficial change consists in an increase of weight and an amelioration of symptoms. In other words the improvement under these conditions, is general (improvement of general condition) but not local, as regards the condition of the lung itself. Drs. C. T. Williams and Brehmer have observed that gain in weight bears no relation whatever to the actual condition of the lung. I have long been convinced that a mere gain in adipose tissue is a hindrance to the absorption of an infil- tration, and vice versa. Dr. Williams says in his work upon " Influence of climate in pulmonary consumption " after speaking of the percentage of local improvement in cases treated at home climates : "This forms a marked contrast to the changes in general health, and demonstrates only too faithfully how all the appearances of an improved state of health may be present and yet the disease may continue its insidious and steady march unchecked. We have forty per cent, of locally improved against sixty-five per cent, generally better; and thirty-eight per cent, worse locally against twenty- six and three quarters generally so. The moral is that we must not trust too much to general appearances and that an opinion to the effect that the patient has improved, must not be given unless a very careful examination of the chest confirms it. " You are perfectly safe in the conclusion that both sea and mountain air contain in large measure the requirements for benefiting phthisical cases. In both we have the absence of infectious germs, which is an indispensible factor in all cases and stages of phthisis, both as regards the improve- ment of the general condition and in the local healing pro- TERRESTRIAL FACTORS. 1 I I cess. An aseptic atmosphere is to be looked for at the sea shore and at elevated stations. Their difference is in the factor of dryness, that requisite without which the local pro- cess in the lungs cannot be successfully dealt with. Imagine now, that two roads are open to you for the cure or permanent arrest of consumption ; one by acting directly upon the destructive process by mountain air, which arouses the hearts action and drives the blood through the capilla- ries ; the other by first improving the general condition and through it turn the destructive into a healing process by the action of sea air. For improving the general condition then long sea voyages stand uppermost, provided you feel reason- ably sure that the patient's system will hold out long enough to first have irritability allayed by the sensitive influence of warm sea air and then to receive the benefits of its tonic effects. By the term "altitude" we dignify all more or less con- siderable elevations above the level of the sea, ranging from a few hundred to thousands of feet. In order to quench our thirst for classification, Dr. Lombard of Geneva has divided altitudes into low, medium and high altitudes. This divi- sion was made with reference to the mountains of Switzer- land and its object was to ascertain at what stated elevations, if any, pulmonary phthisis ceased to have an existence. In other words, at what elevation a people could be found with whom consumption did not originate and had not originated for generations. Several such localities were ascertained and the elevation corresponding to this phenomenon was put down as the " line of approximate immunity." In Switzer- land this was found to be above five thousand feet. 112 TREATMENT OF CONSUMPTION. The reasons for this immunity are variously given ; from the belief that the constitution is improved by an increased appetite and more powerful digestion, to that of Walshe and Jourdanet, to the effect that continued inhalation of rarefied air causes increased capacity of the lungs and chest. Kue- chenmeister and Brehmer have endeavored to construct a fixed law of immunity from these and other observations. It is held that for every degree of latitude of approach to the equator, an additional elevation of three hundred and seventy five feet is necessary to insure immunity. That is not strictly true, as I have shown you when speaking of Ice- land and other rare and beautiful climes, where the inhabi- tants with or without elevation revel in ignorance of shattered lungs and profound cavities. Many facts combine to bring about this immunity, not the least of which is isolation and hardy out-door life. In the mountains at respectable alti- tudes, dryness and purity of atmosphere are leading factors as you already know. The line of immunity, I desire you to know and remem- ber, is that elevation in some particular locality or country at which the atmospheric air is free from germs a7td enjoys the unobstructed effects of heat, light and electricity. And in addition to this, I tell you that various places within the same degree of lati- tude often differ entirely in climatic conditions ; and, in accordance with the peculiar conformation of a country or locality, every variety of climate may be found in a compara- tively small compass. The most that can be said of an altitude of approximate immunity in general is, that it is found higher up, the nearer we approach the equator from the North or South. TERRESTRIAL FACTORS. 1 I 3 You are well aware that elevated regions have a rarefied atmosphere. Air is twice as rarefied at the height of three and a half miles as at sea level, four times at seven miles, sixteen times at fourteen miles, &c. This expansion of the atmosphere is accompanied by a loss of part of its humi- dity through the accompanying cooling. In high altitudes therefore, we are likely to find one of the principal of the factors for an ideal climate, namely, dryness. If you would ask me why dryness appears to be the leading factor, I would say that its presence eases the insensible respiration of the skin and of moisture from the lungs. It aids the normal performance of water abstraction from the body. When altitude treatment was found to yield good results in the treatment of pulmonary phthisis, Dr Brehmer of Goebersdorf promulgated his theory (since abandoned) that the benefits derived were due to diminished barometric pres- sure. The effect produced was variously attributed to super- ficial but more rapid breathing or to slower and more profound inspirations. All these manifestations do occur in ascending heights. A variety of influences are here at work, which either cancel each other or are evened out by the regu- lating apparatus of the body. In any event it is certain that the human organism is quite capable of accommodating itself to changes in the pressure of the air column of i-ioth to i-6th, the reduction commonly existing at high altitudes. Just how quickly the heart's action will accomodate itself to altitude is to my mind one of great therapeutical value. The general effects of altitude on man are more readily understood, when we consider the lessened pressure of the air- column, which exists at great elevations. The surface of an 114 TREATMENT OF CONSUMPTION. average human being's body may be said to be sixteen square feet, and the presence of the air-column upon a square centi- metre of surface at mean barometric pressure 1033 grammes. At the height of 6,000 feet for instance, the surface of the human body is relieved of a pressure of three pounds to the square inch, which is equal to 7,000 pounds for the whole person. So much for the outer surface. The respiratory mucous membrane of the lung has been calculated by Lie- berkuehn to be 1400 square feet. The lungs are the organs chiefly influenced by the reduced pressure of the air column, whereby primarily increased activity in breathing is brought about, which in turn secondarily influences the centres of circulation, assimilation and innervation. In a comparatively short space of time, these functions will have accommodated themselves to the change. The proportions of oxygen, nitrogen and carbonic acid are the same at high altitudes as at sea level. At the height of 6,000 feet, where the pressure of the air-column is diminished one-fifth, a given space of air will, of course, contain one-fifth less of oxygen, and, therefore, at first the lungs must inspire one-fifth more of air to get the same amount of oxygen. The oft-disputed question, whether increased frequency of respiratory movements or greater profoundness in breathing, makes up this one-fifth deficiency, is best decided by first examining the known effects of inhaling rarefied air, and ex- spiring into the same, at low altitudes. These effects may be summed up as follows : First ; The muscles of inspiration are strengthened, inasmuch as the atmospheric pressure in the lungs is lessened, while that on the surface of the chest remains the same. TERRESTRIAL FACTORS. I I 5 Second — There is an increased determination of blood to the lungs from relaxation of tension upon the bronchial tubes and air-vesicles. This relaxation allows the lung to contract in the exhaling process, and by expulsion diminish the amount of residual air. Keep in mind now for a moment, that this increases the capacity for taking in of the air. Third — The blood being determined to the lungs, the left heart is somewhat relieved from pressure, and this causes, as we know, at first, rapid action and softness. Fourth — Elimination of carbonic acid is favored, because of the diminished density of the inspired air. So we have of immediate effects : Increase of venous blood in the lungs, rapid action of heart, increased riddance of carbonic acid and increased room in the air-vesicles for fresh air. Now let us first, and entirely overlooking the permanent effects for the present, transfer these facts to our high elevation, where we likewise inspire and exspire into rarefied air, but with this difference from the foregoing, that now the pressure on the outside of the chest is diminished, (for convenience sake we will again assume one-fifth. ) Then, we will get of the immediate effects mentioned above, only those which are caused by a rather sudden change from a denser to a rarer medium. And these effects are always temporary unbalancings of the functions, are disturbances of innervation, pure and simple, manifested by rapid breathing and accelerated heart's action. Increased rapidity of propulsion causes not merely fullness of blood vessels in the lungs, but drives the blood into and through the capillaries ; it begets a determination to the periphery. Let us say then that lungs and periphery (lesser and greater calculation both) are I I 6 TREATMENT OF CONSUMPTION. in a temporary state of venous fullness, caused by a disturb- ance of innervation of the heart and lungs from an unac- customed change from a dense to a rarer medium. The lungs will rid themselves of this stasis first by taking in oxygen. But the peripheral stasis can only be permanently relieved, after the left heart has acquired more force of con- tractility, and the right heart is no longer crowded by back- ward pressure from the lung. Of course, I am fully aware that such conditions cannot exist for any great length of time and I have taken care to speak of them as "temporary.'' Yet, both the capacity of the system for standing changes of any kind for a length of time, as well as that the compen- sating hypertrophies (heart) and dilatations (air-receptacles, and subsequently the chest walls), take place in a compara- tively short space of time, are facts too often overlooked. The stasis is soon compensated for and answered by dilata- tions of the capillaries, and their consequent increased capac- ity for holding blood. In inspiration of rarefied air at sea- level, carried on through a number of months, daily, the effects outlive the respiratory act and in a measure beget hypertrophy of the heart's muscle and a moderate expansion of air-vesicles, through increase of their contractility. Event- ually, however, the outside pressure of the air column will regain its supremacy sufficiently to cancel most of the benefit derived, not so in the rarefied air of high altitudes, where the pressure of the air-column is at all times reduced, barely disturbed by any rise of the barometer, because moisture is wanting. Here the permanent conditions will bring about permanent changes, to wit : Hypertrophy of the muscular tissue of the heart, and distension of the pulmonary respira- tory membrane, as represented by the air-vesicles. TERRESTRIAL FACTORS I I 7 Now let us not forget that the endosmotic action of oxy- gen though the lung membrane is of a more rapid and thor- ough kind in the clear, rarefied atmosphere, the very rare- fication of which is a guarantee for its ready passage through membranes. The increased elimination of carbonic acid, at first due to a determination of a large quantity of blood, and answered by increased absorption of oxygen through more rapid inspirations, is now answered by deeper and fuller in- spirations, and the taking up of the same quantity of oxygen as before. As soon, then, as increased frequency of respiration and heart's action approach the normal once more, to be sup- planted by deep, full respirations and regular but more powerful heart's action, we are justified in assuming, that the respiratory /miction has adapted itself permanently to the change of elevation. Dilatation of the capillaries and expan- sion and tension of the air-vesicles with their substructure of elastic tissue have now become permanent, as evidenced by enlargement of the circumference of the chest. To recapitulate : The lessened pressure of the atmos- pheric column from without, is answered by increased activity of the organs within, which results in hypertrophy of the muscles of the heart, fullness and subsequent dilatation of the pulmonary and peripheral capillaries and expansion of the air-cells. These changes beget perfect adaptation to the change of elevation, and re-establish the equilibrium previously existing between external and internal forces. This explanation readily accounts for the varied effects upon the circulation of different persons, and chiefly as re- gards cases of hemorrhage from the lungs. Every individual I I S TREATMENT OF CONSUMPTION. whether safe and sound or afflicted with disease, has to pass through — First, ihz functional changes and second, the result- ing organic changes. The character of the tissues of the heart and blood vessels, will determine the issue in each case. For the great majority, even of sick persons, great reliance may safely be placed upon the wonderful adaptability of the human organism to all manner of changes. But a heart loaded down with fat, blood vessels whose elasticity has been impaired by atheromatous changes, calcareous deposits, or when resistance to the pressure of blood is diminished by syphilitic or scorbutic changes, or the hemorrhagic diathesis (more frequent than is generally supposed) ; stumps of occlud- ed vessels, from whose mouths hemorrhage has occurred before — all such may give way to increased pressure, and a hemorrhage be the result. Here then we have the advantage which in home practice is denied us, of a remedy which will strengthen the heart's action and keep it up permanently. Not temporarily, as by digitalis, but continuously though slowly. This permanent heart stimulation and consequent regaining of its muscular power, is the one element, which high altitudes alone fur- nish. While marine climates and other inland climates may possess certain elements benefiting certain functions, this one is found at high altitudes only and will serve in great meas- ure to explain, why after all at high altitudes some wonder- ful cures are effected. But as there is no sunshine without shadow and no roses without thorns, so with the influence of rarefied air upon the action of the heart. The trouble is that there is always some risk to the heart on account of the possibly too drastic action. TERRESTRIAL FACTORS. II9 The possibility of failure of the heart's action and the possi- bility of fatal hemorrhage are mishaps, to which we cannot close our eyes. The very possibility of such occurrences would suggest caution and cause us to permit the patient to reach high altitudes only by slow approaches. The decision in each case must be left to the intelligence of the physician. He must strike a general average of the patient's remaining strength and resisting powers as com- pared to the destructive process in the lung and, above all, use his judgment in regard to the muscular strength of the heart and its innervation. I have spoken of high altitude as possessing the chiefest of our ideal factors : Dryness, and this because humidity changes with increasing altitude. In some altitudes this is combined with a reasonable equability of temperature ; but by no means in a majority of the same, I wish you to understand, for these would constitute the actual ideal. The diurnal thermometrical range is often very great at high altitudes. On the eastern slope of the Rocky Moun- tains for instance the diurnal range reaches as high as thirty- eight degrees. But, as I have previously told you, these changes, though thermometrically great, are sensationally small. As long as your sensations do not convey to you the fact, that the thermometer has made a raid, you may feel quite happy -and comfortable in your ignorance. Why is this? Because, for each 375 feet (or thereabouts) of eleva- tion, the decrease in the temperature of the air is calculated at one Fahr. From this we draw the instructive lesson, that when considering our factor of equability of tempera- ture in connection with high altitudes, allowance has to be made for this fact. 120 TREATMENT OF CONSUMPTION'. I have shown that the earth has four times the capacity for absorbing heat that water has, and how in high regions, surrounded by mountains, turned up as it were, and presenting their surface to the sun, the absorption -of heat goes on very rapidly, and quickly warms the enclosed plateau. The degrees of heat are, of course ; correspondingly great and would so be felt at low altitudes, especially when laden with mois- ture ; but on a high plateau of 6,000 feet, where, in the nat- ural course of things, it ought to be cold, the higher degrees serve to cancel the one degree of Fahrenheit of reduced temperature for each 300 feet of elevation, and thus what is thermometrically great, will convey only the sensation of comfort. Then, at 6,000 feet, we have at 92 Fahr. in the shade, the sensation conveyed the same as if it was 72 minus any appreciable moisture, and plus all the beneficial effects of the intense sunlight. In winter should the thermometer indicate zero, this would be felt as if it were 20 to 25 above zero with the same addition of light and rapid warming of the earth's surface as soon as the sun rises, and its rays pass unobstructed through the rarefied atmosphere. Or, to make my meaning still plainer : For each 300 feet of increased elevation, the temperature is reduced about one degree of Fahrenheit. The heat of summer, therefore, (as indicated by the thermometer would be the same at 6,000 feet as at sea level, but for this reduction of one degree for 300 feet which at 6,000 feet is equal to twenty degrees. In winter the thing is reversed : on the one hand a low tem- perature, as indicated by the thermometer, but not by our sensations. These are largely governed by the relative amount of moisture. So we have, on the other hand, as an TERRESTRIAL FACTORS. 121 off-set to the thermometrical showing: absence of moisture, almost continued unobstructed rays of heat and light, which have to penetrate no mist before reaching us, a more than double expanse of surface absorbing the heat (by the upturned sides of mountains) and the protection against winds which these latter afford. Besides dryness and reasonable equability of temperature, high altitudes have some of the other of our ideal factors. It is necessary for you to know that a majority of our factors, though too often the less important ones, are equally as well found at localities of low and medium altitudes and of course the presence of any or all of the factors is much dependent upon local conformation, conditions and peculiarities. The difference in favor of high altitudes is, that here we find some well-defined, positive facts, common to all great ele- vations, as against qualities entirely dependent upon local condi- tions. But I desire you to keep continually in mind that what we are seeking in any and all regions or localities, where the majority of our "ideal f.ictors" exist in Nature or else are at- tainable by civilized influences, no matter whether this be at a dazzling altitude or at the bottom of the ocean. Here then we present such factors as are common to high altitudes and reserve to especial localities their own peculiar good qualities. Abundance of sunlight is more likely to be found as a uniform factor at high altitudes, than any where else. There the transparency of the air is greater on account of the air being rarefied, (thinner if you like), which of course permits of greater intensity of sunlight. 122 TREATMENT OF CONSUMPTION. The quality of the soil differs of course at high altitude stations and is by no means of a porous character in many regions. But the general conformation of high altitude re- gions is such as to favor natural drainage, on account of undulation of the surface. Variegated scenery is likewise an advantage common to most regions of high altitudes. The last but by no means least, of their common advan- tages, is the frequent changes of the electric conditions of the air. In many latitudes, as I have told you, there may be found a great variety of climates ; and not only does latitude furnish no criterion as to climates but a comparatively small piece of geography (as one State of our Union) may furnish by its peculiar conformation quite a variety of climatic conditions. " Health spots " (as we may call them) are thickly studded throughout this globe ; and our country, is as much, if not more blessed with them, than are other countries and continents. Such a locality, a health spot, may be very lim- ited in extent, not many miles broad or long and yet contain within it sufficient of the dominent factors for a beneficial climate. It is clear that if the same advantages incident to long ocean voyages or to residence in high altitudes can be had nearer home, although without sea breezes and at lower alti- tudes, there are many reasons why such spots should be pre- ferred. These reasons are : First — The greater number of consumptives come from large cities or at least from the more thickly settled states. TERRESTRIAL FACTORS. I 23 Second — Such patients are used to the thousand and one refinements of civilization, which cannot be cast aside ad libitum. Third — If absence from home and friends is a necessity, both patien and friends will be better satisfied if the distance which separates them is not that of a continent. We well know how unfavorably a depressed state of the mind will operate upon a patient. Fourth — In and near centres of civilization, food, drink, comforts of living, and good society must be recognized as generally superior to these same factors in those localities where we find high altitudes, or upon the broad expanse of the ocean. In reference to health spots more or less independent of altitude, you will find that for the presence of the factor of dryness, shelter by mountains or hills is a desideratum, which protectionshould be from the direction of the most frequently prevailing winds. A health spot, must be extensive enough, to preclude the possibility of suffering from influences of surrounding sections, differing in their climatic character- istics. At all times I wish you to remember that the strictest at- tention to details of treatment, such as are laid down in " home treatment" is equally necessary in other climes and altitudes, as it is at home. It is on account of the necessity for strict supervision, that I condemn indiscriminate camp- ing out and ranch life. Theoretically it is beautiful and romantic, but practically it is the climax of generalizing nonsense. Even at the risk of being voted a repeater by you, I wish it indelibly stamped 124 TREATMENT OF CONSUMPTION. upon your mind that each individual patient is a law unto him- self, and you are to bring your judgment to bear upon the sum total of his various complaints, independent of all other past or future cases. Given then, a majority of our ideal factors in a health- spot, near home and well regulated supervision with strict attention to detail, and the sum total will be as beneficial a combination for the phthisical patient as can be found any- where. Upon this basis are founded some of the sanitaria for consumptives in Europe, such as Falkenstein in the Tannus, Inselbad near Paderborn ; Hastings, Torquay and other localities in Great Britain. You are well aware that our country boasts of no such advantages. In Dr. Dettweiler's work on treatment of consumption in "closed institutions, " the advantages of strict supervision are thus set forth : "If all hygiodietic influences are necessary not only in general practice but in the practice of a specialty for accomplishing the highest percentage of cures, this can only be done under clinical, under institutional conditions where the physician is not only the consulting, but the ex- ecutive organ, who, by being constantly within reach, makes an uninterrupted contact possible." * " For not only the prescribing and partaking of appropriate remedies are to be considered in the treatment of phthisis ; equally if not more important, is the parrying of innumerable noxious influences, which retard or altogether prevent the healing process. Their number is legion, a clear insight into them almost a science in itself, since they lurk in every corner under a fre- * Dettweiler ; Behandlung der Lungenichwindsucht. TERRESTRIAL FACTORS. 125 quently harmless mask. The vis medicatrix naturae, the innate tendency of the organism to cancel existing noxiae is to a superlative degree operative in consumption also, and I have long had a firm impression, that a majority of patients with lung troubles die from disturbances af natural convalescence. The accidentally or consciously favorable management of these, begets the maximum of good results in health resorts as well as in sanitary institutions ; these convalescents who have successfully combated the acutest stage, from the great- est contingent of favorable cases. The study and scrupulous devotion to this part of phthisical therapeutics is of such supreme importance, that I hold this one point alone suffici- ent to prove the superiority of institutions. They alone en- able us to thoroughly grasp and comprehend the total indi- viduality of the patient, of his mistakes and weaknesses ; the sanitarium alone offers the highest guaranty of success in the position of the directing physician as acknowledged head, clothed with necessary personal authority, who can bring sufficient pressure to bear upon the execution of promulgated orders. " Chief among occurrences which require constant vigi- lence is "catching cold." This ancient and much abused element in etiology has of late reasserted its right as chief dis- turber of the peace and happiness of consumptives. The importance of guarding against repeated gastric disturbances, however small, has been pointed out to you. The consump- tives inability of adjusting himself to thermometrical changes, is manifested by repeated irritation and inflammation of the pulmonary and of the gastric mucous membranes. This weakness is the direct source of by far the greater 126 TREATMENT OF CONSUMPTION. number of relapses, as it is likewise the immediate cause of the incipiency of phthisis in previously weakened and vulner- able individuals. One of the weakest points in a consumptive of any ad- vanced stage, is his inability to resist and cancel lesser or greater changes of temperature of sudden occurrence. This lack of power of re-action differs in degree in different persons and varies even in the same individual. The old question of whether bronchitis may lead to con- sumption suggests itself here. For the solution of this ques- tion, I refer you to the first chapter, where you will find that the leading of bronchitis to consumption is a possibility, altogether dependent upon the quality or quantity of living matter, which the patient may bring to the case. But in the presence of an already existing cavity or infil- tration, a superadded bronchitis is to be looked upon as a full fledged relapse bringing in Us train the pathological products of additional pus, of cheesy foci, and rapidly developing imperfect connective tissue. Here we are not dealing with any so-called dyscrasia or new infection, but with a first-class, old-fashioned cold, caused by the inability of the patient to bring his vas- cular and nervous system into proper action at the call of a rapid thermometrical change. Whether the characteristics of a cold consists in a shifting of the individual equilibrium, so that in a given case the local withdrawal of warmth comes to be recognized too late by sensory centres (as advocated by Jaeger) ; or whether the same is due to a paretic or paralytic condition of the vaso- motor apparatus of the skin capillaries, is a question which we cannot as yet answer, though we may reasonably suppose TERRESTRIAL FACTORS. \2J one or both causes to exist. We see the manifestations of these deficiencies daily in catarrh of the nose, larynx and bronchial tubes. It would be a boon to consumptives who must be ban- ished from home in order to have a chance at recovery, if the locality selected for them on account of its dryness and other desirable factors, were blessed with a well-regulated in- stitution or sanitarium so-called. Unfortunately the most favored localities and regions as to climate are such as are more or less far removed from the centres of civilization. Hence that all important factor, proper food, is wanting, if not in quantity, in such quality as the patient from a civil- ized country is accustomed to. This is partly the case in the Peruvian Andes, perhaps the most ideal health region thus far known. Even in our own country and Europe the same unfavorable conditions prevail in some choice localities as to food, drink, society and comforts of life in general. Where reasonably good hotels or farm houses, furnishing milk, eggs, and other animal and vegetable products exist, the circumstances are of course more favorable, but still the patient is entirely too frequently left to exercise his own judgment, especially as regards feeding and exercise. His existence is often a continuation of insults to his pulmonary and gastric mucous membranes and a string of relapses in con- sequence. The benefits of a well-regulated sanitarium, as regards the prevention of the above evils and the constant supervision by a skillful physician, cannot be over-estimated. If we are to base our treatment upon individualization and strict at- 128 TREATMENT OF CONSUMPTION". tention to detail, as insisted upon by me, this is naturally best accomplished in a well regulated institution. Still I will not plead for sanitaria as an absolute necessity, since I am aware that outside of them great successes are likewise recorded, as witness Dr. J, H. Bennett's treatment of cases at Mentone in winter time.* Nor is it necessary to dwell upon the advantages and dis- advantages of treating a number of patients under the same roof. Any intelligent physician can reason them out for himself. All I will say is that of disadvantages, possibility of infection is not one ; a subject which we need not here enlarge upon. It suffices to say that the evidence of Dr. Williams, of the Brompton Hospital for Consumptives, of the Goerbersdorf and Falkenstein institutions in Germany, is against that assumption. It was my intention to dwell at length upon a number of institutions in Europe, where consumptives are treated. But partly because I find that this would form a little volume in itself, and partly because of my conviction that the United States (as also Mexico and South America) have a greater variety of suitable climates spread over a more extended area than any in Europe, you must be content with my naming a few. In Germany : Goerbersdorf in Silesia at an elevation of 1700 feet. This was the first sanitarium ever started : was opened in 1854 by Dr. Brehmer. In addition to the open air and climbing treatment, the local douche is used there systematically and to great advantage. Falkenstein — in the Tannus range of mountains, Dr. * Bennett, J. H. — Pulmonary Consumption — 1879. TERRESTRIAL FACTORS. I 20 Dettweiler is director in full charge. In addition to the Goerbersdorf method, great care is given to food and other details in general. Inselbad near Paderborn in Westphalia is in charge of Dr. Bruegelmann. Chief reliance is placed there upon inhalations, in addition to tonic treatment. Inhalation of nitrogen gas in closed chambers is practised. Aussee in Styria, is the location of Dr. Schreiber's sanita- rium, which is in a very sheltered position. In England : Brompton Hospital for Consumption and diseases of the chest. This is the institution with which Dr. Chas. T. Williams is connected. He and his colleagues send patients partly to distant climes, but largely to Hastings, Torquay, Ventuor, Bouraemouth and other places on the coast of England, the benefits of which change are largely climatic. Here mention must be made of the treatment pursued by some French physicians and largely sanctioned by the pro- fession in France. This is their faith in the efficacy of mineral springs in the ewe of consumption. At Eaux Bonnes in the Pyrennees, 2300 feet high, the chief reliance is placed upon saline springs containing sul- phur. Mont Dore in the central part of France is 3400 feet above the sea, has muriated alkaline springs, both warm and cold — Pure air and comparative dryness are probably the chief factors. It behooves me to mention however that the late Dr. Niemeyer endorsed muriated alkaline waters in various phases of phthisis ; though he probably had in mind their Power of assisting the weakened organs of assimilation. I30 TREATMENT OF CONSUMPTION. The above are not all of the institutions of this kind in Europe, but they are the principal ones where pulmonary phthisis may be said to be treated as a specialty. In other resorts, which we will now mention, other diseases are like- wise treated and there is no organized plan upon which con- sumptives are treated. They are mostly at greater or lesser elevations : Kainzenbad 2480 feet high in the Bavarian Alps. In Switzerland, the most noted place is Davos, lying in a valley at an elevation of 5200 feet. It is well protected from chilly winds by towering mountains and there is, on the whole, an abundance of sunshine. We may put Davos down among the cold, dry climates. Next come the villages of the Upper Eugadine of which St. Moritz (6000 feet high) is the chief representative. It has Spas and so-called sanitaria ; the comforts of life are said to be attainable. Cold, moderately moist, and not enough sunshine. Of other stations, which were visited and examined by Dr. J. H. Bennett, he mentions Morgins as the best (4500 feet) as combining cool mountain air with a strong chaly- beate spring. The above are only a small portion of the health spots in Europe. In England, Spain, France, Italy, Germany, Austria, and especially in Switzerland, there are a great number of additional health spots, where partial sanitaria (Kur-Haus, in German) advantages of altitude, mineral springs or fine scenery, or all four are the attractions. A number can lay claim to be able to stand the test of the requisite factors of dryness and equability. Climates fit for the cure or arrest of pulmonary cavities TERRESTRIAL FACTORS. 131 and infiltrations have partly been tried and statistically proven to be of benefit ; in part are now undergoing probation, and again there- are such as are entirely unknown climatically, though not geographically. The latter are favored sections and localities in Africa, Asia and South America as good as totally unknown. That other climates are still under pro- bation is owing to two facts : First — The even now sparsely settled condition of this globe of ours ; and Second — The newness of the investigations in regard to suitable climate. The climatic conditions of regions and stations, which thus far have not had time sufficiently to collect statistical results, should be measured by their ap- proximation to the factors of an ideal climate. Practically, climates are to be considered as to their average temperature and their relative humidity, the two chief factors. Thus we will speak in general, terms of climates being cold, cool, warm or hot, and dry, moderately moist, moist, or very moist. A short abstract of all foreign climatic stations, outside of North America, will first be given. The climatic health resorts of our own continent will be dwelled upon somewhat more fully. IN EUROPE. Eastern portion of the British Channel : Hastings, Tor- quay Ventuor, Bornemouth - cool, moderately moist. Malaga and portion of S. E. coast of Spain — warm and tol- erably dry. 1^2 TREATMENT OF CONSUMPTION. The so called Riviera including the ) i towns of Hyeres, Cannes, Nice, Mentone, [ Cool and dry. San Remo. J Islands in the Mediterranean : Malta ] ^ r ^ „ . i Warm, mod- Sicily (Palermo), Corfu, Cyprus, Corsica \ i erately moist. (Ajaccio). Mountains of Switzerland ] Davos The lower Eugadine j Cold The upper Eugadine (St. Moritz Maria, j. and Samoden) dry Weissenberg Morgins Mountain altitudes in Austria : Meran in Tyrol Aussee in Styria. IN. ASIA. Hill stations in India : Nilgiri range of ) Cool and mod- mountains \ erately moist. Pulney hills. Sandour and other sta- j tions at the base of the Himalaya moun- \ Cold and dry. tains. Parts of Siberia in the Ural. J IN AFRICA. Ttingiers — Cool and dry. Algiers — Warm and moderately moist. Mogador in Morocco. Egypt — Hot and dry. Cape of Good Hope — Warm, moderately moist. Natal — Warm and dry. TERRESTRIAL FACTORS. 1 33 IN POLYNESIA. Van Diemen's Land ) Cool and New Zealand \ moist. Of some of the strictly insular climates in various lati- tudes, a few words should be said. I refer to Madeira, the Sandwich Islands, the Bermudas and the West Indies. If they are singled out from a great number- of islands and island groups, it is because they have been, since time memorial, the Mecca of all patients sent to or seeking of their own accord a so-called " mild climate." In reality they act sedatively, the temporary effects being alleviation of irritation and con- sequent diminution of cough and a deceptive increase in weight, which bears no relation whatever to the excavation or consilidation in the lung. The climate of the Island of Madeira is a warm, very moist one, with all the sedative influences followed by the enervating ones. Nothing of the bracing influences of the sea-air manifest themselves here, nor upon the other islands I am about to mention. The mean temperature in winter is 6o° 6 Fahr. , the rainfall quite great. Of all the results which have been published about Madeira I find no posi- tive evidence of any cures and a shockingly small percentage of " improved." The largest is that of patients sent from Brompton Hos- pital, some 53 per cent, of all kinds of " improved" The West Indies are in most respects quite similar to Madeira, except that their winter temperature averages higher. A good word may be said for Cuba and Jamaica. In these islands we have that type of marine climate with some of the bracing influences of salt-air ; that is in the more elevated, I34 TREATMENT OF CONSUMPTION. hilly portions of them. The average winter temperature is 64 degrees. Nassau, the principal town of the Bahama Islands, has however been the beau-ideal of mild climates. Everything of a disadvantageous character appertaining to such climates is true of Nassau. The statistics so far as available, of con- sumptives seeking" relief there are beyond criticism. True, the monthly range is small in winter (from 9 to i8 c ), but the monthly mean, also in winter, lies between 76 and 79 . A truly tropical climate, with neither the benefits attached to salt-air, nor the advantages of elevation due to local confor- mation. The Bermuda Islands are some 600 miles from the nearest land, from North Carolina, in latitude 30 ° W. What has been said of Madeira applies here, save that the comforts of life, food and society are better, the residents of the chief place, Hamilton, being English. The islands themselves are numberless, but 20 of them are inhabited. In the win- ter months, the mean temperature is sixty degrees ; in summer rarely above 85 . As you know, the Gulf stream flows be- tween these islands and the American coast. Hotel accommo- dations and society are good. The possibility of a change to the mountains in summer, would make the climate of these islands one of the most desirable ; but here the absence of the artificial factors and extreme isolation act as a preventa- tive. The Sandwich Islands deserve separate mention for the additional reason that they actually possess all of the virtues centered in our ideal factor, except sufficient elevation above sea-level. Equably cool and dry is what we can say of one TERRESTRIAL FACTORS. 135 part of the islands. For they have two climates. On one side it is quite dry, on the other almost constantly wet. The northern and eastern portions of the islands receive the full force of the constant trade-winds, cold and moisture is depos- ited, leaving the other side dry. In the dry region it does not rain more than a couple of times in the year. The warmest days in summer do not exceed the warmest days in winter by eight degrees. Mean annual temperature about seventy-five degrees. The continent of South America deserves separate consid- eration, if for no other reason, than for having within its borders certain sections of country where a close approxima- tion to an ideal climate for consumptives is reached. I have reference to the ranges of the Andes (Cordillera de los Andes) with their trend from north to south, extending from io° N. latitude to 45 S. latitude. These mountains do not occupy a far inland position, but may be said to run quite close to the Pacific coast. Here we find in many localities at high elevation an equably cool and dry climate, with all the advantages of salt-air without moisture from the ocean, and of high altitude with its advantages to the functional action, followed by organic changes of the heart, The explanation for this happy combination of factors is : — First — In great part the Andes consist of two chains of mountains running from north to south, with plateaux sep- arating the two ranges. Moisture from the ocean does not reach these plateaux, nor the west side of the second range. Hence dryness. Second — Such moisture as exists on the west coast, 136 TREATMENT OF CONSUMPTION. serves to equalize the temperature by preventing rapid radia- tion. Hence a certain equability of temperature. Third — High altitude, which on the one hand, increases the chances of dryness, as you know, and on the other adds to coolness of the atmosphere, which otherwise under the equator would be very hot indeed. Fourth — The drainage of the Andes, is nearly wholly carried down the eastern side, forming- the great rivers Ama- zon, La Plata and others. Thus ' rapid drainage, freedom from these bodies of water as sources of moisture are ad- ditional reasons for dryness. Fifth — These several conditions : the double chain of mountains with plateaux between, high altitudes in conform- ity with the proximity to the equator, the latitude of the An- des, begets local conformations so varied, as to insure every variety of climate. Many stations therefore can be found where protection from stormy winds is had. Sixth — The great extent of these elevated plains has caused the building thereon of cities and towns, in fact many of the principal ones ; thus insuring many of the comforts of life. Factors of disadvantage for Americans are : The great distance from home and comparative inacces- sibility of the stations as yet. Strangeness of social conditions and language. Difference in the character of the food. So much for the benefits and disadvantages of this most favored climate. I will give a short sketch of a number of stations, for the material of which I am indebted in part to the politeness of a Peruvian gentleman now residing in this TERRESTRIAL FACTORS. I 37 city ; in part to extracts from Dr. Williams work on climatic influences. The capitals of three of the states are suitable places as sanitaria. Quito, capital of Equador, at an elevation of 9451 feet, with about 8o,oco inhabitants. Mean annnal temperature : 60 degrees, which is also the mean of the sea- sons ; no annual range to speak of. La Paz, the capital of Bolivia, at 13,325 feet, dry but rather cold. Santa Fe di Bogota, capital of New Granada, 8,648 feet high, with 40,000 inhabitants, is situated on a plain 60 miles in length. Here the mean annual temperature is 59 degrees with an annual range of one degree, thus capping the climax of equability and coolness. Both Quito and Bogota I am told, are reasonably acces- sible and well provided with all the comforts of life. Peru is even more fortunate in the number of its health stations for consumptives, though they are not always so ac- cessible. The late war with Chili has prostrated and crippled Peru for many years to come. Still we may hope that under the new order of things, the extension of railroads already existing will improve accessibility to these favored regions. Tarma and Jauja are said to be the most favored of all stations, on the evidence of Dr. Archibald Smith, Dr. C. T. Williams and of two private gentlemen of my acquaintance. The late government of Peru had a sanitarium for military consumptives at Jauja. From what I can gather, however, of meteorological data as regards equability of temperature, I am inclined to regard Quito and Bogota as superior. The thermometer at Jauja 138 TREATMENT OF CONSUMPTION. sometimes falls to 28 degrees and seldom above 57 Fahr. Rapid drainage to the east occurs. But the prevailing winds are sometimes powerful and of great velocity. ■ Jauja is on a plateaux, separating the two chains of the Andes. Tarma is some twenty miles north-west of Jauja, at an elevation of 10,028 feet. The climate is equally as variable as at Jauja. Other populous towns and villages exist in the lofty pla- teaux known as the Montana, which in time will be rendered accessible. Their average elevation is about 12,000 feet above sea-level. The republic of Mexico is a country, whose climate much is to be expected of in certain elevated parts, as soon as modern civilization shall have gained a surer foothold there. For it is one of those countries, where proximity to the ocean and local conformations beget a great variety of climate. The climate of Mexico is essentially a tropical one. We are therefore compelled to pass by its tropical heat and sea-moisture at sea-level and on the general surface, and look to altitude for the proper combinations for an appropriate climate. And being in great part in the neighborhood of the equator, the altitudes to be looked for must be high ones. Among them we have equable coolness and only moder- ate moisture, with all the bracing influences of salt-air. But save in the large cities, accessible by rail-roads, all the artificial factors are wanting. The same system of mountains, which are called Rocky Mountains in our country and Cordillera de los Andes in TERRESTRIAL FACTORS. 1 39 South America, traverse Mexico. Six hours ride from the port of Vera Cruz is Orizaba in the Sierra Madre range, four thousand feet high. At this elevation the climate is equable all the year round and no yellow fever occurs there. The air is not so rarefied as it is on the higher plateaux of Mexico ; hence it is a good place for patients to gradually accommo- date their heart's action to elevation. Almost enclosed by lofty peaks, on an extensive plateau of from six thousand to eight thousand feet high west of the Sierra Madre, lies the old City of Mexico. While nearly all of our artificial factors are here at hand, in connection with those of nature, I am informed that on account of the char- acter of the surrounding lower country and some local pecu- liarities, the city is not a very desirable one for consumptives. Mexico is seven thousand five hundred feet above sea level. Puebla lies south-east of Mexico at about the same eleva- tion. It is a well preserved, well built and clean city. Cholula is three leagues distant from Puebla. Cordova is at an elevation of two thousand seven hundred and fifteen feet. ■ In the northern part of Mexico, in the state of Chihua- hua, bordering on our New Mexico and western Texas, are to be found some of the same favorable attributes, which obtain in the Mesilla Valley and Western Texas. Among the foot hills and upland plateaux, lying between part of the Sierra Madre and the Sierra de los Mimbres, we have a variety of altitudes and various degrees of dryness. Especially worthy of mention, is the North-east corner of Chihuahua bordering on the Rio Grande. Favorable results have been attained in these high table lands of which the town of El Paso is the centre. 140 TREATMENT OF CONSUMPTION. STATIONS IN THE UNITED STATES. We come now to the enumeration of stations on this continent and here it is desirable to go into detail as much as possible, as regards each individual region or health-spot. I must premise however, upon which reasonable deductions might be made in regard to such climates which can shew the needful ideal factors. To avoid cumbersome detail I will give climatic attributes in short sketches, reserving for a future publication (at which I am now at work) an ex- tended account of every desirable region. A good general view of the subject is to be found in Wal- tons ' ' A comparison of the European and American climatic Resorts," (Philadelphia, 1877), a portion of which is here given unabridged. "On a general view of the temperature chart, one is like- ly to be impressed with the fact that the European resorts are much more equable than the American. Whilst the mean monthly ranges of the most popular European winter stations lie between eight and eighteen degrees, those of the American resorts fall between twenty-three and forty degrees, with one exception, that of Nassau, Bahamas, which ranges between nine and seventeen degrees. This we would expect to be the case, as it is well known that the whole North American continent is subject to extreme fluctuations in temperature, which are unknown in Western Europe. The cause is not far to seek. The trend of the mountain ranges throughout this country is from North to South in parallel lines, forming broad avenues, up and down which the winds sweep in unimpeded course from the equator to the pole ; whilst in Europe the mountains lie east and west in frown- TERRESTRIAL FACTORS. 14 1 ing battlements, which roll back the fierce north winds on the plains of Germany and France, or toss them high in the heavens, to be lost amidst the warm winds from the great desert, leaving the winter stations, which nestle on the north shores of the Mediterranean untouched by their frigid breath. Another influence tending to equalize the temperature Or the European resorts is the most land-locked Mediterranean sea, upon the coasts of which the European stations mostly lie. The effect of the evaporation of such a vast volume of water in absorbing latent heat on the surrounding shores — need only be mentioned. The Gulf of Mexico, on our coasts, does not compare with the Mediterranean in this re- gard, for the current of its warm waters flows directly away from our coasts across the Atlantic ; and the western winds, which, according to Blodget, prevail there during the winter months, sweep much of the beneficial effects of its moisture- laden air far out to sea. "When we direct our attention to the rainfall, we per- ceive that the European stations are much more subject to rain than those of our own country. The majority of the stations in this country average between one and two inches per month, whilst those of Europe range from two to four inches per month. However, we are not to conclude from this that the humidity of the air at European resorts is greater than at the American ; for it is a well known fact that the atmosphere may be heavily laden with moisture, and yet little precipitation occur. Neither should we conclude that a considerable precipitation indicates a great deal of cloudy weather, as in tropical showers a large amount of rain may fall in a few hours. For this reason a chart or table 142 TREATMENT OF CONSUMPTION. showing the average number of rainy days for each month is desirable ; but the facts necessary to construct such a chart are not obtainable." In the enumeration of the various stations and their ad- vantages, there is no need of division into insular and conti- nental climates, of sea-shore or mountain altitudes, since that will appear from geographical location. Of the climatic advantages of our continent in general, and of the United States in particular, there are a few general points, which I wish to impress upon your mind as founda- tions upon which to build. First — You have been told that sea-air and mountain air at high altitudes furnish a pure, aseptic air, an atmosphere relatively free from infectious germs. Second — Our country has an extensive sea-coast with both favorable and unfavorable relations to that warming agent, the Gulf stream. The trend of our mountain ranges is chiefly from North to South. Third — Both sea and mountain air can furnish the ideal factors of coolness and dryness, or an approach thereto. The choice of such localities is largely governed by the fre- quency and velocity of prevailing winds, bringing with them as they do the rapid thermometrical changes (so hurtful to consumptives) and moisture ; thus tending to destroy equa- bility of temperature on the one hand, and dryness on the other. Fourth — Theoretically then, we would find dryness coupled to a certain equability of temperature upon this con- tinent chiefly in three kinds of places, in accordance with the physical geography. TERRESTRIAL FACTORS. I43 First — Stations near or still within reach of the bracing influences of salt-air, but sheltered and partly surrounded by mountains ; stations where the prevailing winds are not car- riers of a moist atmosphere, but blow sea- ward. Secondly — Stations situated between two separate chains of the same range of mountains, where one chain receives the deposit of moisture from the ocean. But as the trend of our mountain ranges is from North to South, some spur of mountain continuity should be so placed across the regular range, as to keep off north and north-west winds. And so it is with — Thirdly — High mountain plateaux, whose far inland position render them free from any suspicion of ocean mois- ture and where elevation and rarefied atmosphere take the place of the salt air in the matter of insuring a pure unadul- terated air. Here also, the probability of equable coolness is rendered more certain by a spur of foot hills thrown across the range as it were, for protection against North and North- west winds. The above is a theoretical general basis. Now let us see what we know of health resorts thus far. (It is necessary here to repeat that the bulk of this work will not allow of giving local statistics, which I have at my command, nor of giving vent to my individual belief in the efficacy of a partic- ular locality in the mere enumeration. Both points are reserved for a future publication). On the Atlantic coast from Maine down, I know of no locality which has received a trial. The first we reach from above downward, so to speak, is The Adirondack Mountains, in the Northern part of New 144 TREATMENT OF CONSUMPTION. York. To a certain portion of them, known as the St. Regis region, Prof. Loomis and others have sent patients for some years past. The results in arrest of phthisis have been quite satisfactory. A few total cures have been effected. The climate in that region may be set down as equably cool and moderately moist. In the summer, minimum and maximum temperatures are about 50 to 70 degrees : the winters are equably cold. The altitude of the St. Regis region is about one thousand seven hundred feet above sea-level. The Ramapo Valley at the foot of the Ramapo Mountains in New York, about thirty miles from the City of New York. The New York, Lake Erie and Western Railroad have a station there, called Sufferins, which is protected to the west, north and east by the mountains. The thermal variations in winter are small. We may set the station down as dry and cold. In New Jersey several stations in and about the Orange Mountains have obtained quite a repute. I find upon careful inquiry that superficial catarrhal conditions and general breakdowns do well there. Their best feature is shelter from frequent and strong winds, preventing in a measure those sudden changes to which consumptives so illy adapt them- selves. Pennsylvania contains the largest portion of the Alle- ghany Mountains. It is wonderful how little is known of the many localities which exist in the Alleghany Mountains, passing as they do through the greater portion of the width of the States of Pennsylvania and Virginia, and sending side ranges and TERRESTRIAL FACTORS. I45 spurs into West Virginia, North Carolina and Tennessee. No trials worth recording have been made to locate suitable stations for phthisical subjects. Two distinct mountain chains belonging to the same mountain system, traverse the State of Virginia: The Blue Ridge in the eastern part, the Alleghanies west of these. Theoretically it would seem as if the Blue Ridge should catch the moisture of the ocean and thus render the eastern slope of the Alleghanies dry; practically no specified treat- ment for consumptives has been initiated, and no statistics exist for this region. In Virginia certain localities in the Alleghanies are popu- lated and resorted to, which contain the various mineral springs. Something of the specific treatment system is car- ried on there with these waters, as it is in France, only not upon an organized plan. Red Sulphur Springs is worth mentioning, as possessing therapeutical action not often met with. It is claimed that these waters exert a direct action upon the innervation of the heart and reducing its action; while their sedative effect allays irritation of the pulmonary and gastric mucous membranes. These effects must be due to a very delicate and volatile chemical composition. In its decomposition ammonia is formed and hydro-sulphuric acid is liberated; or, if heat be employed in the experiment, sulphur is separated. In the middle and western portion of North Carolina we find the Blue Ridge Mountains, and in its range various stations which, as regards climatic factors, may be denomi- nated as cold and dry. The mean in winter is about 43 °, in summer 75 ° Fahr. I46 TREATMENT OF CONSUMPTION. Asheville, in a valley near the French Broad River, at the southern extremity of the Appalachian chain, was until recently the location of the " Mountain Sanitarium for Con- sumptives," conducted by Dr. J. W. Gleitsmann, now of New York. Elevation: 2,250 feet. Dr. G. tells me that the average relative humidity is 69 per cent, at Asheville, which would not entitle that station to be placed under the head of dry, but rather of moderately moist and cool. " The temperature in winter rises during mid-day, with few exceptions, to 50 and over, and in shel- tered places with southern exposure, where patients congre- gate, to 70 and 8o Q in the sun. The greater number of days in winter have clear and bright sunshine, and insolation being notoriously more powerful in the highlands than in the lowlands, makes out- door life all the more pleasant."* Coming to South Carolina, we reach the border of the warm Southern climes, which are so objectionable in my eyes for two reasons: First — The mean summer temperature is too high (75° to 85 °), whatever the annual mean; thus making felt the de- bilitating and enervating influences of a hot climate. The results attained in the treatment of consumptives is one of the chief points in evidence against hot and dry, as against cool or even cold and dry climates. Second— The malarial influences prevailing over the lower and moister region of these States, which influences^ are in a great measure carried to higher altitudes also, on the wings of the wind. ♦Biennial Report of the Mountain Sanitarium for Pulmonary Diseases, Ashe- ville, N. C, by Dr. W. Gleitsmann. TERRESTRIAL FACTORS. I47 However, the Blue Ridge Mountains with the sandy soil of the elevated portions of the State towards the north and west, are dry and porous. Two other factors in their favor are the presence of pine trees, adding to the air being fit to breathe, and a variety of scenery. Aiken occupies a high sandy ridge near the Savannah River. In equability of temperature and comparative dry- ness, it has been held by Walton to be more nearly similar to the Riviera on the Mediterranean than any other resort on our continent. The annual mean temperature is sixty- five degrees, which mean is begotten from a summer tem- perature too high for the ideal, and classes Aiken among the hot and comparatively dry. The town of Spartanburg is in a region where the air is cooler; a nearer approach to the ideal than at Aiken. So is Greenville (160 miles from Char- leston); the trouble is that at the latter places the comforts of life are not as attainable as at Aiken. All that has been said pro and contra about mild Southern climates in a previous chapter, applies to Florida as a health resort and I refer you to that chapter. Of elevations there are none in Florida, save near the boundary of Georgia, and even there the greatest altitude is three hundred feet. Too hot and moist is the correct verdict, for which equability and mildness are no compensation. The equability moreover is in summer, when 92 are reached and adhered to. In winter 31° is the lowest. Of beneficial factors of several stations I must mention : freedom from sudden thermal changes, a reasonable amount of sunshine, porous sandy soil, presence of pine forests and fresh tropical fruit. I re- peat however, as in a preceding chapter, that the only suit- 148 TREATMENT OF CONSUMPTION". able cases are superficial catarrhs of limited standing and remnants of pneumonic processes in constitutions hereditarily healthy, but below par from the effects of the lingering acute trouble. And for such cases even, Florida is fit in the winter months only. Localities favorably mentioned are Magnolia on St. John river ; Jacksonville and Pilatka. Georgia is a state much less known than others climati- cally, and yet it is within its borders that I firmly believe a close approach to the ideal climate for consumptives can be found in more than one especial locality. For in addition to geographical location in general, as affecting the mean temperature, there are elevated plateaus, sheltered in direc- tions which render them safe from such winds, as carry moisture, and such as produce sudden changes of tempera- ture. The mean temperature in the central and northern part of the state is 50 in winter, and about 75 in summer. The latter is rather a high one for the mean of a season, but it does not apply to all localities. Another factor is the presence of extensive pine woods, extending along the east- ern and middle portions of the state from one end to the other. That consumptives derive benefit from an air charged with the odors of pine trees is not to be denied and is owing to two causes : Firstly, the terebinthine odors exercise an effect inimical to the development of the lower forms of animal and veget- able life — thus rendering the air relatively pure and antiseptic. Secondly, as stated in a previous chapter, continuous respiration in an antiseptic atmosphere may yet lead to re- sults hitherto unattained. The odorous part of the pinus TERRESTRIAL FACTORS. 149 palusties and other varieties, is the resin turpentine and the volatile oil therein contained. We know how valuable oil of turpentine is as an allayer of irritation of the pulmonary mucous membrane, besides being an arterial stimulant of the first order. Atlanta appears to me to be a suitable place; or still more so the village of Marietta, near the Kenesaw moun- tains, not tar from Atlanta by rail, and 1,132 feet above sea- level. At Atlanta the annual mean temperature is 6i°. The winter mean is 45 , and the summer 75 . Mean relative humidity about 56 per cent. Rainfall 4 inches. Augusta, the capital of Georgia, and Athens are clean and beautiful cities, where the comforts of life are attainable. Among the sand hills, zy 2 miles from Augusta, in the extreme eastern part of middle Georgia, stands the town of Summerville, a few miles from Augusta. I make this extract from the " Hilly Pine Region of Georgia and South Carolina," by Dr. S. E. Habershaw: " This plateau is, properly speaking, the true summit of the hills in the State, being the highest point attained by it. * * * The gradual slope of the plateau to the south and east, the sandy nature of the soil, with the pine and oak growth (black jack), make it extremely dry and well adapted for those pulmonary sufferers who require a very dry climate and low dew-point. " A letter in the same pamphlet from Dr. L. A. Dugas, contains this passage: "This favored belt commences at the primitive region, where the rivers of the Atlantic Slope tumble over the last ledges of granite rock, that is to say, at Augusta, Milledge- ville, Macon and Columbus — and varies from 30 to 60 miles in width below the shoals." I50 TREATMENT OF CONSUMPTION. At Summerville the mean annual temperature is 64°, with a range of 34 (minimum of 46°, maximum of 8o Q , evenly distributed throughout the year. Number of clear days, 238. Northern Georgia is about 1,100 feet above sea-level. It is chiefly in the Kenesaw mountains, at a moderate eleva- tion, that I look for some of the future ideal resorts, which shall be classed among the cool, dry and balsamic. Next to, and on a par with northern Georgia, the eastern portion of Tennessee claims our attention. In eastern Tennessee, at an average elevation of 2,000 feet above sea-level, are what are called the Cumberland Table Lands, extensive plateaux in the mountains of the same name. I have before me an essay by Dr. C. M. Wright, of Chattanooga, "A People without Consumption" demon- strating that upon a certain portion of these table lands, known as Walden's Ridge, consumption is not an indigenous disease among the inhabitants. The climate permits them to spend most of their time in the open air. As far as my present information goes, the climate of the elevated plain is equably cool and tolerably dry. As might be expected, none of our chief factors for an ideal climate are found in the States bordering on the Mis- sissippi River, in the so-called Mississippi Valley. But far up in the north, at such distance from either ocean as to in- sure absence of moisture from that quarter, and at a respect- able elevation, in parts at least, we find the State of Minne- sota. Here we have a true example of the cold and dry cli- mate. The objections to a climate where the mean temper- ature is low have been stated. It is absolutely necessary TERRESTRIAL FACTORS 151 that consumptives should be able to be out in the open air a greater part of the time. In cold climates, however dry, this requires a certain amount of bodily vigor, which again implies a reasonable stock of vitality and capacity for resist- ance and reaction. The advantages which [Minnesota has to present are : far inland position ; general elevation of one thousand feet above the level of the sea, and in the north- western portion of 1,450, feet ; and an abundance of pine forests. The mean annual temperature is about 44 degrees ; the diurnal variations are quite small. There are no sudden changes of temperature, the annual range of some 54 degrees being evenly distributed throughout the year. I will here state that thus far the statistics of [Minnesota as a sanitarium are very unfavorable. One cure in fifteen. Of course this is due to many circumstances, relating partly to the patients themselves, in part to the absence of our minor factors. Of places more sheltered than others, I name St. Paul, Red Wing and the Hassan Valley. From the sources of the Father of Rivers we turn our attention to the region west of its mouth, the State of Texas. The western part of Texas, bordering on the Rio Grande, is a region of moderate altitude of from 1,500 to 2,500 feet. Here the climate is warm and dry. Upon this elevated plateau stand the German towns of Boerne, on the beautiful Comal River, and Fredericksburg. The comforts of life, the purest of water and variegated scenery are to be found in this region. Perhaps the best feature of this section is its un- doubted equability of temperature. Another little para- dise is Kerrville, not far from the above, in the Upper Guadaloupe Valley. I52 TREATMENT OF CONSUMPTION. Thus far we have had to deal with regions where either sea air or moderate elevations with or without the influence of salt water air ; or, with the same, enjoying the additional advan- tages of an air continuously impregnated Avith the odors of pine forests. We now come to a climate purely and strictly representa- . tive of the benefits of mountain air, independent of salt-air, mostly of great altitude, as compared to what we have seen, and dry from the fact of its great distance from either ocean alone, aside from other factors. The Rocky Mountains traverse the States of Wyoming, Colorado, New Mexico and send spurs into Arizona. They are over 100 miles across and contain among their foot hills and the approaches to them, among their elevated plateaux in the mountains proper, as well as on their eastern and western slope, all imaginable climates so far as temperature is concerned. In order to be systematic, we will consider in turn : First — The relations which form an approach to the mountains from the east. Second — The eastern slope of the Rocky Mountains and the stations among its foot hills. Third — The plateaux and natural basins at the top of the general range. Fourth — The Western slope. The whole vast plains from the Missouri river to the foot of the Rocky Mountains is not, as was once supposed, and as it certainly looks to be, a dead level. There is a gradual and even rise, until at the foot of the mountains an altitude of 4,000 feet has been reached. The whole western half of the TERRESTRIAL FACTORS. irq State of Kansas and Eastern third of Colorado are representa- tive of this gradually rising enormous plateau at a general elevation of from 1 500 to 4000 feet. Let us apply the test of our factors to this region: Dry- ness is secured ; not relative, but almost absolute dryness, so far as moisture from any large body of water is concerned. Distance from the great seas insures that. The mean annual temperature in Western Kansas may be set down as49°, and with a moderate range throughout the year. But this range is not evenly distributed through- out the twelve months, but is the result of great diurnal changes, and these again are in great part due to winds of great frequency and still greater velocity. This latter feature alone almost counterbalances the presence of other bene- ficial factors, for the reason that in summer this air is wretchedly hot, caused by the free and unobstructed radia- tion of heat from these naked prairies; and in localities it carries with it dust in unlimited quantities. No moun- tainous shelter breaking the force of the winds, they have it all their own way as regards velocity. In cool and cold weather, as you know, sudden changes cannot be counter- balanced by the average patient ; and you likewise know that velocity of wind has a great deal to do with too rapid with- drawal of warmth from the body. On the whole then, considering the beneficial factors present as against those absent, I will say consumptives may with advantage to themselves seek one of the more populous towns (of Western Kansas for instance) for such length of time as will be required to strengthen and lessen the rapidity of the heart's action ; this time should not be above a limited I54 TREATMENT OF CONSUMPTION. number of weeks, and not be in the middle of either the hottest summer or coldest winter season. I mention " populous towns" advisedly, because on the one hand the comforts of life (food, society, medical attention) can only be had there, and on the other no variegated sceneiy need be looked for in the country, either in the shape of woods or water. Again, the former style of traveling by slow approaches in wagons or on horseback might be reviewed ; but it involves the absence of many important minor factors, so that, save in exceptional cases, I do not think well of it. Of more or less populous towns on these elevated plains, I would mention : Abilene and Wallace, on the Kansas Pacific Railroad ; Dodge City and Emporia, Kansas, and Las Animas, Col. , on the Atchison, Topeka and Santa Fe Railroad. Second — The Eastern slope, in which we include : The towns at the base of the mountains, the foot hills with their enclosed parks of lesser dimensions up to an average altitude of 6,000 feet, and the towns among the foot-hills. Foot hills in this instance must not be confounded with hills in other parts of the country, where they would be rated as high mountains. You must remember that the valleys and table-lands among the foot-hills are as high as ordinary mountains elsewhere. For much that might be said of the eastern slope of the Rocky Mountains, the highest general altitudes, as well as of the western slope, I refer you to the chapter on high altitudes for a synopsis of general characteristics and of beneficial effects of mountain air in general. Our concern is therefore in the first place to apply the test of the greater and lesser TERRESTRIAL FACTORS. 155 ideal factors to each region, and in the second place to name a number of stations known to possess certain advantages, as well as such as are likely to possess them in the future. Dryness on the eastern slope of the Rocky Mountains is, practically speaking, almost absolute. This greatest of fac- tors is its chief recommendation, and its importance cannot be over-estimated. The reason of this dryness results from its physical geography, and is two-fold : First — Absolute inland position ; such distance from any great body of water, as is not equalled by any region upon any continent upon this globe. Second— Any moisture from the Pacific or the country west of the Rocky Mountains is cooled and condensed as the air crawls up on the western slope, thus leaving the eastern slope dry. As regards equability of temperature, this cannot be said to exist to any satisfactory extent. The annual mean of elevated stations on the eastern slope is about 47 , and cer- tainly not above 49 (49. 2 at Santa Fe, N. M.), while the annual range is about 119 degrees. If, as I have told you, we apply the rule that every 375 feet of elevation brings with it a decrease of temperature of one degree, we can readily understand the occurrence of low temperatures. But apply- ing the rule to our sensations, we approximate the truth when we add one degree for every 300 feet of elevation above sea-level. At the freezing point, therefore (32 ), our sensations would be on a par with 52 degrees. The great annual range would indicate a high thermometrical reading in summer ; this is the fact, and the reason thereof is also two-fold : I56 TREATMENT OF CONSUMPTION. First — There is no moisture to intercept the sun's rays, which pass unobstructed without losing any of their power. Second — The greater the surface presented, the more heat can be absorbed, and this condition is present in the shape of the numerous upturned sides of the mountains, presenting a greatly increased surface for radiation of the absorbed heat. A temperature of from 88° to 92° ought to be felt severely ; but we apply again the rule of one degree of cold (or reduc- tion of temperature) for every 375 feet of elevation, which would make 92 ° convey the sensation of 72 ° at sea-level. The higher degrees serve only to cancel the one degree of lowering for every 300 feet of elevation, and thus what is thermometrically great will convey only the sensation of comfort. Our sensations have to be "corrected for eleva- tion. '' The diurnal range however is of course great (as high as 38 ). " Of course," I say, because a cloudless sky and dry atmosphere beget on the one hand a rapid warming of the earth's crust and its multiplied expansion in mountainous regions, on the other an equally rapid and complete giving out of the same at night time. You will now say : Well, if dryness and an abundance of sunshine are incompatible with equability of temperature, the ideal factors can never be made to harmonize. No, they cannot; at least not at high altitudes, but I attach a much greater importance to dryness as a factor, especially when connected with intensity of sunshine. Abundance of sunshine is one of the factors present. As the sun shines in a usually cloudless sky (the number of clear days has been as high as 303 in certain localities in TERRESTRIAL FACTORS. I 57 Colorado. I myself have seen ■$$ clear days in succession), there is a proportionately longer influence of sunshine in each 24 hours. Thus we have even on winter days, when the sun is clearly visible for 8 hours only, a sunbath, which, in its in- tensity, purity and fullness of effect makes amends for the de- ficiency in time. But now we come to the bad factors : In many parts there is a frequency and velocity of winds which are little short of beastly ; and the charm is not increased by volumes of gravel dust. I do not accept the maxim that the wind ex- ercises much less force on account of the reduced weight of the atmosphere, due to elevation, as a medical fact. -Rapid cooling of the body takes place as rapidly in rarefied as in ordinary air, and its dryness abstracts moisture alJ the faster. Other disadvantages are the absence of the lesser ideal factors. Too great a distance from the present centres of civilization, doubtful food (of which lack of fruit is one of the worst), scarcity of water, and equal scarcity of soft and reduced scenery ; too much grayness and baldness, too many rocks and not enough water. The rainfall throughout the year is barely sufficient to sustain sparse vegetation, and not always that. I have dwelt thus at comparative length upon the ideal factors present and absent on the eastern slope of the Rocky Mountains, because this region is the best representative type of high altitudes. In speaking of the general range, these mat- ters need not be repeated. If indeed I am guilty of a repe- tition of some statements already made when speaking of high altitudes in general, my excuse is that this application I58 TREATMENT OF CONSUMPTION. in loco made it easier to understand, and also because it is well to point out the approximation to an ideal climate. The average height of the Rocky Mountain range is about 11,000 feet, which represents the timber line. Of course mountain tops like Pike's and Long's Peak and Mt. Lincoln tower above the range. At elevations ranging from 7,000 to 9,000 feet we find the great parks, plateaux of enormous ex- tent, mostly well timbered. The large parks are the North, Middle and South, and San Luis Parks. Among those of lesser dimensions we have Estes' Park, Manitou Park, and a great number of others. All that has been said in regard to the eastern slope ap- plies here, this region being in reality a part of the slope. I ■ mention it separately chiefly to draw attention to the inhabit- able altitudes of great elevation. Remembering what has been said of approximate lines of immunity, in Colorado this may be set down at 6,000 feet ; in other words, the best altitudes for consumption are between 6,000 and 7,000 feet. Of localities in Colorado I would name : Boulder, 5,536 feet above sea-level. Denver — 5,200 feet; capital of Colorado. Comforts of life attainable. Good food, excellent society. Bad water, and still worse drainage. Colorado Springs — altitude 6,000 feet. Beautiful town, but very windy. Manitou — 6,124 feet — 6 miles from Colorado Springs, in a nook of the foot-hills. Well sheltered. Iron, sodium and magnesium springs. Pueblo — 4,400 feet. Windy and dusty. Canon City — 4,700 feet high. Dusty, but well sheltered. Good in winter time. TERRESTRIAL FACTORS. 1 59 Puncha Springs — 8,000 feet above sea-level. Sixty miles west of Canon City. Pagosa Springs, in the San Juan country ; altitude about 7,000 feet. Estes' Park, at an elevation of 7,500 feet above sea-level. Manitou Park — 7,752 feet; reached through the Ute Pass from Manitou. In New Mexico : Santa Fe — 7,000 feet above sea-level; Las Vegas, Albuquerque and Ojio Caliente. This latter place is within a region of country which is likely in the near future to become one of the ideal cool and dry climates. I refer to the north west corner of New Mexico ; roughly speaking, so much of it as lies between Colorado and the 35th degree of latitude from north to south, and from the Rio Grande del Norte to the Arizona State line from east and west. Again as a warm dry climate, the Mesilla Valley in southern New Mexico has an undoubted future. Here, as in parts of Arizona, the sun shines almost every day in the year. It is here that the dryness of the air is such that flesh does not decompose, but becomes dessicated by water abstraction. The bodies of the dead were formerly exposed in this valley and surrounding country, and became as mummies. Another advantage of this region is, that vegetables and fruit flourish to an unlimited extent. The finest and largest grapes are raised there. The valley itself is from one to six miles in width, and 70 miles long. In elevation it rises from 4,000 to 6,000 feet from the Rio Grande upwards to the foot-hills. New Mexico and Arizona are only beginning to be suffi- l6o TREATMENT OF CONSUMPTION. ciently civilized to furnish in addition to the ideal factors, lavished upon them by nature, some of the lesser factors, relating to home comforts and ready communication with the rest of the world. But I want you to remember this section as one of the future centres of ideal climate for consumptives, on a par with certain parts of Georgia, Tennessee and Texas. In Arizona may be found medium, as well as high altitudes in close proximity. This will enable the patient to spend winters at such places as Yuma, Florence, Prescott, Tucson or Maricopa Wells, while the summer may be spent in the neighboring mountains. Food is abundant and good in the above named places. At Yuma the rainfall has sometimes been less than one inch, .though the usual quantity is from 3 to 5 inches. When in addition you consider the great distance from either ocean, you need not wonder that the factor of dryness is beyond dispute. As regards abundance of sunshine, I quote from Col. H. C. Hodge's book, "Arizona as It Is :" " The sky here during the whole year is almost invariably a clean, blue expanse of ether." The author made a special note of the fact that during his resi- dence there of over two years there was never, not in all that time, in summer or winter, one single day without bright, beautiful sunshine. The extreme purity of the atmosphere, and the almost continued and perpetual sunshine which pervades the Ter- ritory, has attracted the attention of every observant person who has been there either for a few months or few years. It has become clear to my mind from all reports and per- sonal observations, that for the United States the most TERRESTRIAL FACTORS. 10 I favored climes are to be found (roughly speaking) below the 38° of latitude. The misfortune is, that the regions with the nearest approach to the ideal climate lack most of the minor factors which, together with strict supervision, cannot and must not be set aside. Without trying to be exact, and without any desire to squeeze into a fixed frame of rules the most favorable regions, I think that by looking at a map of our country you will be enabled to formulate a broad basis, which the future will endorse. In the United States nature's ideal factors are best found: First — Far inland, with shelter to north and west, and at high altitudes. Second — Inland, with shelter to north, north-east and east, at medium altitudes. Third — As regards latitude : Between 32 and 38 of north latitude. Fourth — Of the former, I would further bound the region by naming New Mexico, Arizona and Southern Colorado, between the 105th and 115th degree of longitude and between the 32d and 38th degree of latitude and certain stations in California. Fifth — Of the latter, by naming Northern Georgia, Eastern Tennessee (Cumberland Mountains), and Western Texas. The western slope of the Rocky Mountains is to a great extent an unsettled country, and though there can be no doubt that local conformation must give rise to a beneficial climate, I must say that at present it is, climatically speak- ing, a terra incognito. I 62 TREATMENT OF CONSUMPTION. Surgeons of the United States Army who have served in Utah, and in that generally elevated region with high moun- tain plateaux, lying between the Rocky Mountains and the Wasatch Mountains in Utah, and between the latter and the Sierra Nevada of California, speak well of a number of locali- ties as to equableness of temperature, dryness and a variety of altitudes. We come now to consider the Pacific Coast, or rather what for our purpose amounts to the same thing, to Cali- fornia. No climate upon the earth has had as much said or writ- ten for and against it as California. After searching through all the literature in reference to California, medical and non- medical, deliberate and prejudiced, I have at last been able to form some estimate of its true characteristics. One trouble appears to be that the State has every possible variety of climate, hot and cold, dry and moist, marine and mountain. This fact, and the old notion of the beauty of a "mild " climate, account for most of the discrepancies in statements, as also the variety of results attained. California is the climate par excellence for equability of temperature, and if other facts were in accord, idealism would here be reached. This is unfortunately not the case. As a total the climate (or rather the stations now resorted to) must be set down as equably cool and moderately moist. Two mountain ranges run through the State longitudinally, the Coast Mountains and the Sierra Nevada. Theoretically I should judge that the first named would act as a condenser of moisture for the second, thus leaving the west- ern slope (or if not that, the eastern) dry. But as a fact, the TERRESTRIAL FACTORS. 1 63 Sierra Nevada does not occupy a sufficiently far inland posi- tion to escape the moisture of the Pacific. In my future publication I will endeavor to collect the necessary data for establishing the character of the climate of the eastern and western slope of the Sierra Nevada, more especially south of the Yosemite Valley. The well-known health resorts are all on or near the sea- coast. In the upper part of the State the diurnal changes are very great, as at San Francisco. This is credited to a deep sea current coming down from Behring Strait, which dimin- ishes the ocean temperature, and flings cold winds into the warm interior as soon as the sun goes down and the heat radi- ates from the earth. Now if you look at a map you will find that at a point further south (below Concepcion), the shore turns to the south-east, and the current no longer exercises any effect. The warm Japanese current tempers the air in winter ; hence the equability. Of all stations, Santa Barbara has the greatest reputation. This is a strip of land which begins at Point Concepcion, running from west to east, is sheltered on the north from the winds and rains of the Pacific by the Santa Clara range, and in part on the south by islands, from sea-moisture. The mean temperature is about 6 1 degrees (maximum of 8o° in summer). The rainfall is from 12 to 15 inches. But I have ascertained that the mean humidity is between 65 and 70 per cent, of saturation. At Santa Barbara then the climate may be rated as equably cool and moist. Fourteen miles from San Francisco is San Raphael, shel- tered on the north and west from sudden changes. San Bernardino is 75 miles inland, sheltered by moun- tains to the north, west and east. 1 64 TREATMENT OF CONSUMPTION. In the Santa Clara Valley, back of the range of the same name, is San Jose, 50 miles from San Francisco, cool and moderately moist. Finally, let me draw your particular attention to two localities which have been favorably reported on by the State Board of Health of California in connection with the estab- lishment of a sanitarium : First —The Sierra Madre Valley, in Los Angelos County. Second — Atlas Peak, in Napa County. Both places are the best illustration of the possibility of combining the best factors without great altitude and at no considerable distance from the ocean ; or, in other words, where the existence of the best ideal factors are due to local conformation. Atlas Peak is the more accessible. It is on the second range of the Coast Range Mountains, about 12 miles from Napa City, at an elevation of 1,500 feet. The mean temper- ature is 62 degrees (summer mean 74°, winter mean 50 ). There is said to be a freedom from harsh winds. The best feature, however, is the mean relative humidity, which is only 45 percent., as low as in Southern Colorado. Verdict for this place : Moderately and equably cool and dry, a close approach to the ideal. GENERAL CONCLUSIONS. Out of the foregoing web of many facts there are some points which I desire you to impress well upon your mind, and to refer to them when necessary. Classifications in pathology are possible only in three dif- ferent ways : First — Anatomical, in accordance with the pathological anatomy. Second — Clinical, to be determined by difference in symptoms, differential diagnosis. Third — Historico-etiological, as formed from the family history, as well as from predisposing remote and immediate causes. We have seen the different factors found in pulmonary phthisis, according to pathological anatomy, to consist of hyperplasia of connective tissue, cheese and tubercle. A clinical classification is not feasible when it is remem- bered that dullness, moist roles, etc., admit of the presence of any one or all three of the pathological products. A classification based upon family history and the etiology of cases, will often allow of placing them under fixed head- ings with some approach to exactness The two factors in etiology are : Hereditarily scrofulous and directly inflammatory, and the products in either case may be proliferation of con- 1 66 TREATMENT OF CONSUMPTION. nective tissue, cheese or tubercle, or any two or all three combined. Under hereditary scrofulous we place : First — All those with hereditary tendencies not too remote. Second — Such in whom beneficial influences have been at work upon the organism for a long time, thus pressing their stamp indelibly upon them. Long-continued imperfect nutrition, bad ven- tilation, and of the lungs especially ; chronic blood-poison- ing, as in syphilis ; long-continued abuse of the nervous sys- tem, as in onanism. The second form is that of more or less directly inflam- matory or acquired. The most common causes here are remnants of acute inflammations ; desquamation as a sequel of a finished inflammatory process ; influences from without, causing "colds," which are subsequently neglected ; in- fluences from within, in the form of toxic conditions. Patients with hereditary dispositions of course may acquire direct inflammation also, but you must remember that their relatively small amount of living matter renders such an inflammation of a low grade and sluggish from the beginning. Theirs are the corpuscles of low vitality and im- perfect development, the fate of which is skrinkage and the formation of cheesy foci. This classification is valuable in the matter oi prognosis. Chronic phthisis of from eight to ten weeks' standing may be relied on for the presence of a destructive process or the residue of one ; oftenest a small cavity. It follows therefrom that cavities, in a scientific sense, are the chief objects of treatment. This shows that cavities occur oftener than formerly supposed, and likewise that they are more amenable to treatment. GENERAL CONCLUSIONS. 1 67 "The lungs are made to breathe cold as well as warm a i r — indeed, air of any temperature from Zero to ioo° Fahr." — (Bennet). The products of the clinical picture known as pulmonary consumption, are those of low forms of inflammation, the products of stagnation and embolism (necrobiosed pro- toplasm), pointing indisputably to defective nutrition ; and this again is the result of a vitality either absolutely lowered or temporarily depressed below the physiological standard. The best climate, collectively speaking, is a dry, cool, and sunshiny one. Broadly speaking, we may say that consumption may be treated by Natures factors (climatic influences), or by arti- ficial means (strict hygienic supervision and medication at home). Remember always, that in expatriating patients, you must make sure that in their new surroundings medical supervision and local treatment are not abandoned. 1 insist upon this as the most vital point in the treatment of con- sumption. Climatic influences and strict supervision and medi- cation shoidd not and must not he separated. In reference to treatment in general, remember : Our prime object is to cure ; regardless of whether the basis of our disease is one of specific inflammation ; whether the infection is dependent upon cheesy or specifically caseous material ; or upon immigration of corpuscular elements or of fungi ; or whether finally the deviation of the elementary tissues from the normal is of a histological or histo-chemical character. " Only through animated interchange through the blood is it possible that such changes should take place in the pro- ducts of inflammation, which lead to reabsorption, organi- 1 68 TREATMENT OF CONSUMPTION. zation, corpuscular proliferation and softening. As the heart's power is dependent upon the nutrition of the heart and normal innervation by normal blood, and as normal acts of diffusion in the tissues are governed by the composi- tion of this general juice of nutrition, it is above all of im- portance to endeavor to gain influence over this condition of blood by every well-tried means.'' — (Winternitz) Whether a consumptive patient had better be treated at home, or by sending him to an institution or to a different climate at large, depends first of all things upon his means. Next you should make it clear to yourself whether you are dealing with a case of hereditary vulnerability or one of abso- lute acquirement. Next ascertain whether there exists a " fatal circle," and whether it be complete or incomplete, and then be governed by the following rules : i. The fatal circle must be broken before a climatic change is to be thought of. Waste must not have too great an advance on repair. 2. The hereditary-vulnerable consumptives with a bad general condition, should remain and be treated at home, as change of climate will not compensate them for the change of food and habits. 3. The hereditary-vulnerable with acquired bad habits. To a cool or warm and dry climate, where above all you are sure of constant supervision by a conscientious physician. Best, perhaps, to a well-regulated sanitarium, if such can be had. 4. Hereditary-vulnerable patients with good digestion and assimilation. To a cool or cold and dry climate. The chief instruction to all the vulnerable should be, to GENERAL CONCLUSIONS. 1 69 immediately root out any perceptible irritation or dis- turbance of their pulmonary or gastric mucous membranes as soon as they occur. 5. Patients with acquired phthisis and a good general condition (includes those with recent pneumonic remnants): To the sea-shore or on a long sea-voyage, provided the phthisical process has not existed for more than a limited period. Or to a cool or cold and dry climate. Superficial catarrhs of less than ten week's standing or so, are good cases for a sea-voyage or a warm, dry climate. 6. Acquired pulmonary consumption, but with disturb- ances from bad habits : First correct the functional disturb- ances at home, and then send the patient to a cool, dry climate, where the "artificial factors " are known to be satis- factory. 7. Acquired phthisis, with bad general condition : To a warm or cool and dry climate, or to a sanitarium not too far from home, located in a " health spot."' 8. The proper altitude to start with in a given case, is to be governed by the strength and rapidity of the heart's action. 9. Pharyngitis, nasal catarrh, naso-pharyngeal catarrh laryngitis, in short, all irritations of the more superficial parts of the respiratory tract, must not be sent to a climate where low temperature and frequent winds are two of the factors. High altitudes (such as are found in Colorado) do not agree with this class of cases. To go to a cold, dry cli- mate, the patient must be free from disease down to the clavicle. Next let me give you some points, dwelt upon by Dr. 170 TREATMENT OF CONSUMPTION. C. T. Williams, of London, as to the climatic treatment of consumption. He establishes a few clear rules, which can safely be transcribed to our climate, and, based as they are upon the general stages of consumption, do not conflict with our etiological decision as given above. First — If a phthisical patient in any stage can take a fair amount of exercise without contracting fresh lung-irritation from exposure to meteorological changes, and if he have a good appetite, with diminishing cough and increasing weight, I should unhesitatingly advise him to remain at home and trust to treatment and to the food of the best dietary in the world — that of Old England.* If, however, he cannot take exercise without constantly catching cold ; and if, when confined to the house, he lose appetite, become low-spirited, pine for fresh air, sunshine and change of scene ; and, above all, if the confinement act unfavorably on the digestive organs, causing bilious derange- ments and disinclination to the cod-liver oil, equally unhesi- tatingly I advise a trial of another climate, if the strength per- mit. There are a number of consumptives who profit more by food than climate, and never seem to thrive except on British fare. These had better stop at home, and try the sun- shine of the south-coast. All cases deemed advanced, whether on account of exten- sive tubercular consolidation of the lungs, or on account of considerable excavation of one or of both lungs, and cases of active tubercular disease ; or, again, those manifesting great irritation of the pulmonary or of the gastric mucous membrane, had better remain in England, as * I subscribe to the above. — Author. GENERAL CONCLUSIONS. 171 change of climate would not yield them a sufficient return for the alteration of food, life andhabits, as well as the risk of the journey. Nevertheless, those are often the patients who are most anxious to winter abroad ; and even when at death's door, they will not give up their hope that in another and a sun- nier clime new life may be vouchsafed to them. On the other hand, first stagers, and even where the con- solidation is extensive, if the consumptive disease arise from inflammatory and catarrhal attacks, and if it be confined to one lung, do well to leave England ; and we may also advise the same to third-stage cases, where the vomica is small and quiescent. Second — As regards the second point, be it remembered that a sea-voyage is a long and trying experiment, to which the invalid has to submit when once he embarks, whether • it suit him or not, for several months. * * * * Then, again, the element of sea-sickness must be borne in mind, though fortunately consumptives appear to suffer less than other people. * * * * The cases which I have seen profit most by sea-voyages are, first, cases of hemorrhagic phthisis ; second, cases of limited consolidation with no pyrexia, occurring in young men overworked at indoor occupations, and who have suf- fered from the septic influences of life in great cities. * * * Third — * * * * The question whether a cold dry or warm dry atmosphere is the best for ordinary chronic phthisis, depends to a great extent on the individual's power of maintaining circulation and temperature. When these suffice, the cold climates are preferable ; but in the majority, 172 TREATMENT OF CONSUMPTION. and especially for women, whose circulation is weaker, the warm and dry are the best, for they are thus enabled to live more in the open air. Elevation is of great importance, and I should always choose a mild climate with elevation to one without it. Mountain-air is not beneficial solely on account of its purity, for on this point sea and desert air may vie with it ; there is another factor in the low barometric pressure and atmospheric rarefaction, and the expansion of the lungs thereby caused may be of great value in chronic first stages. At present the trial of mountain climates must depend on the supply of suitable accommodation and food for invalids. Fourth — -As to the desirability of moist climates for con- sumptive patients, the evidence is decidedly against their use in the treatment of ordinary chronic phthisis. The addition of warmth only makes the damp tell more unfavorably, though a strong saline element and invigorating breezes do something to counteract the humid influence ; still even j these do not place a moist climate on the same level as a dry one. There is one exception, however. Phthisis of catarrhal origin has been shown to profit most by a warm and equable climate, even though accompanied by a certain amount of moisture, as the evidence of Madeira witnesses." Without wishing to overload the subject, let me add another general rule as to climate : Any change from city to country, or from sea-shore to the mountains, or vice versa, will most likely improve the general condition to the extent of gain in weight by the accumulation of adipose tissue, and an amelioration of such symptoms as cough and the irritation which calls it forth and keeps it up. But remember that the local process in the lung is equally as likely to remain in GENERAL CONCLUSIONS. 1 73 statu quo. Therefore to cause an arrest of the lung trouble itself, it will be necessary to follow such change by an addi- tional one to a dry, cool high altitude, or to a medium alti- tude, if the same be blessed with a sanitarium, or the con- veniences of civilization be greater and nearer than can be obtained at high altitude. In either case remember that the climate and altitude chosen must have a governing majority of the factors of an ideal climate, of which dryness is the chief, and a certain equability of temperature the next. Or in other words, the cli- mate chosen must have such of the factors as will unques- tionably entitle it to the appellation of an aseptic climate ; of one which does not promote fermentation. Another lever to assist you in perfecting your decision, is in the subjective feelings of the patient himself. This is especially valuable in cases where, to the best of your judg- ment, several climates and regions would appear equally favorable. The best rules in this connection are laid down by Prof. Loomis in his work on " Diseases of the Respiratory Organs. '' " Every phthisical patient has a climate adapted to his peculiar diathesis ; a few well-directed questions will enable you to determine in which direction and in what locality your patient will be most likely to receive benefit. In the first place, by careful questioning, determine whether your patient, when in a state of health, was most vigorous in warm or cold weather, in a damp or dry atmosphere. Again, you must determine whether he has most vigor in a dry and cold, or a dry and warm atmosphere, or in a warm- moist, or cold-moist atmosphere." 174 TREATMENT OF CONSUMPTION. ' ' If these questions cannot be settled by the experience of the patient, direct your patient to travel in the direction which seems best suited to his case, until he finds a locality where he is comparatively comfortable ; endeavoring to select a climate where he may be out-of-doors every day, and at any hour of the day." * * * "In whatever locality a phthisical patient finds himself improving, it is important that he remain in that locality so long as he continues to improve."' -f^Ow 91 ^^.tAe- DATE DUE WcTo t iCT15 ZQ02 NOV 3 ^ 20Q2 0D1 i/iai 12^ /ERSITY LIBRARIES 113191 DEMCO 38-296 DUPLICATE HX00013080 %wMm