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 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.
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 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.
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 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