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and it is difficult to find a form of exercise which so admirably answers the purpose of giving plenty of fresh air and thoroughly warming both body and extremities with so small an amount of fatigue.
Habitation.—The residence of the consumptive patient should be situated on a dry soil of sand or gravel, free from admixture with clay or other material likely to collect or retain moisture. It should stand on slightly elevated and sloping ground, so as to ensure thorough surface drainage. Vegetation should be present in order to keep up the supply of oxygen, and it should not be rank, succulent, or in excess; but short, herbaceous, heathery, and flower-bespangled, like the grass fields of a dry and open country, or the downy herbage of a hill-side or elevated common. Shrubs, such as broom, furze, thorn, and thin copse-wood are welcome, and a few trees scattered or arranged with a view to shelter; but dense woods and large deciduous trees, the chief ornament of park scenery, do not add to the healthiness of the air, but greatly increase its humidity. There is no objection to the neighbourhood of pines, especially on the north side of the dwelling, their dry shade and fragrant odour being very pleasant, and forming the great attraction of certain localities, as Bournemouth and Arcachon; indeed, the turpentine inhalations from this source are held in great repute in many parts of the Continent, and form one of the numerous ' cures ' so congenial to the German mind.
The vicinity of marshy or swampy ground is of course to be avoided, as likely to cause malaria, and even that of low lands and valleys with a clay soil or sub-soil, for moisture is generally excessive in such districts.
Peat bogs, on account of some antiseptic property, do not engender malaria, but are not exempt from the imputation of dampness; and anyone who has witnessed the swarms of midges on a Scotch morass can testify to their capacity of breeding one kind of plague at least. The close proximity of the house to lakes or ponds of fresh water, or of slowly running streams, little below the level of the ground, is not desirable, as the amount of moisture in the air is thereby increased; but this does not apply to the margin of the sea, for there is certainly something corrective, if not antiphthisical, in salt water and the vapour arising from it, which renders sea damp less injurious than land damp.
The house should be protected from northerly and easterly winds, and well open to the south and west. The walls should be thick and the windows large, so as to allow, if necessary, of thorough ventilation; the rooms should be lofty and airy, and the temperature kept as near 60° F. as circumstances will admit of; whilst means are taken to maintain this degree of warmth, others should not be omitted to ensure a frequent and abundant supply of fresh air, either through the top of the window, or through ventilators opening outside, and also for the removal of the impure air. We need hardly add, that the drainage arrangements should be efficient and complete.
Immunity of Localities from Consumption not assignable to anyone condition of life—Objections to High Altitude Theory—Kirghis—Icelanders and Fero'ese—Objections to " Koumiss " theory—Twofold causation of Consumption—Influences originating Inflammatory Attacks—Septic Influences— Nature of disease dependent on its causation—Knowledge of Countries where each class prevails: a guide to climatic treatment—Objects of change of climate—Division of Climates into Marine and Inland—Marine— Their stimulating and equable qualities—Caution as to Seaport Towns—Cool and moist British Coast Stations—Dry Climates of Mediterranean Basin— Warm and moist Madeira group—Inland Climates: their great diversity— Division into three groups—Calm and soft—Dry and warm—Climates of elevated regions—Marine Climates suitable for Consumption arising from Inflammation—Choice dependent on degree of irritability of system—Inland localities best fitted for most irritable variety—Climate of elevated regions indicated for Consumption of Septic origin—Restrictions—Residence at high altitudes important as a preventive measure—Ordinary Chronic Consumption best treated by warm stimulating climate in winter, and cool bracing climate in summer—Importance of Exercise—Inland Climate of North America—Sea Voyages—Advantages and disadvantages—Cautions— Certain cases of Consumption unfit for change of climate—Practice of sending Patients in advanced Consumption Abroad condemned.
Climate.—We cannot attempt, in the few remaining pages of this book, to discuss the important subject of Climate, in all its relations to Consumption, but must refer our readers to what we have published elsewhere on the subject.1 What we aim at doing, now, is to point out the existence of certain indications which should form the
1 The Climate of the South of France as suited to Invalids, with Notices of Mediterranean and other Winter Stations, and an Appendix on Alpine Summer Quarters, and the Mountain Cure, 2nd edition.
ground for the physician's decision, as to the climate most likely to he of benefit. And here we must premise, that taking a fair survey of our present knowledge of the geography of phthisis, we cannot subscribe to any theory which assigns immunity from the disease to any one condition of life, and to that only, as, for instance, elevation above the sea, or dryness of soil, or to the use of certain kinds of food, as koumiss, blaand, etc. To the supporters of the high altitude theory, the existence of the Kirghis, who are quite free from consumption, living on vast steppes, 100 feet below the level of the sea, is, as Dr. Charlton 1 well shows, an insuperable objection, which is borne out by the inhabitants of Iceland and the Faroe Isles, who live at but slight elevations above the sea, and, as regards their dwellings, under very unhygienic conditions, but are equally free from this disease. To those who consider that the use of koumiss2 or fermented mare's milk among the Kirghis, and that of blaand or the sour whey from cow's milk among the Icelanders and Feroese, is the cause of their immunity from consumption, may be opposed the example of the dwellers on the high table lands of the Andes and of the Alps who do not commonly use such beverages.
We may here remark, that in the somewhat revolting diet of the Icelanders and Feroese, which embraces fish and flesh in an almost putrid condition, there is one article which seems more likely than blaand to explain their salubrity, viz. cod-liver oil, for this, under the name of ' muggy,' is consumed by all classes and largely.
A more probable view, and one more likely to explain the various phenomena presented by the distribution of
1 Northumberland and Durham Medical Sociely's Proceedings.
S We may mention that this drink has lately been tried at the Brompton Ilospital on consumptive patients, but that the experiment was not sufficiently successful to warrant its continuance.
THEORIES OF IMMUNITY FROM CONSUMPTION. 387
phthisis throughout the world, is given in page 106, viz. that its causation is at least two-fold, and possibly more complex. Firstly. The influences which excite and keep up inflammatory affections of the lungs, the products of which are apt to be of a lowly organised kind, tending to contraction or to caseation. Such influences are the prevalence of cold and damp weather, and frequent changes of temperature. Secondly. Septic influences, which blight and corrupt portions of the bioplasm of the. blood, or of the lymphaties, and thus sow the seeds of decay. As, for instance, the combination of warmth and humidity, foul air, bad or insufficient nourishment, weakening diseases, and other general causes. As has been stated, the co-operation of these two classes of causes often takes place and renders the effect more certain, as when a person deteriorated by foul air is exposed to chill, or when the subject of an inflammatory attack is confined in an impure atmosphere and deprived of the healthy influence of fresh air, of light, and of good food.
This two-fold causation of phthisis is rendered more probable by the marked difference in the kind of disease which each class of causes gives rise to. Consumption arising from the first class of influences is generally a limited disease of one or both lungs running a chronic course, and is that which prevails most largely in cold and temperate countries. Consumption arising from the second class is a disease with more marked constitutional symptoms, is generally tubercular, and runs a more or less rapid course. This type, as Dr. Guilbert has well pointed out, is the prevalent one of hot countries; but instances may be found in abundance, in temperate climates, which are traced to some of the above-mentioned septic causes, foul and hot air, bad nourishment, and the like.
It is evident that in our selection of a climate for a patient we should consider the probable mode of causation