The Frimley Sanatorium Routine.

Otago Witness, Issue 3061, 13 November 1912, Page 4

The Frimley Sanatorium Routine.

THE TREATMENT OF CONSUMPTION

BY REST, EXERCISE, AND WORK. Recently an interesting and important advance in the treatment of consumption has been made by Dr Marcus Paterson, of the Frimley Sanatorium. It is known as the treatment by auto-inoculation. To make clear what is meant by auto-inocula-tion, and to show how it may be applied to the treatment of consumption, it is necessary to explain, broadly, what hapfens when disease germs enter the body, f the conditions are suitable for their growth and development, the germs by rapid multiplication establish a headquarters, or focus of infection, as it is called, and as they grow they produce substances known as toxins; which may pass into the blood-stream and act as poisons. It is this passage of germ poisons, or toxins from the focus of infection to the blood-stream that is called auto-inoculation, or self-inoculation (for the subject inoculates himself with the toxins of his own disease). Auto-inoculations are induced by any movements that affect the focus of infection, and -they occur more readily when the focus is situated in close contact with the blood-stream, as then, the toxins escape easily into the circulation.

When toxins enter the circulation the blood responds to the invasion by producing substances that neutralise the poison. These protective substances are called antibodies ; and it is important to remember that they are called into being bv the action of the toxins on the Wood and tissues. The poison excites the production of its own antidote.

Now, whether any bacterial invasion succeeds or fails depends upon the power of the blood to produce a sufficient number of anti-bodies. In a normal healthy person the defensive power, of the blood is high, and gems are unable to obtain a footing, for no sooner do they enter the body and'begin producing toxins than,the blood at- the first scent of battle calls up a vast army of anti-bodies, which completely overwhelms them,. In a weakly person, on the other hand, the germs establish themselves at some spot where the tissue defence is particularly feeble, and begin pouring their toxins into the blood. If the discharge of toxins (autoinoculation) is too frequently repeated, or the doses that enter the circulation too large, the blood response is inadequate, the available anti-bodies are defeated time and again, the disease progresses, and unless the auto-lnoculations are checked the patient dies. But if the doses of toxins are small and not too frequently repeated the chances of the blood are better. For a small close of toxins may result in the production of a force of anti-bodies more numerous than is needed to repel the invaders. : Some of the antibodies survive the encounter, and thus the blood is in a better position now than it was before the engagement, for it possesses the elements of a reserve force. Another small invasion is even more easily repulsed, and the reserve force is increased in numbers by another draft of surviving anti-bodies. In this way, step by step, a large reserve force of anti-bodies is built up, and stronger and stronger invasions of toxins are repulsed. At length a stage is reached when, no matter how large a dose of toxins enters the circulation, the blood is able to counteract its effects, and the patient remains tree from symptoms — the disease is arrested. Finally, the blood, with a vast army of veterans, attacks the germs in their stronghold, utterly defeats and eradicates them, and the' disease is cured.

This happy result could not have been reached had not the toxins stimulated the blood to produce anti-bodies. Auto-inocu-lations. therefore, are necessary for the cure of a bacterial invasion. Indeed, it is only in tin’s way, bv the gradual augmentation of the defensive power of the blood as a result of successive auto-inoculations, that many diseases caused by germ infection can be cured. Attempts are made, and with a certain amount of success, to act upon the blood with toxins introduced by a hypodermic syringe, as in the tuberculin treatment of consumption; but Dr Paterson has shown that advantage may bo taken of the natural process of auto-inoculation, and he has taught us how to control and direct Nature’s curative efforts.

In the light of this explanation, it will he seen that in the treatment of a disease like consumption the aim should be, firstly, to restrain auto-inoculations when the blood is poor in protective, substances, and so unable to deal with thorn; and, -• secondly, by artificially inducing autoinoculations carefully adjusted to the protective power of the blood and tissues to gradually increase their anti-toxic pro- Tperties until eventually they are able to : ■ cope successfully with any anto-inoulation,’ : no matter how severe. The practical means by which these two ends are served; * ‘ are summed up by Br Paterson in the' ! two words “ rest ” and “exercise.” It'- 1 *' is now necessary to consider the party*'* played in the treatment by these two I '', factors. " " ■ ‘ ’ ' - :tV *

A MEAN’S OF RESTRAINING EXCESSIVE AUTO-INOCULATION. A consumptive patient suffering from fever, headache, loss of appetite, and pains in the back shows the symptoms that appear when auto-inoculations exceed the power of the blood to deal with them. These auto-inoculations, therefore, must restrained, and as they- are caused by movements affecting the focus of infection, this may be done by keeping the patient at rest. But to be effective the rest must be absolute. At Frimley Dr Paterson sub- ' jects his feverish patients to what he calls complete immobilisation. They are put to bed and treated, with the exception of the diet, exactly like a patient suffering from typhoid fever. They are not allowed to move in bed, to read, to wash themselves, to cut up their food or go to the lavatory. As cough increases the activity of the lunge and so stirs up the focus of infection, every effort is made to restrain unnecessary coughing. Talking is interdicted, and therefore visitors are prohibited. To prevent patients being worried and so made restless by the receipt of bad news, letters are censored. In the case of patients who have been feverish for a month or more, this treatment is continued for about a week after the temperature has returned to normal. Then for three, days the patient is propped up in bed and allowed to read. If with this his temperature remains normal, he is allowed to sit up in bed for half an hour, and if all goes well this period is gradually increased until he is able to be up all day fully dressed. The success of this method of treatment depends largely on the willingness and ability of the patient to submit to the restrictions. Figure I is the chart of a patient who would not lie still in bed. Compare it with figure 11, which is the chart of a patient who faithfully observed the principles of complete immobilisation. EXERCISE A MEANS OF INDUCING AUTOINOCULATION When the excessive auto-inoculations have been controlled in the manner described, the next step is to increase the resisting power of the blood and tissues by inducing auto inoculations and so driving larger and larger doses of toxins into the blood. This is effected by increasing the movements of the lungs, and it is carried on until the patient is able to take severe and prolonged exercise without suffering from fever and constitutional disturbance. It is also necessary to improve the patient’s general physical condition; and these two ends may be accomplished by a system of graduated labour. At Frimley the system includes a preliminary period of walking exeircises and six grades of labour. Walking exercise is prescribed for all patients to begin with Those who have been in bed with fever start by, walking half a mile a day, the remainder of the day being speii*; in resting. The half-mile walk is continued for a week, and then If all goes well—that is, the patient remains free' from fever and headache, the distance is increased to a mile a day for another week ; then to two miles a day for a further week, and then to four, and finally six miles. When patients reach the four-mile grade they are required to sweep and clean their wards, make their beds, clean their windows, etc., in addition to walking, and this housework is required of all patients who are in or who have passed the four-mile grade. Under favourable conditio'ns patients pass through these grades automatically ; but if on any grade a patient shows symptoms of constitutional disturbance, he is either subjected to complete immobilisation if the symptoms are severe enough to warrant it, or he is continued on that grade until the symptoms disappear. If a patient is admitted to the sanatorium who has not been in bed with fever but has been engaged in manual work it is unnecessary to start him on the half-mile walk. As a general rule if • patient is able to be up and about all day and is in fair physical condition, he is started at one? on the two or four-mile grade. Patients who have completed the six-mile walking grade pass into the first grade of labour, which consists in carrying small baskets containing various materials a distance of about 50 yards. The weight carried is about 101 b, and the distance travelled in one day is, roughly, seven miles. If patients pass through this grade without showing constitutional symptoms they are advanced to the second grade at the end of a week. This consists in carrying large baskets containing about 181 b weight of material. The third grade consists in doing light work, such as chopping firewood, sweeping paths, cutting grass edges, hoeing, etc., and patients remain on it for about a week. In the fourth grade patients use a small shovel, and on an average dig two tons of earth a day and raise it seven feet into a cait. Mowing grass with three iren to a 16iu mower is equivalent labour. In the fifth grade a la rue shovel is used and heavy navvv work of every kind is undertaken. Patients on this grade can lilt six tons a day a distance of seven feet, or mix 10 tons of concrete in the same time. In the sixth grade patients spend five hours a day at the hardest navvy work, in addition to the one hour’s indoor work, which is incumbent upon all patients in the labour grades. The working hours for patients in the first five labour grades are from 9.55 a.m. to 11.50 a.m.. and from 2.30 p.m. to 4.50 p.m. Patients in these grades are required to rest from 12 to 12.45 p.m. In grade 6 work is carried on from 10 a.m. to 12.45 p.m., the rest being omitted, and from 2.30 p.m. til! 4.50 pm. If patients show constitutional symptoms as a result of overwork and are obliged to rest, they are permitted, after a few davs* walking exercise, to start work in the grade reached when they goffered from over exertion. I**tlents who pass successfully through thise grades are before their discharge put to work at their trades in order that

the muscles used in that particular work may become accustomed to it. The grades of work for women are the same as those for men, but women are not allowed to work so hard as men, and the various implements used are of smaller size. They keep in order their own part of the grounds, cultivate a small kitchen garden, and look after the poultry. The final stage for women is the same as for men—namely, digging gravel in a pit. It may be thought that this work is unnecessarily hard for women, but in practice women are found to be quite capable of doing it without injury, and in theory it is necessary that they should do it, for the object of it is to induce auto-inoculations.

It must be clearly understood that the rest enjoined upon the patient is as important as the labour. Ii a patient does not remain at rest when he should, or if in his enthusiasm he exceeds the task allotted to him, he inoculates himself too freely with toxins, and accordingly suffers constitutional disturbance and affords the disease an opportunity of progressing. Figure 111 shows the effect of walking exercise on the temperature of a patient who ought to have'been resting; forgetful of the fact that he was under treatment, he went for a short walk of half a mile, with the result shown in the chart. Even playing the piano must be regarded as exercise, as Figure IV shows. Patients are not allowed to play outdoor games until they have reached the basket stage, for

they are apt to get too keen over the oames. and. forgetting that they are under treatment, exceed the prescribed amount of exercise.

Care is always taken to give tlie patients useful work to do in order that their interest in it may not flag and that they may enjoy seeing the result of their labour. That at Frimley tin's object is successfully attained is abundantly shown by the illustrations. ADVANTAGES. There arc- advantages in the graduated labour system apart from the specific one of increasing the patient’s powers of resistance by th j inducement of auto-inocu-lation. lii Dr Paterson’s own words: “Everyone knows the demoralising effect produced upon the sick of long periods cf mental and physical activity. It is one of the most difficult problems that confront our hospitals and sanatoriums. When bodily strength is lowered by sickness and mental vigour is weakened by disuse, listlessness, ennui, and morbid depression act anch react upon each other in endless vicious circles. In this connection graduated labour has a moral value which it is difficult to over-estimate. Many patients when they first start work are remarkable for their sullen and apathetic attitude: as soon as the bacterial products become influenced and their physical condition improves. all trace of gloom and depression

vanishes and they become transformed into cheerful and lively individuals. Outdoor work is, 'of course, an admirable antidote to physical and mental disorders; it is a healthy occupation from every point of view; it hardens the body, and diverts the mind. But the value of graduated labour to the consumptive is much more than this. When it is remembered that the average patient going through the treatment spends a week on each grade of walking, a week on the first three labour grades, a fortnight on grade 4. three weeks on grade 5, and three weeks on grade 6, it might well be supnjd that the process is monotonous and . This is the reverse of the truth. To the patient who wishes to regain his health and return home, the grades are definite steps in his recovery which he is slowly but surely mounting. As the days pass he observes the diminution in his expectoration, becomes conscious of increased physical fitness, and realises without medical prompting that he is making steady progress. Even if he receives a large dose of bacterial products and is sent to bed, he knows he will start again on the step where he left off and Bot at the bottom of the ladder. There can he no monotony to the patient who is aware that each fresh grade he reaches marks a higher level of improvement and sees around him in his fellow patients practical object-lessons in the successful result of the treatment.”