THE ADIRONDACK REGION AS A THERAPEUTICAL AGENT IN THE TREATMENT OF PULMONARY PHTHISIS. (Read before the Medical Society of the State of New York.) BY ALFRED L. LOOMIS, M.D., PROFESSOR OF PATHOLOGY AND PRACTICE OF MEDICINE IN THE MEDICAL DEPARTMENT OF NEW YORK UNIVERSITY, N. Y. [Reprinted fromJJte Medical Record of April 26 * May 3, 1879.] "/ NEW YORK: WILLIAM WOOD & CO., 27 GREAT JONES STREET, 1879. THE ADIRONDACK REGION AS A THERAPEUTICAL AGENT IN THE TREATMENT OE PULMONARY PHTHISIS. (Read before the Medical Society of the State of New York.) ALFRED L. LOOMIS, M.D., BY PROFESSOR OF PATHOLOGY AND PRACTICE OF MEDICINE IN THE MEDICAL DEPARTMENT OF NEW YORK UNIVERSITY, N. Y. ; [Reprinted from the Medical Record of April 26 and May 3, 1879.] NEW YORK: WILLIAM WOOD & CO., 27 GREAT JONES STREET, 1879. THE ADIRONDACK REGION AS A THE- RAPEUTICAL AGENT IN THE TREAT- MENT OF PULMONARY PHTHISIS. Mr. President and Gentlemen of the State Med- ical Society :-I invite your attention to the Adi- rondack region as a therapeutical agent in the treat- ment of pulmonary phthisis. I have long been convinced that the most important factor in the suc- cessful management of pulmonary phthisis is to be found in climate. It seems to me that at the present time no subject of medical study is more deserving of attention than the climatic treatment of disease, yet to a student of the medical literature of to-day there is none more confusing and unsatisfactory. Some localities have been considered especially favor- able on account of their equability of temperature, others on account of their luxurious vegetation or their peculiarity of soil; some on account of-the dryness, others on account of the humidity of the atmosphere. From the data given, widely differing conclusions have been reached by different observers. In regard to the localities which are claimed to be especially adapted to the treatment of pulmonary phthisis, few writers have carefully observed, for any considerable length of time, the effect of the climate upon indi- vidual cases, or, if they have so observed, they have not made public the result of such observations ; and on this account very definite conclusions as to the re- lative merits of the different localities have never been reached. In the preparation of this paper, my object has been to show the effect of the climate of the Adirondack region upon all the cases of well-developed phthisis, which under my observation have given the region an 4 extended trial. I am largely indebted for facts given, and the history of cases, to my friend Dr. Edward L. Trudeau, who, a phthisical invalid, took up his resi- dence in this region five years ago. By way of explanation, I would state that clinically and pathologically I recognize three varieties of pul- monary phthisis, viz., catarrhal phthisis, fibrous phthi- sis. and tubercular phthisis. In catarrhal phthisis, the primary changes are in the cavities of the alveoli and bronchi, and are epi- thelial and cellular in their nature. Tn fibrous phthisis, the primary changes occur in the bronchial and alveolar connective-tissue, and are con- nective tissue hyperplasias. In tubercular phthisis, the primary changes occur in the lymphoid elements of the lung, associated with connective tissue hyperplasias forming little masses or nodules, which ordinarily are termed tubercles. The development of tubercle in a lung may be pre- ceded or accompanied by an alveolar cellular process, or by a connective-tissue hyperplasia, and as the one or the other predominates, so is the duration of the case long or short In the later stages of these different varieties of phthisis, it is always difficult and sometimes impos- sible to distinguish the one from the other; but in the earlier stages, in most cases, the differential diagnosis can readily be made. The peculiar clinical feature of catarrhal phthisis is, that at the onset the local symptoms are well marked and precede or accompany the constitutional. The local signs may be those of pneumonia or of localized bronchitis of the small tubes, while the peculiar clinical feature of tubercular phthisis is, that at the onset of the disease there are few local signs, while the constitutional disturbance is very marked. Fibrous phthisis is distinguished from all other forms by its greater chronicity. Usually it commences as a chronic affection, coming on very insidiously. Its chief clinical feature is, that its development is preceded by a chronic bronchitis or pleurisy limited to one lung, or perhaps an unresolved pneumonia. In rare instances, it is developed in the course of some constitutional disease-as syphilis, gout, etc. 5 These three varieties of pulmonary phthisis not only differ in their origin, mode of development, progress and termination, but necessarily they require different plans of treatment, and are differently affected by climate. To rightly estimate the effect of the climate of any place or region, it is absolutely necessary that we be able to determine what variety of phthisis it is that is cured or arrested in that locality. Frequently, in- dividuals with catarrhal phthisis will do badly at an altitude at which those with fibrous phthisis will be benefited. Besides, in determining the locality in which phthisical developments will be most likely to be arrested, we must take into account the age and general condition of the individual. For instance, an enfeebled and broken down middle-aged phthisi- cal subject does badly in a high mountain region, but is benefited by the air of the sea. The region known as the Adirondack region is com- prised in that portion of our State which lies north of the Mohawk and west of the Champlain Valley. It may be said to include the counties of Clinton, Fran klin, Essex, Hamilton, with portions of adjoining counties, and has an area equal in extent to nearly one-third of the State of New York. Within its limits there is a plateau from 1,500 to 2,000 feet above sea level, 150 miles in length (latitude), and 100 miles in breadth (longitude). On this plateau there are more than two thousand square miles of primitive forests, mostly evergreen, and many hundred lakes and ponds. From the surface of this plateau rise granitic mountain peaks more than five thousand feet in height. The drainage of this table-land is toward Lake Champlain on the east, the St. Lawrence River on the northwest, and the Hudson River on the south. Many of the streams which flow in these different directions inter- cept each other, and some of them, as well as the lakes, are navigable for light canoes or boats. Occa- sionally, there are easy portages between these bodies of water, and sometimes we meet with rapids or falls. I doubt whethei' any region in this country furnishes to the invalid or pleasure-seeker, such a stimulus to out-of-door life. Mr. Verplanck Colvin, in the conclusion to his re- 6 port, published in 1874, on the Topographical Survey of the Adirondack Wilderness, uses the following words to express his enthusiasm-words which fitly express the enthusiasm of many another one familiar with this region: " The Adirondack wilderness may be considered the wonder and glory of New York. It is a vast natural park, one immense and silent forest, curiously and beautifully broken by the gleaming waters of a myriad of lakes, between which rugged mountain ranges rise as a sea of granite billows. At the north- east the mountains culminate within an area of some hundreds of square miles; and here savage, treeless peaks, towering above the timber line, crowd one an- other, and, standing gloomily shoulder to shoulder rear their rocky crests amid the frosty clouds. The wild beasts may look forth from the ledges on the mountain sides over unbroken woodlands stretching beyond the reach of sight-beyond the blue hazy ridges at the horizon. The voyager by canoe beholds lakes in which these mountains and wild forests are reflected like inverted reality; now wondrous in their dark grandeur and solemnity; now glorious in re- splendent autumn color of pearly beauty." These words are the enthusiastic outburst of one who has a more accurate and comprehensive knowl- edge of the topography of this region, than has any other man. It is not surprising that in such a region the tired worker' and worn-out invalid find the rest and quiet which is so powerful a restorer of health. Here, as I have already intimated, there is every inducement for one to lead an out-of-door life, the very surroundings infuse new life into the feeble body, and one daily grows stronger and stronger and feels better, scarcely able to tell how or why. One condition which I regard of the greatest importance in seeking a suitable home for a phthisical invalid is here met with, viz. : dryness of soil. Undoubtedly, a damp warm as well as a damp cold climate acts unfavorably upon phthisical invalids, but the peculiar dampness which acts most unfavora- bly is not usually present in those localities where there is the greatest rain-fall, nor is it present because 7 large bodies of water are in close proximity, but it mainly depends upon the nature of the soil. To avoid this dampness, the soil should be porous and sandy, a loose soil of sufficient porosity to permit the rapid filtering of water from its surface, so that after a heavy rain-fall the surface will soon become dry. All clay soil drains slowly and imperfectly, and the peculiar dampness arises which acts so unfavorably on phthisical invalids. Laennec states, that the dampness arising from such a condition of soil is one of the most certain developing causes of phthisis, and he makes mention of a locality having such a soil, in which the dampness was so constant and of such a character that more than two-thirds of the resident population died of phthisis. In determining the fit- ness of a locality as a residence for phthisical invalids, I have come to regard the external configuration and conformation of the soil as of greater importance than the amount of rain-fall, or the relative moisture. The climate of the Adirondack region may be con- sidered a moist, cool climate. The rain-fall is above the average for other portions of the State, and may be roughly estimated at 55 inches. The spring is cool and there is considerable rain until about the middle of June. There is a dry period during the summer, when little rain falls, and the days become hot, while almost without an exception the nights are cool, often cold, and heavy dews fall. There is rarely at any time excessive heat, and during the warmest weather there are but few nights even in August when a blanket is not needed. My friend Dr. Trudeau, who has remained here summer and winter for the past five years, makes the following statement: " That he has never found the mercury above 87° during the past six summers, and this high temperature was only maintained for a few hours during the afternoon. The air during the fall months, with the exception of one or two long rain storms, is bracing and admirably suited to out-of- door life. During the winter the cold is almost un- interrupted, no thawing of any consequence taking place before the month of March. There is a prepon- derance of cloudy days and snow storms. The mer- cury, during January and February, frequently for days at a time stands many degrees below zero. As 8 the cold weather usually continues until the end of March, the thawing takes place quickly, and owing to the sieve-like nature of the soil the snow disappears very rapidly, consequently the change from winter to spring is soon accomplished. There is no marked preponderance of clear days at any season; on the contrary, the sky, especially in winter, is constantly overcast. This cool, cloudy weather is a marked feature of this climate. The altitude varies with the different localities; but the immense plateau which forms the lake region of the Adirondacks is about 1,800 feet above sea-level. The soil is very light and sandy, with here and there rocks, but little or no clay. There appears at first sight but little to induce one to consider this locality as favorable for persons af- fected with phthisis. Hitherto heat and cold and absence of moisture, or an equable temperature, have been regarded as necessary in order to favorable re- sults in the treatment of phthisis; but it has been shown- by trial that neither cold, nor heat, nor mois- ture, alone, are all-sufficient factors in guiding us to a right understanding of the most favorable atmos- pheric conditions for phthisical patients. In a writ- ten communication to me Dr. T also says: " High mountains, the desert, and the open sea have perhaps given so far the best results in the treatment of chronic chest disease; and yet all these differ widely except in one respect, namely, purity of atmosphere. It is neither hot nor cold air, damp nor dry air, but pure air which is necessary to diseased lungs. Many conditions render the atmosphere of these mountains perfectly pure. The elevation of this region, its sandy soil, the undulating nature of the country, which ensures perfect drainage ; the absence of culti- vation, even of dwellings-all these conditions pre- clude the presence of telluric or miasmatic poison, and we have a purity of atmosphere unknown in more settled districts. The forests of this region are almost unbroken, stretching over the valleys, covering the mountains often to their very summit, and extending in some directions for nearly a hundred miles, while innumerable lakes dot this elevated plateau, and give moisture to the air. That the atmosphere of such a 9 region, especially when set in motion, should, by its contact with myriads of tree-tops and pine sheaves, become heavily laden with ozone is a natural sequence. Whatever other properties this gas may hereafter be found to possess, we know that it is a powerful dis- infectant and Nature's choice agent for counteracting atmospheric impurities. This process, which during the summer months is carried on by all varieties of trees, during the winter months is maintained by the evergreens, while the deciduous trees are deprived of their foliage. Pine, balsam, spruce, and hemlock trees abound, and the air is heavily laden with the resinous odors which they exhale. An agent which it is universally admitted exerts a most beneficial in- fluence on diseased mucous membranes is thus brought in contact with the air-passages, while balsamics, which are also disinfectants, purify the atmosphere, which is constantly impregnated with them. Besides this, the air of the wilderness is optically pure, no- ticeably free from dust or visible particles of any kind. The invalid, therefore, is here surrounded by a zone of pure air, which separates him, as it were, from the germ-pervaded world, and his diseased lungs are supplied with a specially vitalized and purified atmosphere, free from germs and impurities of any kind, and laden with the resinous exhalations of myriads of evergreens." Though as yet but few phthisical invalids have been induced to give the Adirondack region an ek- tended trial, the good results obtained by those wflio have remained there for any considerable length of time are the strongest arguments in its favor. Dr. T writes: " My own personal experience and my personal observation of other phthisical invalids lead me to say that any comparison of the relative good effects of the climate of St. Paul, Minn., or of the South, with that of the Adirondack region is decided- ly in favor of the latter." In regard to camp life, he writes: " Camping out, which is the peculiar feature of this place, if done in an intelligent manner, from June to October, I consider an important and bene- ficial measure in the treatment of phthisis; if done carelessly, it is by no means free from risk. The advantages gained by this mode of life are evident. 10 The phthisical invalid for four months, night and day, lives out-of-doors, in a pure atmosphere; he is quiet, has perfect rest, plenty of good food (for which this mode of life gives an amazing relish) ; he has no opportunity to daily observe the effect upon other phthisical invalids of the disease from which he is suffering ; his surroundings are such that he can lie down whenever standing fatigues him, can eat when- ever he is hungry, sleep when exhausted, and dress as suits his own comfort-all of which comforts the re- quirements of society sometimes interfere with. " All these things-the breathing of the pure air of the wilderness, the perfect rest, the wholesome food, and early hours-combine to make tent-life a power- ful weapon in combating this disease. " Exposure in inclement weather, which this mode of life at times renders almost unavoidable, is well borne in this climate by phthisical invalids who steadily live out of doors. During the past six years I have never seen any evil results from this mode of life; but I have seen men in camp lose their cough and gain in flesh, while it rained daily, and in the midst of occa- sional frosts and snow-storms." Dr. Trudeau expresses himself strongly on this point, having faithfully tried tent-life, and he adds: " Many of the risks supposed to attend out-of-door life exist only in the imagination of the timid; " he believes that tent-life, and a return to the invigor- ating, out-of-door existence of the savage is Nature's antidote for a disease which is almost an outgrowth of civilization and its enervating influences. To proceed to results obtained from a fair trial of this region. Case I.-Eleven years ago, in the summer of 1867, as an invalid, I first visited this region. For several months previous I had suffered from cough with muco-purulent expectoration, loss of flesh and strength, night-sweats, and other rational and physical signs which attend incipient phthisical development. The only survivor of a family, every member of which (save, perhaps, one) had died of phthisis, I had come to regard my case a critical one. A Southern trip had not relieved if it had not aggravated my phthisical symptoms. In this condition I went into this region 11 and. into camp, and when, before the summer months had passed, I came out of the Adirondack or north woods, free from cough, with an increase in weight of about twenty pounds, with greater physical vigor than I had known for years, I very naturally became an enthusiast in regard to them. My personal experience that summer convinced me that there'was something in the air of this region especially adapted to diseased lungs; that, if the cli- mate had no direct influence in arresting or prevent- ing phthisical developments, it certainly allayed bron- chial irritation, and. the phthisical invalid soon be- came able to spend the greater portion of his time in the open air; still more, his surroundings were such that if a lover of nature or of sport, he neces- sarily forgot himself, and thus was nature aided, and vigor and health restored. I would mention here that my personal experience, as well as my experience since that time in regard to its effect upon others, leads me to believe that, during the warm season, a camp or tent life is of the great- est service to pulmonary invalids, if they are not en- feebled. From time to time, since that summer, eleven years ago, I have sent phthisical invalids into this region. At first I sent them only during the summer months, but I found that while temporary relief was afforded, and in some instances marked improvement took place, in cases of fully developed phthisis the latter was not permanent, and although the winter months might be spent at the South, yet before another sum- mer came around the disease progressed. Not until 1873 was I able to persuade any phthisical invalid to remain during the winter. The effect of the winter climate on this invalid showed so markedly the bene- fit to be derived from a winter's residence in this re- gion, that from that time, each winter, others have been induced to remain. Fourteen remained last winter. A brief analysis of the cases which have been under my own personal supervision, or that of Dr. Trudeau, will, I think, enable us to reach some satisfactory con- clusions in regard to the therapeutical effects of the climate of the Adirondack region. They are un- 12 selected cases, and the only cases of value, as these are the only phthisical invalids who have remained in the region a sufficient length of time to give the cli- mate anything like a fair trial. Case II.-Dr. E. L. T., aged twenty-five; fam- ily history good; began to lose his health in the winter of 1872. His symptoms very rapidly becoming urgent, he was examined by several physicians. Ex- tensive consolidation at left apex was found, extend- ing posteriorly nearly to angle of scapula; on the right side nothing was discovered save slight pleuritic adhesions at the apex. He was ordered South, but returned in the spring in no way benefited. On the contrary, night-sweating had set in, and his fever was higher. In the latter part of May he started for the Adirondacks, the ride in the stage being accomplished on an improvised bed. His condition at this time was most unpromis- ing ; he had daily fever, night-sweats, profuse and purulent expectoration, had lost his appetite, and was obliged constantly to have recourse to stimulants. Weight about 134 pounds. He began to improve at once, his appetite returned, all his symptoms de- creased in severity, and after a stay of more than three months he returned to New York, weighing 146 pounds, with only slight morning cough, presenting the appearance of a man in good health. A few days after his arrival in New York he had a chill, all his old symptoms returned, and he was advised to leave for St. Paul, where he spent the entire winter. He did badly there; was sick the greater portion of the winter. In the spring of 1873 he again went to the Adirondacks. At this time he was in a most debili- tated state, was anaemic, emaciated, had daily hectic fever, constant cough and profuse purulent expecto- ration. The marked improvement did not commence at once, as it did the previous summer, and the first of September found him in a wretched condition. I then examined him for the first time, and found com- plete consolidation of the left lung over the scapula and supra-scapula space, with pleuritic thickenings and adhesions over the infra-clavicular space. On coughing, bronchial rales of large and small size were 13 heard over the consolidated portion of the lung. Over the right infra-clavicular region the respiratory murmur was feeble, and on full inspiration pleuritic friction sounds were heard. I advised him to remain at St. Regis Lake during the winter, and although he was repeatedly warned that such a step would prove fatal, he followed my advice. From that time he began slowly to improve. Since that time he has lived in this region. At the present time his weight is 158 pounds, a gain of 22 pounds since he first went to the Adirondacks in 1873, and 10 pounds more than was his weight in health. He has slight morning cough and expectoration, his pulse is from 72 to 85, and he presents the appearance of a person in good health. In his lungs evidences still remain of the disease he has so many years combated. Although he has made three attempts to live in New York, at intervals of two years, each time his removal from the mountains has been followed within ten days by a chill, and a return of pneumonic symptoms -symptoms so ominous that he has become convinced that it will be necessary for him to remain in the Adirondack region for some time to come. Case III.-In the fall of 1873, Mr. E., aged twenty, with decided hereditary tendency to phthisis, went into the lake region of the Adirondacks. He had then been ill about 18 months, had spent two winters in Nassau, and for the three months immediately preceding his arrival, he had failed very rapidly. When he first consulted me in September, 1873, I found him extremely emaciated, weighing 108 pounds, pulse habitually ranging from 110 to 130, morning temperature from 102 to 103. He had loss of appe- tite, night sweats, and a constant harassing cough with slight hemorrhages. Physical examination re- vealed a large cavity on the right side posteriorly, with entire consolidation of the right lung. At the left apex there was also a small cavity with fine crackling rilles over the upper third of the left lung. His condition remained desperate during the fol- lowing winter, but, in the spring he somewhat recov- ered his appetite, regained strength, and had long intervals during which he was entirely free from fever. He spent the spring and summer of 1874 in 14 camp, and his improvement was very marked. A physical examination of his chest in the fall of 1874 showed a marked decrease in the pulmonary consoli- dation on the right side, the cavity had apparently diminished in size, and vesicular murmurs could be heard below and on either side of it. On the left side the crackling sounds had disappeared, and no signs of cavity could longer be detected, but broncho- vesicular breathing was still distinctly heard. His heart was hypertrophied, pulse 88, evening tempera- ture 991, weight 116 pounds. For the succeeding eight months he steadily improved. In June, 1875, after an exposure which it would have been unwise for one in health to risk, he was seized with a pro- longed chill, which was very severe and was followed by a pulmonary hemorrhage so profuse that for some time he was thought to be dead, but he lingered until morn- ing, and died from pulmonary congestion and oedema. Although this case terminated fatally, I regarded it as one of arrested phthisis. The beneficial effects of the climate of this lake region were so positive and well marked in this case, that I assumed the responsi- bility and induced other phthisical invalids to make a trial of it, contrary to the advice of other physicians, and regardless of the expostulations of friends. Case IV.-Mr. M., aged twenty-seven, with a good family history, after an illness of several months, which was marked by cough, expectoration, and loss of flesh, spent the summer of 1870 at Saranac Lake, where he markedly improved, lost his cough, and gained in weight. After his return to New York in the fall, his cough returned, other physical symptoms developed, and he was quite ill throughout the winter. The next summer he returned to the Adirondacks much worse than he was the previous year. Again he improved, and he thought he was almost well. He went to Cali- fornia for the winter, did badly there, and on his return to New York in the spring, two physicians of large experience pronounced his case a hopeless one- one which would probably terminate fatally within six months. In the early summer of 1872 he reached the Adirondacks in a most pitiable condition. Both lungs were extensively diseased. At the apex of the left lung were the physical signs of extensive consoli- 15 dation and softening. The upper third of the right lung was consolidated, and was the seat of large and small mucous rales. He had hectic fever, extreme dyspnoea, a rapid pulse, and other symptoms of advanced phthisis. He soon began to gain flesh and strength, his appetite improved, he coughed less, his expectoration was diminished in quantity, and by early fall he was able to keep otit of doors the greater portion of the time. For five years he remained in the lake region. At times his condition was most promising, although little change took place in the physical signs. Last spring, tired of the seclusion, he returned to his home in New York. Unquestionably this was a case of catarrhal phthisis, and the results obtained from his first summer's resi- dence in the Adirondack region lead me to believe that if Mr. M. had remained in the region the winter succeeding this first summer, he would have reached complete recovery. Even after reaching an advanced stage of the disease, when there was no longer a pos- sibility of recovery, a condition of stasis was reached when he permanently resided in the region. Case V.-Mrs. L , aged forty, good family his- tory ; early in the summer of 1871 went to the Adiron- dacks. She had been ill eight months with a cough and other phthisical symptoms. At the time of her arrival she was in a state of extreme exhaustion ; for several weeks previous she had lived entirely upon beef-tea and champagne. She had a harassing cough, with profuse expectoration and hectic fever. Physical ex- amination revealed a moderate amount of consolida- tion at the apex of the right lung, with crackling rales of large and small size; no evidence of softening. At once her desire for food returned, and she began to gain flesh and strength; gradually her cough and expectoration diminished, and late in the fall she re- turned to her home markedly improved. Since that time she has spent some time every summer or fall in this region, and for the last three years none of the ra- tional or physical signs of phthisis have been present. In this case the rapidity and completeness of the recovery was quite surprising, when we consider how unpromising was the condition of the patient at the time when she first reached the Adirondacks. 16 Case VI.-Mr. R ■, aged thirty, with no heredi- tary tendency to any disease, first consulted me in the spring of 1875. He had been 'll six months with cough, expectoration, hectic fever, gradual emacia- tion, and other well-marked phthisical symptoms. Physical examination of chest revealed consolidation at the apex of the right lung, with sharp crackling rales, most abundant posteriorly, where distinct bron- chial breathing could be heard below the spine of the scapula ; left lung healthy. I advised him to take up his residence in the Adirondacks. He remained in camp in the lake region during the summer of 1875, with only a slight increase in weight, a slight im- provement in strength, and no change in cough or physical signs. During the fall and winter he had several hemorrhages, with fever, and was confined to his bed at different times. Early the next spring he went into camp, and remained until September. When he came out of camp he weighed 181 pounds, had gained forty pounds; he had no cough, no expectora- tion, no fever. An examination of his chest revealed no abnormal sound, except pleuritic creaking and feeble respiratory murmur posteriorly over the former seat of the pulmonary consolidation. I regarded him a well man, and permitted him to return to his home. He remained well until the following spring, when he had an attack of acute cystitis. He was confined to his bed for six weeks; as soon as he was able to travel he returned to the Adirondacks, but the cystitis be- came chronic, was complicated by pyelitis and nephri- tis, and in early winter he died from acute uraemia. At the time Mr. R. took up his residence in the Adirondacks his digestive and assimilating processes were in a feeble condition. Undoubtedly this ac- counted for the fact that for nearly a year there was little, if any, improvement in his lung disease. His five months' camp life during the second year of his residence in the'Adirondacks not only cured his dis- eased lung, but wrought an entire change in his physi- cal condition. So great was the change that one would scarcely recognize him. When he left the woods the following fall no evidence of lung disease could be detected, nor was any detected during the remainder of his life. 17 Case VII.-Miss C , aged eighteen, in the spring or early summer of 1875 reached the Adirondacks in a very feeble condition. She had had a cough for six months, with frequent pulmonary hemorrhages, at- tended by fever, loss of flesh and strength. Physical examination of the chest revealed dulness on percus- sion, bronchial respiration, and crackling rales at the apex of the right lung. Her improvement began at once; at the expiration of three months she had gained eleven pounds in weight, had no cough, and had so regained her strength as to be able to take ac- tive out-of-door exercise. In early fall she returned to her home, and has there remained in good health. In this case the pulmonary consolidation was evi- dently catarrhal in its nature, and of recent date. That she came to the Adirondacks in the earlier stages of the disease probably had much to do with her rapid and complete recovery. Case VIII.-Mr. B , aged thirty-two, with a de- cided hereditary predisposition to phthisis, took up his residence in the lake region of the Adirondacks in the summer of 1875. After he left home, before he reached the Adirondacks, he had a severe hemorrhage. For three months after his arrival he was in a critical condition, had severe cough, frequent hemorrhages, fever, and rapid emaciation. He did not begin to improve until late in the fall, after which time his improvement was steadily progressive. During a two years' residence in the region he fully regained health and strength, his cough ceased, and in August, 1878, I could find no trace of disease in the lungs, except old pleuritic thickenings and adhesions at the apex of the left lung. In September, 1878, he left the Adi- rondacks. During his first year's residence in the Adirondacks no physical examination was made, but he stated that previous to his coming into the region his medical ad- visers had told him that his lungs were extensively diseased, and that he had come with a " forlorn hope." His disease commenced as a " severe cold," and un- questionably his case was one of catarrhal phthisis. Case IX.-Dr. T , aged thirty-two, with marked hereditary tendency to phthisis, came to the Adiron- dacks in the summer of 1875. For ten months he 18 had been ill with well-marked phthisical symptoms. The upper third of the right lung was consolidated, with circumscribed liquid rales in the supra-scapular fossa. At the apex of the left lung there was ex- aggerated rude respiration, but no rales. He remained four months, in camp the greater portion of the time. As he improved he became restless, and could not be induced to longer remain. His weight was now 148 pounds; he had gained twelve pounds, and had no cough. After leaving the Adirondacks he went South, but returned in the spring in a most enfeebled condition; weight 127 pounds, with pallid counte- nance, difficult breathing, and so weak that he was obliged to lie down the greater portion of the time. The entire upper lobe of the lung on the right side was consolidated, and abundant rales were heard throughout the consolidated portion. The respira- tions at the apex of the left lung had become markedly bronchial in character. He began to improve, and by the first of December had regained his appetite and strength. Again he became restless, left the Adiron- dacks, went to Colorado and California, was twice near death, and in early summer returned to the Adiron- dacks " in extremis," with a large cavity in his right lung, and commencing softening in his left lung. Having thrown away his chances for recovery, he died in early winter. A series of mistakes marked the course of this patient. A short time previous to his death he stated to me that in attempting to follow the advice of his Philadelphia physician, who recommended a warm climate, and that of his New York medical adviser, who recommended a cold climate, he had made the result a failure. As we review his history, it seems to me that we are warranted in coming to the conclusion that the result might have been different had he remained in the Adirondack region for the two or three years succeed- ing his first visit. Case X.-Mrs. M , aged twenty-eight, with no hereditary tendency to phthisis, consulted me in the fall of 1876. She had a cough which was paroxysmal in character, with little expectoration. For several months she had been losing flesh, had had daily 19 fever and night-sweats; at times she had suffered from severe attacks of dyspnoea, which were followed by an expectoration which she termed "stringy." Physical examination revealed pulmonary consolida- tion posteriorly at the apex of the right lung, with sharp bronchial rales over the consolidation. At dif- ferent points over the chest dry and moist rales were heard, and I made .the diagnosis of probable fibrous bronchitis, with pulmonary consolidation at the apex of the right lung. I advised her to spend the winter in Asheville, N. C., where she obtained little if any relief. During the winter she expectorated a number of well-formed bronchial casts. On her return, I found her more feeble than when I first saw her, and the area of lung consolidation increased. Following my advice, in June she went into the lake region of the Adirondacks, remained nearly a year, and entirely recoved from the bronchitis and pulmonary consolidation. This case was one of well-marked plastic bronchitis, with circumscribed consolidation at the apex of the right lung. When we recall the fact that the majority of cases of chronic plastic bronchitis are followed by phthisis, and terminate fatally, the complete recovery reached in this case is somewhat surprising. I would call attention to the fact, that in this case the climate of the Adirondacks produced such dif- ferent results from that of Ashville, N. C. Case XI.-Miss F , aged nineteen, of a non- phthisical family, consulted me in March, 1875, having taken cold the previous January. She was rapidly losing flesh, had an almost constant hacking cough, night-sweats, with other well-marked phthisical symp- toms. On physical examination, I found complete consolidation of the upper third of the right lung, with crackling rides posteriorly. Evening tempera- ture 103°, and pulse feeble. She had lost ten pounds since January, and was easily exhausted. Ten days after I first saw her she had a profuse hemorrhage; in two days this was followed by a second. She was so reduced in strength by these hemorrhages, and her general symptoms became so aggravated, that unless soon arrested it was evident her'pulmonary disease 20 would progress very rapidly, and soon terminate fatally; I feared acute phthisis. In the early part of April she went to Washington, was carried to and from the cars; she remained six weeks, with very little improvement in her condition, the entire upper lobe of the right lung having now become in the pulmonary consolidation. The early part of July she reached the Adirondacks. She rapidly began to improve, and when I examined her the following October, she had gained twenty pounds in weight, coughed only in the morning after rising, had no fever, and had a pulse of 80. Bronchial breathing was heard posteriorly over the area of the pulmonary consolidation, while quite extensive pleu- ritic adhesions and thickening could be detected in front. She spent portions of the summer and fall months in the Adirondacks for the two succeeding years, and now regards herself perfectly well, and is so regarded by her friends. The pleuritic changes which occurred during the active progress of the disease alone give evidence of her former pulmonary disease. When this patient first went to the Adirondacks, not only did her disease in- volve a large amount of lung-tissue, but her general condition was very unpromising, her stomach was exceedingly irritable, and her emaciation was rapid and her anaemia extreme. Case XII.-Mrs. P , aged forty, from a non- phthisical family, first came under my observation in March, 1877. Since 1869, she had suffered with phthis- ical symptoms ; at times her case had been regarded as hopeless. Physical examination revealed fibrous in- duration of the upper lobe of the right lung, with the physical signs of cavity under the right clavicle, and pleuritic thickening over the entire lung. Pulse 100, feeble and easily accelerated. Temperature 101°; extreme dyspnoea consequent upon exertion. She had night-sweats, was extremely ansemic, not markedly emaciated, but her weight was less than when in health. Cough paroxysmal and violent, with slate- colored expectoration; her appetite was capricious, and her disease had made marked progress since the early part of January. In early summer she went to the lake region, where she remained until fall. In her 21 general health the improvement was very marked; but little change took place in the physical signs. During the winter there was little change in her con- dition. Early the following summer (summer of 1878), she went to the Adirondacks and into camp, where she remained until the following October. Not only was the improvement in her general health very marked, but her cough almost entirely disap- peared, and her general physical condition was better than it had been since the commencement of her dis- ease. The fibrous induration remained at the apex of the right lung, although vesicular breathing could be heard over the remaining portion of the lung. When I first examined this case I regarded it as one of fibrous phthisis, and only hoped for that complete cicatricial process to be developed which renders the diseased lung-tissue inactive. While, as yet, she has not reached such a condition, her steady improve- ment without any new lung-tissue becoming involved, and the absence of any evidence that degenerative processes have been developed in the lung-tissue already involved, leads me to believe that if the same climatic influences be continued, which during the past two years have produced such beneficial results, at length the desired result may be obtained. Case XIII.-Mr. S , aged thirty-one, with a good family history; at my suggestion went to the Adirondacks in the early part of the summer of 1876. He first consulted me in the fall of 1875, had then been ill about one year; had well-marked phthisical symptoms. He had received a most unfavorable prognosis from medical men in this country and in Europe. A physical examination revealed quite ex- tensive consolidation of the apex of the right lung, with sharp crackling rales. I advised him to spend the winter in Asheville, N. C. On his return in early summer, I found that although his general condition had somewhat improved, his pulmonary disease had made considerable progress. Soon after his arrival in the Adirondacks he was seized with an acute cystitis, which prostrated him very much. Although he re- mained nearly two years in the lake region, his pul- monary disease steadily but slowly progressed. In 22 the spring of 1878, in an extremely debilitated con- dition, he returned to his home in Ohio. In this case, the disease from its onset steadily pro- gressed, and the diagnosis of tubercular phthisis which was made the first time I saw him, was confirmed by his subsequent history. While he was in the Adiron- dack region, although at times he seemed to be im- proving, the periods of improvement were of short duration, and each exacerbation of fever left him in a more and more enfeebled condition. With each exacerbation of fever, new areas of lung-tissue became involved. At the time he left for his home in Ohio, suspicious bubbling sounds were heard over the origi- nal seat of his disease, and his respirations were amphoric in character. Case XIV.-Mr. L , aged twenty-two, with well marked phthisical symptoms, had been ill six months, when, in the summer of 1877, he took up his residence in the Adirondacks. At the time of his arrival his cough was constant, his expectoration was of a green- ish color, and of tenacious consistency. He was rapidly losing flesh, had night-sweats, and shortness of breath upon slight exertion. Physical examination revealed consolidation at the apex of the right lung, with fine crackling rales in the supra-scapular fossa. He remained about one year, spending the summer and early fall in camp. His cough disappeared, and he gained fourteen pounds in weight. Ten months after his arrival no abnormal sound could be heard in his lungs, except feeble respiratory murmur, and pleu- ritic creaking at the end of a full inspiration at the former seat of the pulmonary consolidation. He has continued perfectly well to the present time, and is now studying law. This was a case of catarrhal phthisis in its first stage, in which, like the previous case of which I have made mention, the recovery from the pulmonary disease was rapid and complete. Case XV.-Mrs. G , of a non-phthisical family, first consulted me in April, 1878. She had suffered with well-marked phthisical symptoms for six months, the result of a cold contracted the previous summer while she was in a debilitated condition, which had been followed by a cough. Physical examination of the chest revealed consolidation of the upper two- 23 thirds of the right lung, with circumscribed moist rales under the right clavicle with amphoric breathing. She was very feeble; had rapidly lost flesh ; had night- sweats, loss of appetite, almost constant cough, an abundant expectoration, with occasional spitting of blood, and dyspnoea upon slight exertion. Tempera- ture in the evening, 103°; pulse, 110 to 120. She went into the lake region of the Adirondacks in June, and returned the last of September. She made little or no improvement until the last of Au- gust ; from that time she began to rapidly improve, and has continued to gain flesh to the present time. She now weighs 38 lbs. more than before she went to the Adirondacks, and coughs only in the morning. Physical examination shows vesicular breathing over the seat of the former consolidation, except posterior- ly, where the breathing is broncho-vesicular in char- acter, and pleuritic creakings are well marked. No signs of cavity can be detected. The improvement in this case did not commence until two months after she reached the Adirondacks ; in fact, for a time the disease seemed to be progress- ing with some degree of rapidity. During this time she had two quite profuse hemorrhages. The changes in the diseased lung were so extensive, and of such a nature, that I did not hope for recovery. The in- crease in weight has been greater and more rapid than in any other case of phthisis which has come under my observation. Case XVI.-Mr. R , aged thirty, of a phthisical family, began to cough in the winter of 1876. Two months after he began to cough he had a hemorrhage. Soon after the hemorrhage he began to have fever and to lose flesh. He first consulted me in May, 1876. He then presented the appearance of one in advanced phthisis. He was emaciated, had an even- ing temperature of 102° and 103°, and had great difficulty of breathing, becoming exhausted from the exertion attending the ascent of a flight of stairs. Physical examination revealed extensive consolida- tion of the upper lobe of the right lung. Distinct bronchial respiration could be heard from the clavicle to the upper border of the fourth rib. He went into the Adirondack region, where he remained a year. 24 On liis return to New York he presented the appear- ance of perfect health. He had no cough, and said he weighed more and felt stronger and better than he had for years. Physical examination revealed only pleuritic thickening over the former seat of the pul- monary consolidation. No physical examination of the chest was made from the time he went into the Adirondack region in early winter until his return to New York, one year later. He stated that his im- provement commenced about three weeks after he reached the Adirondacks, and that every day during the winter months he spent from six to eight hours out of doors. He has remained in New York until the present time, and has had no return of his phthisical symp- toms. Case XVII.-Mr. A , aged thirty-one, with a strong hereditary tendency to phthisis, had his first hemorrhage in Feb., 1877, after which he rapidly lost flesh and strength, and in June, when I first saw him, he was extremely emaciated and ansemic; had a con- stant hacking cough, with muco-purulent expectora- tion, and frequent slight hemorrhages. Temperature ranged from 100° to 103°; pulse never below 100, and easily accelerated. Physical examination re- vealed slight consolidation at both apices, with moist, bubbling rales in left supra-scapular fossa. He went to the Adirondacks in July, and remained nearly a year, during which time his disease slowly but steadi- ly progressed. A physical examination in July, 1878, revealed a cavity at the apex of left lung, with infil- tration of the entire left lung. I advised his return to his family. In this case the diagnosis of tubercular phthisis was made at the first examination. The subsequent history and the uninterrupted progress of the disease fully sustained the diagnosis first made. Case XVIII.-Mrs. O , aged thirty-four, with no hereditary predisposition to phthisis, first consulted me in May, 1878. She had coughed for six months, had repeatedly had hemorrhages. She went south during the winter of 1877-1878, where she did badly, rapidly losing flesh and strength, and had afternoon fever and night-sweats. Pulse 102° F., feeble and easily 25 accelerated. Afternoon temperature 102.° She com- plained of dyspnoea on slight exertion, and became easily fatigued, was anaemic, had no desire for food, and was dyspeptic. A physical examination revealed consolidation of the upper third of the left lung, with bronchial rales and pleuritic adhesions over the entire left side. In July she went to St. Regis Lake (Adirondacks), where she remained three months. Immediately she began to improve; the cough became less and less troublesome, her appetite returned, and she soon gained 14 lbs. in weight. By the first of September her pulse and temperature were normal, and by the first of Oc- tober the only physical evidences of disease were slight pulmonary consolidation under left scapula, and pleuritic creaking in left infra-clavicular space. She has continued to improve since her return, and is now apparently well. This was another case in which the rapid and con- tinued improvement was unexpected. The general appearance and condition of the patient when first seen by me was unpromising. The perseverance or fixedness of purpose, and good sense of the patient, I believe had very much to do with her marked im- provement. She remained out of doors nearly the whole of every day, took no risks, and made use of everything in her surroundings which would aid in bringing about the desired result. Case XIX.-Mr. M , aged thirty-four, consulted me in the spring of 1877, having had a pulmonary hemorrhage. For the previous three months he had been rapidly losing flesh and strength, had fever, night-sweats, and was extremely .anaemic. He had had cough with expectoration for more than a year. Physical examination revealed consolidation of the apex of the left lung as far as the lower border of the third rib, with quite extensive pleuritic changes and marked retraction of the left side of the chest. He had repeated hemorrhages, was confined to his room for several weeks, and it was the latter part of June before he was able to travel. Early in July he started for the Adirondacks. He presented the appearance of a person in advanced phthisis, and physical ex- amination at this time detected marked retraction of 26 the left chest and bronchial dilatation in the left supra- scapular space. During July and August his improvement was very slight, and it was the latter part of August before he was able to go into camp. He remained about two months in camp, during which time he regained his normal weight, his strength returned, and he had great physical endurance. Late in the fall he re- turned to New York, presenting the appearance of one in health, although he still had cough and short- ness of breath, and physical examination showed little change in the consolidated lung. His improvement continued until the following March, when he again grew worse, lost flesh, and had occasional fever. In May he had another slight hemorrhage. An examina- tion of his chest showed an increase in the pulmonary consolidation since the previous examination; pleuri- tic adhesions and thickenings were detected over the whole of the left side, with more marked retraction of the left side. He again went to the Aclirondacks, and remained in camp the greater portion of the sum- mer and fall. He rapidly regained flesh and strength, and all his active phthisical symptoms again disap- peared, excepting morning cough with expectoration. Little change could be detected in his physical signs. Unquestionably, this is a case of fibrous phthisis, and although while he remains in the Adirondacks he re- gains his flesh and strength, and the progress of the disease seems to be arrested, yet little or no improve- ment can be detected in the diseased lung. Case XX.-Miss H had her first pulmonary hemorrhage, which was quite profuse, in January, 1877. Within the week following this first hemor- rhage she had frequent hemorrhages, averaging more than one per day. During the preceding year her physical and mental labor had been unusually taxing or severe, and she was not in her usual health. For several months she had suffered more or less from nasal, pharyngeal and bronchial catarrh. She first con- sulted me in June, 1877, at which time she presented all the symptoms of well-developed phthisis. She had constant cough, with muco-purulent expectora- tion frequently streaked with blood, was emaciated, 27 had fever, night-sweats, loss of appetite, shortness of breath, etc. A physical examination revealed consolidation of left lung from its apex down to the fourth rib, with abundant mucous rales over the left scapula. In the early part of July she went into the Adirondacks, and into camp. On her return from the region in Novem- ber, I found her much improved; she coughed little, had no fever, had gained eight pounds in weight, could walk long distances without fatigue or short- ness of breath. Physical examination showed marked diminution in pulmonary consolidation in the left infra-clavicular space; bronchial respiration and mu- cous rilles were still heard over left scapula. She steadily improved until the middle of February, when she had a severe attack of influenza, from the effects of which she did not entirely recover, and June, 1878, found her in a worse condition than she was in June, 1877. Following the influenza, a pleurisy was estab- lished over the whole of the left pleura. This greatly increased her difficulty of respiration. June 11th she again left for the Adirondacks, went into camp July 1st, and remained in camp until October 20th. Dur- ing the summer she had two slight hemorrhages, but she steadily regained her strength and weight, and seldom coughed. A physical examination, made the following November, showed entire absence of pul- monary consolidation at the apex of the left lung, and the only remaining physical signs of disease were pleuritic adhesions or thickenings over the upper third of the lung, with localized bronchial rales in the left supra-scapular fossa. Since November her improvement has been steadily progressive, she has the appearance of one in health, yet she has slight cough with muco-purulent expectoration; and physi- cal signs of disease are still present. The statement previously made in regard to the probable effect; of a longer stay in the woods, holds true in this case. A brief summary of the foregoing cases gives the following results: Of the twenty persons who have tested the thera- peutical power of the climate of the Adirondack re- gion, by giving it an extended trial, ten have re- 28 covered, six have been improved, two have not been benefited, and two have died. The ten cases of recovery were those of catarrhal phthisis ; of the six cases in which improvement took place, four were those of catarrhal phthisis, and two were cases of fibrous phthisis. The two cases in which no benefit was received from a stay in the region were cases of tubercular phthisis, in both of which the dis- ease steadily progressed, and at no time could it be said that it was even temporarily arrested. In both cases of fibrous phthisis, extensive retraction of lung had taken place, with bronchial dilatation and com- pensatory emphysematous developments. Exercise could not be taken, for very slight physical exertion brought on attacks of severe and frequent dyspnoea, and the severe attacks of coughing interfered with digestion and nutrition. In both cases, failure of the right heart was well marked. In both, the improve- ment manifested itself in the gaining of flesh and strength, rather than in any change in the lungs which could be appreciated by physical examination. I be- lieve these cases would have done better in Colorado. Those cases of catarrhal phthisis which were im- proved but not cured were those in which the pul- monary changes were extensive, or had reached the stage of excavation-cases in which complete recovery is always problematical. In all these cases the improvement did not com- mence immediately-not until some time after the in- dividual had taken up his residence in the region; and when it did commence, it was not constantly pro- gressive. Each case had a long history of getting better and worse, but each advance toward recovery was more marked than the former. Whether these cases will or will not reach complete recovery is a question, but I am certain that a permanent residence in the region greatly increases the probabilities of such a result, from the fact that in those cases which have come under my observation a temporary absence from this region has been followed by such sad results. In all the cases of catarrhal phthisis which have reached recovery, either the pulmonary changes were not ex- tensive, or they were of recent origin, and improve- ment commenced soon after reaching the Adirondacks. 29 The results obtained established the fact that a large proportion of the cases of this variety of phthisis, if they have not passed the first stage, or stage of con- solidation, can recover. The two cases that terminated fatally were cases of catarrhal phthisis. Although, when they came into this region, their lungs were extensively diseased, they were much benefited during their stay, and it seems to me that impatience and imprudence had very much to do with the fatal termination. Results show that the climate of this region is bet- ter adapted to the treatment of catarrhal phthisis than of any other variety. I believe fibrous phthisis does better in higher altitudes-for instance, in Colorado. My experience leads me to believe that climate has little beneficial effect upon tubercular phthisis. For some time I have believed-in fact, I became convinced soon after I began to study carefully the effect of climate upon phthisical invalids-that a larger proportion of such were benefited or cured in a cold than in a warm climate. The testimony of those who have spent a winter or more than one winter in the Adriondacks is, that im- provement was far more rapid during the winter than during the summer months; and I have found by physical examination of the lungs, that the arrest in the morbid processes and the establishment of the curative processes was more marked during the win- ter than during the summer months. I shall have accomplished my purpose, if by this hastily prepared paper I shall have awakened in my professional brethren the spirit of investigation as re- gards this extensive health-restoring region within the boundaries of our own State, which we have been passing by, while we have sent phthisical invalids far from home and friends to regions far less restorative.