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 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 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 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.
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.