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OPEN AIR CURE., Star, Issue 7024, 14 February 1901
OPEN AIR CURE.
THE NEW TREATMENT OF CONSUMPTION. : FRESH lIR AND GOOD FOOD IN PLACE OF DRUGS, " (By R. M- SMYTH? M.D., Lond.) A .Paper read bef^Tthe Englislr Medical * Society. ..■••„ . Dr Hermann Brehmer, in commencing his fcook on the treatment, of Pulmonary TuberSc treatment, usually, of. vanned stages of the disease,' He proceeds toShow how, when forty^ years *g° «« Vised a special instrument for the appUcaKTof hygienic methods, namely, his however, fronvthe certain Evidence of pathology, that it was curHbk, Lough with difficulty ; he saw the vast imfeortfnce of, alt-ring the patients environment so that it left nothing to chance, and & first laid down definitely and explained fcfe best mode of applying those man,.principles, ferine, rest, cradiiated exercise, SS Me in fresh air. The virtues of fresh fek are now wde known by our daily Press, the oth P v factors of Brehmer's InMJ fcave never, however, been carried out thoroughly enough in this country. Brehmer also clearly saw that to carry, out these principles effectually one absolutely must have two conditions, constant S£»r supervision, wMi the care that .u Wowed on a case of tvphojd fever, and 51 from the distracting influences of bivilisation. His imitators however, as he nimself bitterly complained, have so whittled down hi" system, that to-day, shorn of its more important features, any hotel iberrace is sufficient "property for what fs perhaps Vf 11 termed -THE ATR CURE." ]">r DettweilT. his -pupil and former patient, nr'*- nvid« a. new departure by erect ins? a- R.T.nitorium . at Falkenstein. m +hex*Tann«s TT'IV. within easy reach of-jVs.nkfcrt-on-ibe-Ma-in. Falkenstein has lately received a meeo 1 of praise which, so far as the patients" comfort. :< concerned, is perhaps deservorl. but behind the scenes one regards the place from a different aspect. As I have se e n a number of patients cured elsewhere, who failed entirely ait FalkenBtein. T cannc+ regard it or an v sanatorium pimilar'.y ■t-nndurted as an ideal. Conversations, V" fll nnt rT)^ v v .t>srHfh. , peonle-, but also f'tiyen? of Frankfort- who haw been treat-ed iliP^e. -c^nv'nred me that it fails in the two pointy wihirh Brehmer laid so much : ffress upon— idpquatp supervision, and freedom from, th? prejudicial effects of society. iA visit there confirmed'tny ideas. The institution is far t6?,lanre: tnoreoyer, Dettweiler jr»-ve up the plan of graduated pxercise. maldna lii« patents r<?st upon deckchairs in otien verandah's, a svs«tem aui+« inadpouate for feibrile cas(=s, wh«i ouorbt tr» rest bv themsplv'fß in bed ; ulisi'itable a]po for those who have no fpver. for they should not. lie about, but start at once a course of graduated rx€rcis«*. - There was 'Falkenstein, however, an ob'ject lesson to the Frankfort people, very comfortable for patients and their friends, and easv of access. It is not, perhaps, astonishing that it has been imitated iti most European countries. A sanatorium for consumptives, however, 'must be something far more specialised than fc first-class hotel with resident, physicians. ,' We have heard much of Falkenstein, but, tmtil recently, little of an. institution whicli .txrmy knowledge has cured cases that were losing ground and even dying at FalkenIsbein.- This is Nordrach. in Baden, founded ten years ago, by Br Otto Walther, of ■ ••" 'Fra»4cfort. after a successful attempt to 'cure a phthisical relative. He followed out Brehmer's original principles and pushed them still further. Perhaps it may be in'teresfing to detail my own experiences in connection with Nordrach. ' Tie illness of. a friend who was cured Wiiere six years ago first- directed my attention to the institut'on. ..Tn thp beginning of 1896. I was myself rapidlv stricken down with what seem-v^ at nrst like acute miliary tuberculosis. . The', pneumonic signs were, however, limited to the right upper and . middie lobes. The attack developed the usual ■ symptoms of ,an a«ute tuberculosis, bigh continuous pyrexia, night-sweats, great emaciation, scanty sputum at first, later be- ; comrng nummular.-wit-h rapid softening and 'considsrn-ble exrav;itiop of the ricrlit upper lo*be. After fpven w«cks in bed T was carried out of doors and al!owed to lip out on a long chair, though pyrexia w:>s still of continuous type. I then tried, without appetdte, but with Nordrach ideas, to * EAT PLENTIFULLY, especially of such fatty and farinaceous foods as I could most readily ta.ke. These happened to be fat bacon, and wheat'-meal and maizo jiT^idp-ep marie v : th T>«vnp.shire '.ire^rv "" v -n T hern > rut -- Pesh.-arid, in July. 1896, was enabled, with special arkmgements, to be taken to Nordrach. , My 1 condition, 'however, still seemed hopeess, pyre-xia remained continuous and 1 my *BMjf|tib wae very 10-w. MV *ri*nds wera
sent away, I was not allowed to be out of bed, and saw only the doctor aund a nurse who spoke to me as little as possible. .The windows were wide open day and night. The reaction after the. journey appeared in a few days, and a sudden acute spread of the disease occurred, with fever ranging at first between 102deg. F. and 103deg. F., complete prostration, and delirium at night. My diet, however, was of. solid food in three meals a, day, a dinner, for example, consisting of a" plat© of fat pork and potatoes, a large portion o>f chicken, salad, and more potatoes, then some pastry or pudding. The effect of this diet, which I took in spite of indigestion, was noteworthy. In the first three weeks it seemed to be expended in combating the high feyer, no weight was gained, 'but 'strange to say, ncne was lost. In the rrext fire weeks I gained 221b. the temperature came down gradually till it touched and came below normal in the mornings,' for the first lime during four and a half months. The further course of the illness was. uneventful, final arrest ensued after a'year's+rea-tmentait-Nordrach, and a total gain -there/of 451b' weight. My weight is now two stones more than it formerly was in health, when, be it noted-, it was -much below the normal for the Same height and build. Though this case was more acute aiid therefore more striking than the majority, it is quite illustrative, and by no means exceptional. At first .-.the Xordvach treatment differed only in degree from that carried out at- home, ..but with- a very different result, which was owing to. ai- much -fuller feeding under conditions of perfect rest. .Dr Arthur Kaiisoorie (" British Medical Journal," July 9, 1898), says : "Wonderful results- have 'indeed -been obtained by *he ' stuffing ' plan osf Debove. Watther, and others, but our. aim -#i quid be true physiological feeding, and we should endeavour to nourish the "body to the utmost, without overtaxing t he. eliminatory organs. " Personally, after eighteen months' careful ' observation' of DrWaltJher's methods at Nordrach," I prefer the system which obtains wonderful results, and regret that a scientist should criticise methods which. are assuredly physiological, from a knowledge of facts which must- have been of the scantiest. ' Jfordratfh treatment, is tinged with the ■ powerful personality of Dr Walther. and that accounts for .much'" of its success ; but apart.fromthis Nordrach is not to be classed wit-h the large number of sanatoria' which have followed the lines of Falkensrein. Its methods are quite distinct, though the funda'menital principles — feedirog, rest and fresh air—are, of course, the same. I 'have lived long enough, at Dr Walther's institution to be certain that tihere is no other sanatorium the results of which can •be compared with his, and that this success depends upon totally distinct lines of treatment which can be carried out quite well in our own climate, -where '■ the same conditions, a small -community of patients, isolaited from towns and traffic, obtain. TWO POINTS OF VITAL .IMPORTANCE, .the treatment of fever amd the question 'of diet, I will discuss afe length. '"^ Brehmer says in 'his book that a usual history of the consumptive is that he has never been a good eater. Whether or' no this be the case, the fact remains that tuberculosis most often seizes upon individuals whose body weight is much below the standard' for ■their height and build. Malnutrition and oyef-exertion, in- ithe widest sense possible, probably, contribute 'the, best. conditions for infection with the tubercle bacillus; Malnutrition may be due to constitutional 'habits formed in childhood, such as Brehmer alludes to, or it may be acquired later from circumstances of life. The sedentary pursuite, mental worry and rush of city life, tend to produce loss of appetite and dyspepsia, but ardent physical toil may also produce the same effect from insufficient rest. One knows how difficult it is to eat heartily -when much fatigued. These matters ■probably have a most importamt bearing in the production of a condition whiclh pre-exists And pre-disposes to infection with tubercle. If we study the general methods of "dieting consumptives, we find that-tlhe spirit of /the treatment may be thus roughly summarised: — (1) A slop diet for .cases with high fever ranging 'between lOOdeg and 105deg F. (2) For chronic cases, a diet limited in quality and quantity, to avoid, or to combat, .dyspepsia. * In a practical book by Dr Harris and Dr Beale, " The treatment of Pulmonary Consumption " (1895), we find laid down : — (a) That feeding in the case of a marked degree of fever should usually be with milk diet, of which three litres a day are given. "But then," the author says, "as the metabolism of a patient in bed is not likely to be so great as if he were up and about, we. may diminish the amount of milk to two and a half litres;" ignoring the fact that the patient's destructive metabolism through fever is enormous. Again, as milk is not always liked j" he further reduces the quantity to one and a half litres, and adds one litre of broth. This diet gives 430 grams of solids per diem. Tf the patient is worse we are recommended to give milk only. If he improves, he may be ordered a little egg or fish. . •■■-• ■■■<";■ ■- • -■•'■• . (b) '"-When th£ fever i« not marked, " says the author, '""the patient is up, and so tissue change, may. be greater, and be wants more food.". 0 When digestion is good, he may have for dinner, soup, mutton^ sometimes beef ,. greens, And "one me-dium-sized potato/' milk pudding, seldom cheese. Tinned, and potted meats are to be avoided, also creams and pastry, salmon, mackerel, eels, herrings, sprats, a,nd pilchards, should ako be avoided, as they contain much fat. Swine's flesh, ham and hacon, and uncooked fruits are not to be eaten as a rule! I am well aware that this is only a general scheme of dieting, but it reflects accurately the usual spirit of practice. The Nordrach. mode- of treatment is as follows : — " • (a) The diet i« exactly the same for febrile cases as for others, if anything, the quantity given is rather more for a patient in bed. (b) This diet is as varied as possible from day to day, and the quantity rather large, indigestible things, such as hare been mentioned, are all included, the very items in the preceding list being frequently given, because they are nutritious, and RICH IN FATS AND CARBOHYDRATES. (c) The carbo-hydrates and fats are kept in due excess of the prbteid element of the diet, for the physiological reason that a relative excesa of .carbo-hydrates and fats -tends to promote constructive metabolism, whilst a relative excess of proteid tends to_ produce the opposite effect. The consumptive naturally does not know this, and often thinks that if he eats his meat he may neglect potatoes and bread. As regards the quantity of iood actually taken at Nordrach, it is kss than is usually supposed. Two years ago, by \v pi filing patients before'and after meals, it w;<s found that, on an average, 1150 — 2500 grams of solids and fluids were taken daily by, each patienf,- of which. 600 to 700 grams were solids. This was the amount actually taken, as. well as prescrißed. The usual mode of dieting consumptives assumes that .only ■ easily diges-tibW food can be assimilated, and that wasting depends upon this inability to digest. Dr Walther, however, has demonstrated that, given perfect conditions of mental and pjljjsdoal refits the digestive powers oi tie
consumptive are quite capable, even in '. very advanced cases, of restoring the natural body weight for the patient's height ' and build. I can hardly remember a single case, out [ of scores I have seen treated, at Nordrach, , in which a gain in weight did not begin ' almost immediately. This does not appear L as though there Was incapacity to digest, more especially when we remember that the greatest gain was made in the beginning of the treatment, long before digestion , had time to benefit .by rest or change of climate. The most rapid rate of gain I . have known was 151b in thirteen days, al- \ so 71b in five days, the German 1b being . one-tenth more than the English. Such are cases of sudden rebound, from . starvation diet of Bovnl or other " nutritious" meat essences to a plentiful- and varied solid diet. Dyspepsia, which had induced the patient to cut off first one and then another article of his diet, disappeared by degrees under the increased nutrition produced by a resolute consumption of socalled " indigestible " but nutritious articles of diet. It is common for patients to go on improving in spite of anorexia, in spite of dyspepsia, in spite of occasional vomiting at meals, until 20, 30, 40 or 501b, and occasionally much more, have been gained, in fact, until the normal body weight has been made up. There can be, therefore, no positive incapacity to digest; the consumptive can digest very well indeed when placed in the proper conditions, one of the' easiest things in the treatment being to make the. patient gain weight. It by , no means follows that because he becomes fat he will therefore be cured. This also depends upon whether at the right period he obtains A STRENGTHENING AND REORGANISING STIMULUS from graduated exercise. The histories of patients treatrd 'at Falkenstein, who have later obtained a cure at Nordrach, have been satisfactory at first;' Weight was gained, but after a time no more, the appetite failed, and the patient remained stationary, or began to fall back. It i? exortly at this period, which I call the "tug-of-wnr" stage, that the careful supervision and moral suasion employed at Nnrcirac'.i come to the rescue. Dr WaJther once fed a patienr for several months with his own • hand, literally pulling him through this critical stage. What establishment, conducted on merely commercial lines, could do this; what price could buy such de- , votion? But all this should hs done when .needful, if advanced and apparently hopeless ! cases are to be cured. The. dyspepsia of phthis'i?. then, is l<> be regarded rather as the outcry of » we».k aiut starved organism for adequate res: and ample nourishment than Ai an indini * tion for limiting the dietary in any way. We usually 1 say "If the fever will abatr. his digestion and nurffcion will improve." Nordrach teaching takes an. opposite view. •'We must- improve nutrition at all luiziud-. and that will cause the fever to abate, ti; tubercular process to subside, and digestion 'will' improve later on. The ii».puivrmint r of nutrition is the key to the situation, and it has always seeimd to me, after 'watching many cases go through this process, at- Nordrach, as if pulmonary tuberculosis set up a sort of vicious circle in the organism. Dependent for its inception, perhaps, upon a previous state <■ ' malnutrition, it sets up. fuilli-i'. loss_. appptitf. dyspepsb. and waff in--. In. fiiKbles the tubercular pn»ce:-K advance and to r.ht.iin a firmer hold. In-,, wretched patipnt. then limits the quantity and variety of his food. indu.r.ifurther wasting, and assisting the disease Later on he dies of tuberculosis accelerated , by starvation. ' The first thing to do is to break down this vicious oireK fftpn o. HiffT-nlr rhmg to d'. At the first onset- of dyM?°ptir rro'iolfn i ■ patient wi?-jes io civ^ up. ' ; » l ;i ' iif humoured, re'.n-pses into, a do^d c,~.,ir... Ifc is a cafe of Smdbad ana 1 the Old Man o. th« Sea over again. Jfciteition, therefore, is -the fireat- lewr
which, taking as .its fukrnm -the patieat".* resisting power, brings about arrest of t-.e tubercular process' under the right conditions of life, rest an'd.graduated exercise, and. ol course, existence in ihe free air o.f Heaven as mankind lives in, a . 'li-nliliy natural state. It is not enough to spend 'hai! C- an -hour at Nordrach. but no one. who can stay there j for a reasonable period could fail to be pro- j fnundly convinced t'hat Dr Wa-fther's (practice is .not' a passing fashion of 'treatment. It is indeed a perlfecly 10-gical system, devised by a n exceedingly able main, whose only ambition is to be let alone 'to pursue his daily task. Besides being cuntive. it -goes deeply into the -matter otf prophylaxis ; if .it could be applied always-. 'in 'the earlier stages, 1 believe we should rarely see advanced cases of the dispase. Sam-atoria in -t'his country will succeed so far as they -are CONDUCTED UPON/LIHE LINES OF NORDRAIOH. In my judgment it is a great advance irt, medicine.' which will go far to realise the dictum pronounced fifty years ago by Virchovr: "It is the duly of mankind .to over-, mme tuberculosis, just as scurvy has. beenj. overcome, and perhaps there is more signifi-; canoe in the comparison than- Vi^cho-w meant' at that: time, for he indicated thereby that tuberculosis, like scurvy, is intimately connected with malnutrition. TEHPEBATCRE. The accurate estimate of temperature is: bound up with the effective treatment ot phthisis. • It is esseutnl to start correctly in this matter, and the reason is not far' to seek. Dr J. Kingston Fowler some years ago called attention to the fact that by observing: the temperature in a case of pulmonary tuber-, culosis. it was possible to determine the nature exf the processes at work in the lungs. For our purpose the most important facts are briefly these: — . 5 The height of the temperature in phthisis, especially that taken in the morning, gives a clue to the degree of activity of the tubercular process; Usually if the morning temperature is constantly above normal, namely, 98.6deg F. or 37deg C, active disease, i.e., active deposition of tubercle, is going on. The higher the momirtg temperature above normal, the more active ther process. If the morning temperature falls and remains sub-normal, quiescence of the active process is indicated, but if there is still som evening fever, probably a slow disintegration of former deposit is goin'g on. The higher the evening temperature, the less likelihood that the tubercular process is becoming quiescent. Now the usual mode of taking temperatures in -the mouth is inaccurate, and should never he. employed in pulmonary tuberculosis, for the degree cf pyrexia present dctcr- ! mines our treatment. The temperature taken in the mouth is usually one-half to one and a half degrees too low, neither is it uniform. The only way to assure a uniformly correct .temperature is to take it always in the rectum. The reason for this is simple. The mouth is a cavity often open to the outside air. and a thermometer .placed' in it does not give the temperature of the blood; unless it has been shut for some time, twenty minutes at least, or more. The rectum being a closed cavity kept shut by a sphincter gives the Kood temperature in the time th-e mercury takes to rise, one-half to two minutes. If. then, a thermometer be placed in the rectum, for two minutes, -vie have ■rhe-"c.orse«t/-t«niDera-ture. ■ * ' I think the bearing of these facts is apparent. A quiescent tubercularp process, as indica-ted by the temperature taken in the mouth, may be in reality a, case of active disease, when the temperature is taken per rectum: ' Fr^rtiymy own observations I believe this is wliit often happens. I saw several cases last year -'coming from other sanatoria and Swiss )ie*jth resorts in which the- temperature taken in the mouth has been normal and the patients were allowed to be up and about. On coming to Nordrach they were found to have morning fever as indicated by the rectal temperature, and were therefore kept in bed. Then progress began to be made. Before, the patient's resisting power had no chance to combat the disease, for it was being - - FRITTERED AWAY IN EXERTION. Let me narrate a case in point. An English barrister,' who had slight phthisis, spent six months last winter at Davos. On coming home, his health broke down again. Last June he applied for a vacancy at Nordrach. Meanwhile he wrote to me from Pontresina for some advice as to the treatment. I obtained fragmentary temperatures from him taken in the rectum, which showed that the disease was slightly active. 1 therefore told him to go to bed, enjoined absolute rest, and ( the right dieting. He stayed in bed a- week, and then got up and walked two" miles ; the next d\y he had slight hsemorrhage, which frightened him, so he now kept in bed till his temperature was steadily quiescent. Then he got up, and began to walk more • cautiously'.. In November last he entered Nordrach. During his five mouths of waiting, which was spent chiefly at Davos, he had gained two and a half ft ones. Pnrilli disappeared from his sputum in December, and he wrote me from Novdrach snyincr he had been prescribed long walks at once, nnd hoped .soon
to complete his cure. Why <Ud not these results take place in his first winter at Davos? Doubtless because lie was not treated as a case of active tuberculosis. As it- is, the success is, of course, claimed for the aiv of Davos. ■Dr Waller has found by experience that, a patient whose morning tempera lure is above normal 98.6 deg. Fall., or above 100.4 deg. Fah. in the evening, slum id be absolutely at rest in bed in perfectly quiet surroundings. The higher his temperature, the more netd for rest, both mental and physical, and especially apart from friends and home influences. It is, strange to soy. generally useless to treat a patient in home surroundings. When, however, the temperature keeps below, normal in the morning and in the evening below 100.4 deg. Fah. for about a week, the patient should get up ami cautiously begiu graduated exercise, the *U S ' t-an.ee. depending chiefly on the- state of nutrition and strength. If the temperature remains quiescent, the distance can be increased, always noting the tffect of exertion nn the temperature taken immediately after the walk. This leads me 'to other important points. Plvysica! and also mental exer-" tion have a marked bearing up on the tubercular process. What- the .precise connection is, it remains for clinicans to tell us. It may be noted, however, that the fever usually met with in tubercular disease presents an exaggeration of the normal physiological diurnalv variation. ■•V A 'healthy man's. ' temperature after a sound sleep is sub-normal. ' As soon as he gets out of bed it rises. In a passive state h:s temperature is about 98.6deg. Fah., or a little higher, 99deg Fah. ;. after exercise the temperature rises to 99.5deg or lOOdeg Fah. If it is violent, even, more. ■vl The temperature in quiescent cases of j>ultuberculosis behaves in a similar way, but the temperature after exertion may be higher and may remain high longer than in health. I have observed .by asking patients to take their temperatures several times during a walk, that there is a rise to a maximum dm'ing exertion, and then a decline if the exertion is continued. On resting after the walk, the temperature falls, sometimes with great rapidity, often urthe first two or three minutes aTter resting. . When, however, the" disease is barely ,ijuiescent, or if exertion has been too great, 3|his temperature is higher and falls' more: sjo.wly after rest, merging imperceptibly iflto slight degrees of fever. f TRE EXERTION TREATMENT.recorded by the patient is therefore something, short of the maximum attained. As a- general rule this exertion tempei*ature 'should not exceed 100.4deg F. This is the immediate effect of exertion on t-he temperature. There is also a remote effect. If the patient considerably overexerts himself, several days afterwards he may suffer from what is popularly called a " dbill." This is characterised by a tendency io pyrexia, the morning temperature rising towards or above -normal* and accompanied by increased expectoration and various "subjective symptoms, chilliness, lassitude, loss of appetite <and vertigo. The patient usually puts these down to ".fresh, cold,'' exposure of some kind, wet shoes, thin clothes, quite unmindful •of over-exertion . A quiescent case of phthisis is always in a condition of potential fever. Our business is. t6 watt:h.-tlie,.tem]>eiatiu'.e.,undcr conditious of graduated exertion, to estimate the patient's strength, and always to keep inside of it. There are also, of course, intercurrent causes of rise of temperature, such as intestinal disturbances, quite unassociated with lung symptoms, and which can ba easily distinguished. JJIKT. The question of nutrition is the most important point in the treatment of phthisis as carried out at Nordrach. It has been said that fresh air is the cnrdinal factor. That is a great mistake. It is the stress laid upon adequate nutrition which is the leading feature of the Nordrach method, and which in effect differentiates it from all others. (The open-air treatment for consumption is now receiving a practical trial, at the sanatorium established by Ur R. S. Stephenson in tha neighbourhood of Dunedin. The sanatorium is situated on the northern side of the Flagstaff Hill, at an elevation of about. 1200 feet above the sea-level. Of the twenty-one patients who have entered the sanatorium, all but three have derived more or less benefit from the treatment. Several have returned to work thoroughly cured, and others are continuing the openair treatment at home.)
OPEN AIR CURE., Star, Issue 7024, 14 February 1901
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