Chapter XXIX: Part 29

What influence has the evidence of a congenital tendency and heredity upon the prognosis? It is commonly believed that the chances of arrest and recovery are less in proportion to this evidence. There is doubtless truth in this belief, but it has sometimes too much weight in the minds of both patients and physicians in individual cases. The disease is by no means always progressive even when the antecedents of the patient afford the strongest evidence of an innate predisposition. The following instance is given by way of illustration: In 1861 a young woman, eighteen years of age, affected with phthisis, came under my care. The disease had existed for two years, and she had tried various climates--namely, Cuba, Florida, Minnesota, Kentucky, and Ohio. The case ended fatally in 1863. The mother of this patient and two sisters had died of tuberculous disease. The father was tuberculous at the time of her death, and he died soon afterward with an intestinal complication. There remained two sisters and two brothers. The elder of the brothers, aged seventeen, was attacked in 1861 and died in 1863. The climate of Minnesota was resorted to in this case with no benefit. The younger brother, aged sixteen, in 1861 had a dry cough, which after a short time ceased, and he became apparently well and robust. The physical signs at that time showed a small tuberculous affection at the summit of the left lung. In the winter of 1863 the cough returned, and the signs now showed a tuberculous affection of the summit of the right lung. He was immediately {424} sent to Europe, and he passed the winter and spring at Nice. He returned and went to South America in 1864. He passed the winter of 1865-66 in New Orleans and France, making the voyage in sailing ships. He passed the winter of 1866-67 in St. Paul, and died in the following spring. Of the two remaining sisters, the previous history in the case of the elder, aged thirty, seemed to warrant a retrospective diagnosis of a small phthisical affection which had ceased to progress and from which she had recovered. There were slight dulness of the summit of the chest on the left side and broncho-vesicular respiration. This one of the sisters has been well for the twenty-three years which have elapsed since the date of the supposed phthisical affection. The younger of the two sisters at the age of twenty-two had a cough with small expectoration and a moderate bronchial hemorrhage in the winter of 1862. There was abnormal dulness on percussion at the summit of the chest on the right side, with weakened respiratory murmur, some crepitation, and increase of vocal resonance. After a few weeks the pulmonary symptoms ceased. In this case there was no treatment, medicinal nor hygienic; she had passed the winters in the city and summers at attractive places of resort, entering with zest into social enjoyments, and she has been in all respects well up to the time when I last saw her, in the spring of 1881, twenty years after the phthisical disease.[22]

[Footnote 22: Since that date a recurrence of the affection has taken place, but without being progressive.]

The last two cases are instances of recovery from phthisis irrespective of any medicinal or hygienic agencies; that is, a recovery by self-limitation. Considering the evidence of a family predisposition, a favorable prognosis at the outset would hardly have been justifiable. From my records of cases other instances might be selected illustrative of the caution not to allow too much weight in the prognosis, in individual cases, to the evidence of an innate predisposition.

It might be supposed, from the greater liability to phthisis between the ages of twenty and thirty years, that its occurrence at this period of life affects unfavorably the prognosis. Facts, however, do not appear to sustain this supposition. So far as the ratio of recoveries bears upon the point, the study of a limited number of cases shows it to be not larger after than before the age of thirty.[23]

[Footnote 23: Vide _Phthisis, in a Series of Clinical Studies_.]

The liability to a recurrence of the disease after recovery is important to be considered in connection with the prognosis. Of 44 cases of recovery among those which I have recorded and analyzed, recurrence had taken place in 6 up to the time of the analysis. In one of these 6 cases the disease had recurred twice. The patient recovered from the second recurrence, and is now well, more than ten years having elapsed. In all the other cases the recurrence proved fatal. The recurrence took place after periods ranging from one and a half to over six years from the date of the recovery. So far as these cases warrant a conclusion, it is that in cases of recurrent phthisis the prognosis is very unfavorable. This conclusion might be materially modified by the study of a large number of cases. The fact that after recovery there is considerable liability to a recurrence of the disease has an obvious bearing upon the prophylactic management.

Facts pertaining to the duration of phthisis come properly under the head of prognosis. Of 44 cases of recovery which I have recorded and studied, the duration varied from six months to ten years. In more than one-half of these cases the pulmonary affection was small; in 4 cases it was moderate in amount; in 10 cases it was considerable; and in 1 case it was large and advanced.[24] These facts show that the prospect of recovery is much better {425} when the tuberculous affection is small or moderate, but that a considerable and large affection does not preclude recovery.

[Footnote 24: Vide _Phthisis, in a Series of Clinical Studies_, for abstracts of the histories of these cases. Absence of all pulmonary symptoms was known to have existed in the different cases for periods between six months and twenty-seven years. Throwing out two cases in which the period was six months, and one case in which it was eight months, the average period was six years.]

Next to recovery, the course of the disease is favorable when it ceases to be progressive and life with fair health is continued for a long period. Out of the cases which I have analyzed, there were 28 in which the disease was known to have existed for periods ranging from one year and three months to twenty-five years. The duration was reckoned up to the time of the analysis or of the last information obtained. The number of years noted does not express the duration of life. The average period during which the disease was known to have been non-progressive is a fraction over eight years. The histories in these cases exemplify the fact that phthisis, when it ceases to be progressive, although recovery does not take place, is not incompatible with fair and even good general health and long life. That recovery does not take place is owing to the persistence of pulmonary lesions, such as cavities which do not cicatrize or an interstitial pneumonia with dilatation of bronchial tubes. The tuberculous disease no longer continues, but the local effects of the disease remain. Slowness of progress and prolonged tolerance are to be hoped for when the disease neither ends in recovery nor becomes non-progressive. In some cases the disease ends fatally, having existed for many years where at no time could it be said that its progress had ceased. The prolongation of life under these circumstances depends on the slowness with which the disease progresses and the ability of the system to tolerate it.

The extremes of the duration of the disease in a large collection of fatal cases are so far apart that the average period is of little practical value as bearing on the prognosis in individual cases. In the collection of recorded cases which I have studied analytically, there were 112 the duration of which from the commencement of the disease to its fatal termination was ascertained. The mean duration was about twenty-three months. Laennec found the average duration twenty-four months; Louis and Bayle, twenty-three months; Andral, twenty-four months; Sir James Clark, thirty-six months; and Williams of London, forty-eight months.

TREATMENT.--The author premises the consideration of the treatment by stating that this article was written before sufficient time had elapsed after the publication of the researches by Koch for their confirmation by other competent observers. At the present time (May, 1885) the doctrine that phthisis depends on the presence of a special micro-organism is to be considered as probably established. The grounds for this statement have been presented under the head of the Etiology, and reference to the practical bearings of the doctrine have been introduced in connection with the Diagnosis and Prognosis. It is evident that the doctrine is likely to have important bearings on the treatment. If it be true that the origin, the extension, and the diffusion of the disease within the body require the presence and the multiplication of a particular parasite, it is evidently a rational object of treatment to effect its destruction. For this object an efficient parasiticide is to be sought after, to be administered either by inhalation or by its introduction into the blood-vessels. Already, within the short time which has elapsed since Koch's discovery, extended observations have been made with various substances which are destructive to bacteria outside of the body, but thus far without success. A difficulty as regards inhalation is in the way of a destructive agent in the form of either an impalpable powder or a vapor or a gas reaching the colonies of bacilli in sufficient quantity to effect the object, without doing injury to the tissues or inducing toxæmia. As regards the introduction of {426} parasiticides into the blood, it seems hardly probable that a toxic agent can be safely introduced in sufficient quantity to effect the object. It remains to be determined by clinical observation whether or not these difficulties are insuperable.

Efforts to destroy the parasite in another direction promise to be more effectual--namely, by the removal of the co-operating conditions on which their multiplication depends. It is to be borne in mind that the development and continuance of phthisis involves two factors, one which is the presence of the parasite, and the other the existence of those unknown conditions constituting the tuberculous predisposition or cachexia. The removal of the latter may effect the destruction of the parasite indirectly, but not less certainly than by bringing into direct contact with it a destructive agent. It is in this indirect way that the measures of treatment which experience has shown to be more or less effective may be supposed to operate. And it is to be added that those measures of treatment the usefulness of which rests on clinical observation are in no wise disproved or modified by the parasitic doctrine. At the present time the treatment of the disease is to be governed by principles which, based on reason and experience, are independent of that doctrine.

The intrinsic tendency of phthisis to be either progressive or non-progressive underlies the treatment. In a certain proportion of cases the disease tends to advance steadily and actively, as shown by the symptoms and the physical signs. In these cases treatment cannot be expected to do more than to palliate symptoms, and perhaps prolong the duration of life. These are cases of so-called galloping consumption. In a larger proportion of cases the disease does not steadily or actively advance. Remissions occur. The pulmonary affection increases, and extends by successive tuberculous invasions or eruptions after intervals variable in duration. These cases offer more encouragement for treatment. There is room to hope after each invasion that another will not take place, and that the affection which exists may be tolerated indefinitely if the cases do not end in recovery. In a minority of cases when a certain amount of pulmonary affection has taken place there is no further increase or extension. In this respect the disease ceases to progress. In some of these cases after the lapse of weeks or months all pulmonary symptoms disappear, and the patient may be said to have recovered. The probabilities of the recovery and the time required therefor vary, other things being equal, according to the amount of the pulmonary affection. In other cases recovery does not take place. More or less of pulmonary symptoms remain. The existing lesions which these symptoms represent, however, may be well tolerated, and their existence may not interfere with fair or even good general health and long life.

Whenever the disease ceases to be progressive, with or without recovery, an intrinsic tendency has more or less agency in the cessation of progress. In some instances it is certain that this result is wholly due to self-limitation. Expressing the fact in other language than that of personification, the disease may become non-progressive because the unknown, special, constitutional morbid conditions which it is customary to embrace under the name tuberculous cachexia no longer exist; or, assuming that a particular parasite is essential to the progress of the disease, this organism may cease to multiply in consequence of the non-continuance of conditions which are necessary for its multiplication. Whatever be the explanation of the tendency of the disease--to be, on the one hand, progressive, or, on the other hand, non-progressive--it must be taken into account in estimating the influence of measures of treatment. How largely an intrinsic tendency to be non-progressive is accountable for apparent success in treatment cannot be determined with precision. The evidence of its agency can only be derived from the accumulation of cases of non-progressive phthisis in which no active measures of treatment were pursued. Reference has been made to a few such cases {427} among those which I recorded during a period of thirty-four years. Some cases in addition have come under my observation since the analysis of my cases recorded up to 1875. It is evident that a large collection of such cases cannot be made by a single observer.

From what has been stated, it follows that the treatment in case of phthisis has reference especially to the constitutional conditions which stand in a proximate causative relation to the pulmonary affection. The chief objects are to arrest the disease and to keep the cachexia in abeyance. In the present state of our knowledge measures of treatment addressed directly to the pulmonary affection, albeit important, are of secondary importance when compared with those which either co-operate with or oppose the underlying intrinsic tendency of the disease as manifested in individual cases.

Proceeding to consider the treatment in cases of phthisis, a convenient division of topics is into those relating to the climatic treatment, the dietetic and regiminal treatment, and the medicinal treatment.

Climatic Treatment.--It would be impossible within the limits of this article to enter into a discussion of the various questions connected with climatic influences or to consider the relative advantages of different climates. Nor, were it possible, would this be desirable as regarded from a practical standpoint. I shall confine myself to the general considerations which bear upon the climatic treatment.[25]

[Footnote 25: For an account of the characteristics of different places of resort in different countries, and a full consideration of the subject of climate in relation to phthisis and other diseases, the reader is referred to the article entitled "Klimatstherapie" by H. Weber of London in _Handbuch der Allgemeinen Therapie_, von H. v. Ziemssen, Zweiter Band, Leipzig, 1880.]

In the analytical study of the cases of phthisis I had recorded up to the year 1875, I endeavored to draw some conclusions respecting climatic treatment from the facts contained in the histories. Temporary changes of climate entered into the treatment in 74 cases. The histories were interrogated with reference to the number of cases in which recovery took place, the number in which the disease ceased to be progressive without recovery, and the number in which the disease progressed slowly, with reference to the apparent influence exerted by climate. The changes of climate in the 74 cases were various. In a considerable number the patients traveled in Europe, visiting different places. The foreign resorts in which they sojourned for greater or less periods were Nice, Algiers, Mentone, Egypt, Nassau, Lima, Rio Janeiro, Cuba, and the West India islands. In this country the different resorts were in Minnesota, California, New Mexico, Florida, Georgia, South Carolina, Louisiana, Virginia, Kentucky, the District of Columbia, Michigan, and the Adirondacks. Colorado as a place of resort had not excited much attention prior to my making abstracts of my histories for analytical study, and for this reason it does not appear in the foregoing list. I have notes of not a few cases in which the latter climate was resorted to. It is at once evident that 74 cases distributed over so many places of resort cannot furnish adequate data for judging of the relative advantages of different climates. Nevertheless, the analysis of these cases led to an important conclusion as respects, in general, the usefulness of a temporary change of climate. Of the 74 cases, 9 ended in recovery, 13 were in the list of cases of arrested or non-progressive phthisis, and 5 were in the list of cases in which the disease was slowly progressive. In 33 cases the disease ended fatally, and in 14 cases neither the duration nor the termination of the disease appears in the histories. Moreover, of the 33 fatal cases, in 23 the histories afforded evidence of more or less benefit from the changes of climate.[26] From these facts it seemed warrantable to deduce, as a positive conclusion, that in a considerable proportion of cases a {428} change of climate has a favorable influence on phthisis. It follows also, as a corollary, that a favorable influence is exerted by a variety of climates. Indeed, it would seem, judging from these facts, that the favorable influence pertains to the change rather than to the particular climate selected. If this be true, it follows that the agencies by which a favorable influence is exerted relate to accessory or incidental circumstances more than to purely climatic conditions.

[Footnote 26: For further details vide _Phthisis, in a Series of Clinical Studies_.]

It is an absurd supposition that any climate exerts a specific influence in arresting phthisis. This statement is not in the least inconsistent with the fact that certain climatic conditions are much more favorable than others for an arrest of the disease. Dryness, equability, and purity of the atmosphere are essential elements of a favorable climate. Within late years a high altitude (4000 to 8000 feet above the ocean-level) has been deemed by many of much importance. Aside from the purity of the air incident thereto, the rarefaction is supposed to have a salutary effect by increasing the expansion of the lungs.[27] Few at the present time regard a tropical temperature as advantageous. The choice is usually regarded as lying between a cold and a warm climate, each having favorable elements aside from temperature. There is abundant testimony in behalf of each. Circumstances pertaining to cases individually must determine which to choose. A patient who in health has found cold weather more favorable to vigor and well-being than warm weather will be likely to find a cold climate more beneficial than a warm climate, and vice versâ. In order to derive benefit from a cold climate a patient must have preserved sufficient vigor to endure out-of-door life in such a climate. Confinement much of the time within doors must deprive patients of the benefit to be hoped for from a cold climate. For obvious reasons a cold climate is better suited to men than to women. With reference to the superior excellence of particular health-resorts, caution is to be exercised in weighing not only testimony either for or against their superiority, but the value of reported cases. Putting aside the chances of error in diagnosis, it is to be considered that among those who elect a particular place of resort an arrest of the disease or improvement to a greater or less extent would probably have taken place had any one of many places been selected, and perhaps if no change had been made. On the other hand, in a certain proportion of cases the disease will be progressive anywhere. A limited number of cases must not be relied upon to establish the relative advantages of particular places, especially if there be not data enough to judge of the condition of the patient in each case as regards the amount of the pulmonary affection, the temperature, pulse, and other symptoms. A few cases which have been selected to illustrate either the favorable or unfavorable influence of a particular climate are not entitled to any weight in the formation of an opinion. To gather clinical facts sufficient to determine by analytical study the actual advantage severally of different climates is a work attended by so many difficulties that it must be long before it can be accomplished. Meanwhile, in discriminating between different places of resort the physician is to be governed by rational considerations. In reality, custom and fashion have much to do in this matter. Places which were formerly in vogue as health-resorts have now fallen into disrepute. It is almost inevitable that sooner or {429} later this will be the fate of any place which becomes so popular as to attract very largely phthisical patients, owing to the aggregation of the instances in which no benefit could have been expected from climatic treatment.

[Footnote 27: On this topic the reader is referred to an article by C. Theodore Williams, entitled "The Treatment of Phthisis by Residence at High Altitudes," in the _Transactions of the International Medical Congress_, London, 1881; also to a work entitled _Rocky Mountain Health-Resorts, an Analytical Study of High Altitudes in Relation to the Arrest of Chronic Pulmonary Disease_, by Charles Denison, M.D., 2d ed., 1880.

There is much reason in the suggestion that the immunity from phthisis in situations which are sparsely settled may be due not so much to climatic influences as to the fact that these situations are free from non-climatic causes contributing to the prevalence of the disease--namely, in-door occupations, overcrowded dwellings, etc.]

There is reason to believe that the benefit derived from climatic treatment is often in a great measure due to accessory circumstances. As already intimated, this seems to be a fair inference from the number of instances of arrest of the disease, of cessation of its progress, and of notable improvement in a collection of cases in which many and varied climates had been resorted to. Under the name accessory are embraced a variety of circumstances--in fact, everything not pertaining purely to climatic agencies. The opportunity of living in the open air and freedom from the cares of business, together with relaxation and mental diversion, are in the category of accessory circumstances. These contribute largely in some cases to the benefit derived from change of climate. Patients at a health-resort are apt to carry out hygienic regulations more faithfully than when at home. In contrast to the accessory circumstances which are favorable there are those which have an unfavorable effect, such as home-sickness, ennui from lack of usual occupations, anxiety lest affairs should suffer for want of personal supervision, interruption of fixed habits, and the want of home comforts. These in some cases may go far toward counteracting the benefit from climatic influences.

All these accessory circumstances, as bearing upon individual cases, are to be taken into account in deciding the question as to the importance of climatic treatment. Of course a change of climate is important, other things being equal, in proportion as the climate in which the patient resides is humid, variable, and the atmosphere impure. So far as purely climatic influences are concerned, it may be important only that the patient escape the more trying seasons of the year--namely, the spring and the hot summer months. A malarial climate should certainly be exchanged, if practicable, for another during the season when there is danger of being infected with the malarial miasm. To avoid this cause of disease, as well as the changes of temperature, etc. incident to the spring and summer months, it may not be necessary to go very far from home. It is probably better not to go to a distant climate for a few weeks, in order that the double acclimatation caused by going and returning within such a brief period may be avoided.

It is of essential importance to take fully into account the condition of the patient as regards the pulmonary affection and the general symptoms before advising or sanctioning a change of climate which involves long journeys and separation at a distance from home and friends. There is more reason to expect benefit from a change the stronger the evidence against an intrinsic tendency of the disease to progress actively. Whenever the temperature and circulation denote activity of progress the propriety of a change is doubtful. Whenever there is great emaciation with muscular feebleness there is little ground to expect material benefit from any climate. The experiment is allowable at an advanced period of the disease only with a view to satisfy the wishes of the patient and the friends, having a full understanding with the latter in respect of the danger of dying away from home. It should be added that sometimes in cases which offer no ground for the expectation of any essential benefit journeys or voyages are well borne, and life is apparently prolonged by a change from an inclement to a genial climate.

Distance is a point to be considered in the selection of places of resort. It is often an objection to crossing the ocean that communication with relatives or friends is attended with delay and difficulty. The voyages, as a rule, are not objectionable. Our own country embraces almost every possible variety of climate, and therefore, so far as purely climatic influences are concerned, it is not necessary to resort to foreign countries. The latter, however, have for many the advantage of being made more attractive by novelty and {430} historical associations. Moreover, there are often better arrangements for comfort and enjoyment. The accessory advantages are always to be considered with reference to the particular tastes and needs in individual cases. Good food in abundance and well cooked, large and well-ventilated rooms, facilities for walking, riding, and driving, opportunities for hunting, fishing, and other out-of-door sports, ample provisions for in-door exercise in bowling, etc., agreeable society,--these are among the accessory advantages without which often the best climatic influences will prove inoperative. To these is to be added available judicious medical advice.[28]

[Footnote 28: For details concerning the health-resorts of the Riviera, Hyères, Cannes, Nice, Mentone, and others which are much esteemed in Europe, the reader is referred to a work entitled _The Riviera_, by Edward I. Sparks, London, 1879.]

A mistake often made by those who find benefit from a change of climate is to continue the change for too short a period. The benefit speedily obtained may be speedily lost when the patient is again placed under the climatic and other circumstances attending the development of the disease. It is to be borne in mind that the benefit from a change of climate does not depend on any special remedial agency, but on a combination of favorable circumstances, and that the salutary influences connected with climate are exerted not so much directly upon the lungs as upon the general system. It follows that the beneficial effect may be manifested more by increase of appetite, better digestion, greater endurance of muscular exercise, and especially gain in weight, than by immediate improvement in the pulmonary symptoms. Many patients cannot afford the loss of time and the expense of lengthened absence, and therefore are unable to make trial of change of climate. These may be consoled by the fact that not a few cases of phthisis do well without any climatic treatment. In some of the most striking of the instances of arrest of the disease which have come under my observation change of climate did not enter into the treatment. Important as is this fact, it does not conflict with the belief that additional chances of arrest and the prospect of more or less improvement are often secured by climatic treatment. It is a wise precaution for patients to reside permanently in a climate in which an arrest of the disease has taken place. Of course this is not always practicable. Its importance is attested by reason and experience, and it is the duty of the physician, according to his discretion, to suggest it. The many obstacles which are often in the way of its adoption are sufficiently obvious.

Sanitaria for phthisical patients at health-resorts are doubtless serviceable in many cases, because hygienic measures are enforced which would not under other circumstances be thoroughly carried out. An offset to this advantage is the depressing effect upon some minds of association with other patients. Owing to this moral effect it is sometimes judicious to advise patients not to go to places which, for the nonce, are especially popular, in order that they may not have before their eyes cases exemplifying all the phases of the disease, and be led to talk over symptoms with other patients affected with phthisis. As regards sanitaria, those in which the chief object is to enforce measures of hygiene are perhaps most likely to be serviceable. If these measures be secondary to some system of medication, there is room for distrust.

It is hardly necessary to say that the treatment of patients in such institutions should be under the charge of competent physicians who have not originated or adopted any peculiar notions respecting the pathology and therapeutics of the disease. As a matter of course, there cannot and should not be any restriction in either originating or adopting ideas and methods of practice, however much they may be at variance with commonly-received opinions; but a physician who appreciates his obligation to his patients will hardly feel willing that they should be made subjects for testing pathological and therapeutical novelties in behalf of which his own belief is not committed.

{431} Dietetic and Regiminal Treatment.--The dietetic treatment resolves itself into a few simple principles. It may be assumed that as much assimilation of aliment as is possible is desirable. No one probably will contend for the propriety of any restriction of diet with a view to limiting the amount of the nutritive constituents of the blood. The difficulty in this part of the treatment lies in the impairment or loss of appetite and in lack of digestive or assimilative ability. It is useless to consider whether such or such articles of food are suitable or not for phthisical patients. All wholesome articles which can be taken with any relish and digested are suitable. Nothing could be more ill advised than to direct kinds of nutriment which a patient does not like, and to enjoin avoidance of those which the patient's appetite would dictate. Pains should be taken to ascertain the articles of diet most acceptable or against which there is the least repugnance, and to excite the appetite by variety and culinary attractions. It is important not to judge too hastily of the ability to digest the food which can be ingested. The evidences of indigestion are nausea, vomiting, flatulence, acidity, and diarrhoea: whenever these symptoms are wanting it is fair to assume digestive ability. Nor should evidence of indigestion deter at once from continuing articles which appear to have occasioned it. The processes of digestion are so apt to be disturbed by extrinsic accidental circumstances that a meal which will occasion indigestion to-day may not do so to-morrow. In short, so far as regulation of the diet is concerned the patient is to be encouraged to take all kinds of wholesome food according to appetite and taste, giving to each and all a fair trial as regards digestibility. Fully aware that these views may not commend themselves to the approval of many who think that the diet should be regulated on scientific principles rather than by the instincts of the patient, I do not any the less adhere to them, believing that they are based on experience and common sense. As regards the liability, where the instincts are followed, to the over-ingestion of food and to the ingestion of food indigestible from its quality or modes of preparation, it is far better to incur whatever inconvenience may therefrom arise than the evils of inadequate nourishment. In short, the dietetic instructions to a phthisical patient may be summed up as follows: Eat of wholesome articles of food whatever the appetite may dictate; endeavor to maintain and develop appetite and relish for food by the excitement of variety in kind and in preparation; eat whenever hungry; satisfy the appetite; eat without any expectation of harm; do not hastily attribute an indigestion to any particular articles of diet; incur the risk of over-feeding rather than of the greater evil of under-feeding.

Anorexia in a degree which I have characterized as invincible--that is, an almost complete inability to take food--is one of the most discouraging of symptoms in cases of phthisis. Of course if the symptom continue the duration of life is simply a question of time and tolerance. Milk is an invaluable form of food when appetite is completely lost. The advantage sometimes of substituting for simple cow's milk buttermilk, koumiss, or milk made sour by fermentation with yeast is due wholly to these being taken more readily and more easily digested. The same is true of the substitution for the milk of the cow that of other animals--the goat, the ass, and the mare. Eggs may be given in a liquid form with milk or other fluids. Very little reliance is to be placed on the various meat-extracts (Liebig's, Valentine's, and others) as representing any considerable amount of nutriment. Meats artificially digested--that is, in the form of peptones, as in Leube's meat solution--form a valuable addition to beef-tea. Rectal alimentation may be resorted to. A. H. Smith has reported marked benefit from defibrinated blood as a form of rectal diet.[29] A French writer, Debove, has lately reported notable benefit from forced alimentation, food being injected through a tube introduced into {432} the stomach.[30] If in any way food can be introduced, in spite of the anorexia, and assimilated, there may be room to hope that a return of appetite will be among the beneficial effects. Cod-liver oil and alcoholics will be considered in connection with the medicinal treatment.

[Footnote 29: Vide _N.Y. Med. Record_, 1881, No. xix.]

[Footnote 30: Vide _Bullétin générale Report_, Paris, 1881. Another French writer more recently in the same journal, Desnos, has pointed out a source of danger in forced alimentation--namely, the occurrence of violent acts of vomiting, during which portions of food ejected from the stomach are inhaled. The danger is from asphyxia and pneumonic inflammation excited by the presence of particles of food within the smaller bronchi. In order to avoid this source of danger, food should be introduced slowly and not in too large a quantity at a time. Intolerance of the presence of the tube within the stomach is an obstacle which may be overcome by use, but in some cases it is insuperable (vide article in _Philadelphia Med. Times_, March, 1882).]

The regiminal treatment embraces changes relating to out-of-door life, exercise, occupation, clothing, etc.

Of all the changes in this category, those relating to out-of-door life and exercise are of greatest importance. In-door life and sedentary habits, if not factors in an acquired cachexia, undoubtedly favor it. This is shown by the place which these hold in the etiology and by their agency in the arrest of the disease. With respect to the latter point, the result of my analysis of recorded cases has much significance. In 44 cases change of habits from those more or less sedentary and confining within doors to those involving out-of-door life and activity entered into the treatment. In all but 4 of these cases the hygienic treatment consisted chiefly or exclusively of the change of habits mentioned. Of the 4 excepted cases, in 1 the patient passed several months in Europe; in 1 the patient passed a summer in Minnesota; in 1 the patient made several voyages to Europe; and in 1 the patient travelled in Europe. Of these 44 cases, 15 are in the list of cases of unknown duration and termination. Deducting these, the remaining number is 29. Now, of these 29 cases, 11 are in the list of cases ending in recovery; 7 are in the list of cases in which the disease was arrested or became non-progressive; and 3 are in the list of cases of slowly-progressive phthisis. Thus, only 8 out of the 29 cases were not included among those in which the course of the disease was favorable in the three aspects just named, and in more than one-third of the cases recovery took place. Of the 8 fatal cases, in all save 1 case the change of habits appeared to be beneficial. The benefit was marked in 2 of the cases, there being in 1 of them no evidence of progress of the disease for several months.[31] Moreover, the majority of the histories of the 15 cases of uncertain duration and termination show more or less improvement. In 7 of the 11 cases ending in recovery the change in habits constituted all the treatment. Making the fullest allowances for an intrinsic tendency in the disease to end in recovery, and in some instances purely from self-limitation, the foregoing facts afford ample proof that changes of habits from those more or less sedentary and confining within doors to those involving out-of-door life and activity have considerable agency in the arrest of phthisis and exert a favorable influence upon the disease when it is not arrested. There is reason to believe that the favorable influence is greater than any other class of hygienic measures, and it is probable that to this source much of the benefit derived from change of climate is to be referred.

[Footnote 31: For details of the changes of habits in these cases vide _Phthisis, in a Series of Clinical Studies_.]

The particular changes to be made in order to secure as much out-of-door life as practicable with a certain amount of exercise must of course vary in different cases. Clerks, school-teachers, mechanics whose business requires in-door life, etc., should, if possible, adopt some other occupation securing the desired objects. Students, clergymen, and men of leisure should systematically devote a fair proportion of time to exercise in the open air, and as far as {433} practicable the exercise should involve recreation. It is needless to say that the importance of change is as applicable to women as to men. Caution is sometimes necessary not to carry muscular exercise to an injurious extreme. If carried to the extent of producing great fatigue or exhaustion, it is debilitating instead of invigorating. Exercise within doors, although much less useful than when taken in the open air, is nevertheless useful. Gymnastic exercises may be recommended when other measures which are to be preferred are not available. They are inferior to rowing, horseback riding, hunting, etc. An increased expansion of the chest is apparently a desirable effect of exercise. Forced efforts of expiration to overcome a mechanical resistance, the lungs being fully inflated, constituted a method of treatment formerly in vogue, and I have met with instances in which it seemed to have been useful. In taking exercise patients are apt to imagine that in order to avoid catching cold they should go out of doors only when the weather is in all respects favorable. Precautions in this regard are often carried so far as to interfere materially with the amount of life in the open air which is desirable. It should be understood that phthisical patients are no more--and perhaps less--liable to catch cold than persons in health, and that a cold, as a rule, does not affect the progress of the tuberculous disease. These excessive precautions have arisen from the error of considering phthisis as a sequel of bronchitis. There is no ground for the great scrupulousness with which phthisical patients avoid the night air, although out-of-door life in the daytime is to be preferred.

Every practitioner has known of cases in which some remarkable changes of habits as regards out-of-door life and exercise have led to recovery, such as performing long journeys on horseback or on foot, accompanying expeditions which involved camping in the open air with hardships, etc. Several instances of this kind have come within my knowledge. In one of these the patient, a young physician who consulted me, on being told that he had incipient phthisis gave up his practice and joined a tribe of Indians in the Far West. He remained with them for more than a year, adopting all their customs, and returned in vigorous health. But in order to rough it a patient need not go to a distance from home and friends. This fact is lost sight of when physicians sanction the exposures and hardships of travel without the limits of civilization, but enjoin upon patients great care in taking exercise out-of-doors so long as they remain in their places of residence.

All who have had the opportunity of observing the effect of sea-voyages in cases of phthisis are agreed as to their utility. A long sea-voyage or a series of voyages entered prominently into the treatment of 20 of the cases which I have analyzed. In a large proportion of these cases the favorable influence was marked. This is an accessory circumstance which contributes to the benefit in many cases derived from a change of climate. It is evident that a certain proportion only of phthisical patients can avail themselves of this measure. It is to be advised especially for those who can leave home and business without anxiety, who are fond of ocean-life, and who as a matter of course are good sailors.

The supposed liability to, and danger of, catching cold often leads phthisical patients to wear an overplus of clothing. When they strip for an examination of the chest not infrequently they remove two or three undershirts, a woollen or fur chest-protector, and sometimes in addition an oiled-silk jacket. The body is kept in constant perspiration by these articles. They occasion not only discomfort, but debility. A single word expresses the governing principle in clothing--namely, comfort. Articles of dress should be so adapted to the seasons and to changes of temperature as to secure comfort. This maxim applies to persons affected with phthisis as well as to those in health. In some instances, from an erroneous theoretical notion, patients {434} make themselves uncomfortable in an opposite way. They dispense with woollen or silk underwear throughout cold seasons with the idea that the system is thereby hardened. A good non-conductor of heat next to the surface protects against changes of temperature and promotes the functions of the skin. Attention to the sense of comfort will enable the patient to avoid error in this direction as well as an overplus of clothing.

Other regiminal observances relate to ventilation and the sponge bath. The apartment in which the patient is expected to pass at least one-third of the twenty-four hours should be sufficiently large and well ventilated. Fresh, cool air in abundance is not deleterious, as it would seem to be regarded when the utmost care is taken to exclude it. It is essential to healthful sleep and invigoration. Here, again, the supposed danger of catching cold antagonizes hygienic treatment. Air should have free access to sleeping apartments in cases of disease as in health. As a measure for invigoration the sponge bath is often useful in cases of phthisis. The water used may be cool or tepid according to the sensations of the patient and the effect. It should be followed by a glow with a feeling of invigoration. The water may with advantage be made stimulating by the addition of salt or of alcohol.

Medicinal Treatment.--The medicinal treatment in cases of phthisis embraces no known remedies having a special influence over the disease; in other words, no drug has as yet been found to be an antidote to the tuberculous cachexia. Nevertheless, medicines in many cases form an important part of the treatment. They have for their objects improvement of appetite, digestion, assimilation, and nutrition, relief from complications or associated affections, and the palliation of symptoms.

Cod-liver oil is considered in this article, as is customary, in connection with the medicinal treatment. It has, however, little or no claim to be regarded as a medicine. It is a nutrient. It is a form of fat which patients often digest readily, and which evidently increases the weight of the body. That it does more than simply increase the amount of fat in the body is shown by the fact that frequently under its use the appetite, the digestion, the condition of the blood, and the nutrition of the tissues manifest improvement. These effects are not inconsistent with the statement that it is simply an article of diet. Although the claims in its behalf as a special remedy which were made forty years ago have long since been disproved, clinical experience has continued to furnish proof of its usefulness in the treatment of cases of phthisis. It should enter into the treatment wherever it is well tolerated and digested. If it occasion nausea or diminish the appetite or give rise to eructations, its use should not be persisted in. In the choice among the different varieties of the oil experience in each case is to be the guide. Some patients find the brown varieties more acceptable than the pale, and vice versâ. I have known in several instances the unrefined, coarse oil obtained at the fish-markets to be preferred. Patients should not give up this part of the treatment until the different varieties have been tried. The popular preparations in which the oil is combined with salts of lime or with some flavoring extract are sometimes tolerated by those who are, or who fancy that they are, unable to tolerate the pure oil. They have probably no advantage for those who are able or who are willing to take the pure oil. The oil should never be given in doses larger than are readily digested, and, following this rule, the doses will rarely exceed half an ounce. They are best given shortly after meals. It is a popular notion that the oil should not be continued in hot weather. The weather should have no influence on its continuance, provided it be well tolerated and digested. The addition of fifteen minims of ether to a half-ounce dose of the oil has been found to promote its digestion, and by means of this addition persons with whom the oil disagrees may be able to take it without difficulty. The ether is to be given {435} half an hour after the oil has been taken.[32] Salad oil, cream, butter, and the extracts of malt may be made to supply, in a measure, the place of the cod-liver oil in the cases in which the latter is not tolerated.

[Footnote 32: Vide report by Dr. Andrew H. Smith, chairman of Committee on Restoratives of the New York Therapeutical Society in the _N.Y. Medical Journal_, April 20, 1879.]

Embracing the varieties of spirits, wine, and malt liquors under the name alcoholics, these are to be regarded as alimentary, but also as medicines. That they are useful in certain cases of phthisis is as well established on the basis of clinical experience as any fact in practical medicine. Their usefulness in this disease, as well as in other diseases, is to be considered irrespective of questions relating to their use and abuse in health. But as bearing on the very important subject of intemperance it may be stated that, administered purely as remedies in cases of phthisis, patients do not become so addicted to them as to make it difficult to relinquish their use whenever this is advisable. This statement is based on a large experience.

Alcoholics are useful in some and not so in other cases. The question as to their usefulness is to be decided in each case by trial. If they produce a sense of comfort without any excitation of the circulation or of the nervous system, they are likely to be useful. If in lieu of a cordial effect they occasion flushing, weariness, or indisposition to exertion or discomfort of any kind, they are not likely to be useful. The quantity to be given is to be regulated by the immediate effects. There is sometimes a notably increased tolerance of alcohol. This is to be ascertained by experimental observation. The quantity of alcohol given should never occasion the least approach to alcoholic intoxication. It should be given at or near the times of taking food, or in combination with food, as in milk-punch or egg-nog.

As to the choice of an alcoholic, this is to be determined by the past and present experience in each case. Each of the many varieties of spirits, malt liquors, and wines is best suited to some cases and not to other cases. There is no rule of choice applicable to all patients. Changes in the form of alcoholics from time to time are often advisable in the same case. In the majority of cases some forms of spirits will be found best to agree. Malt liquors, either the strong or mild varieties, agree best in some cases. Of wine, some patients take with most comfort the light and some the stronger varieties. The effect upon the pulse, respiration, and other symptoms should be observed with reference to the employment of any of the alcoholics, and of the particular ones best suited in individual cases, but much reliance must be placed on the subjective symptoms. It has been proposed to substitute pure alcohol for any and all the alcoholics used as beverages, in order to give to the treatment more distinctly a medicinal character and to avoid risk of the formation of a habit which may lead to intemperance. Since, however, of the many varieties of alcoholics, some agree in certain cases and not in other cases, it is doubtful whether alcohol is able to take the place of all. This is a point to be decided by clinical observation.

Phosphorus in the form of the hypophosphite of soda and of lime was recommended about forty years ago on the theoretical ground that it favored cell-formation and retarded the rapid waste of the tissues. More recently it has been supposed to have a specific influence over tuberculous disease. It has been employed pretty largely in different countries, but without effects sustaining the claim of having a specific action. It seems to be useful, and many physicians attach considerable importance to its use.

The preparations of iodine, from their evident utility in certain scrofulous affections, and in view of the identity of scrofula and tuberculous affections, have heretofore entered largely into the treatment of cases of phthisis. From the fact that they are now but little employed in phthisical cases it may be {436} inferred that in this instance, as in many other instances, theoretical considerations have failed to find support from clinical experience.

Of arsenic it can be said that many able observers have borne testimony to its great usefulness in some cases, as manifested by improvement in appetite, nutrition, and in the powers of life generally, together with the cough and expectoration. Here, as in other instances in which it is desirable to continue the remedy for a considerable period, the doses should be small and not increased. Noël Guéneau de Mussey testifies to a remarkable efficiency in some cases of the mineral water of Bourbole, either exported or taken at the spring.

Sulphur, especially as contained in the Sulphur Springs water, has long been considered a useful remedy in phthisis as in other chronic diseases. The Sulphur Springs of our country, however, although much resorted to for other diseases, have not in phthisical cases with us the celebrity which those in Europe (of which Des Eaux Bonnes are a famous type) have with European physicians.

The symptomatic indications for medicinal treatment in cases of phthisis are many and varied. Among the most important are those relating to appetite and digestion. For the improvement of these functions the preparations of cinchona, salicin, gentian, quassia, and other of the vegetable bitter tonics, including nux vomica, may be selected, according to the choice of the physician, or given in succession. They have more or less efficiency in conjunction with the more potential hygienic measures considered in connection with the climatic, the dietetic, and the regiminal treatment. Pepsin and dilute hydrochloric acid, taken after a meal, promote its digestion, their medicinal action being, however, limited to the meal in connection with which they are administered. The tincture of the hydrochlorate of iron and other ferruginous tonics which are much used in cases of dyspepsia and indigestion are useful in cases of phthisis. The anæmia which exists so constantly in phthisical cases is an indication for their use, and there does not seem to be ground for the conjecture which has been entertained that they promote the occurrence of bronchial hemorrhage. If they had this effect it would not disprove their utility.