Compliments of the Author. Where Shall We Send Our Consumptives? BY WILLIAM W. VAN BAUN, M.D., PHILADELPHIA, PA. Reprinted from the Hahnemannian Monthly, December, 1891 WHERE SHALL WE SEND OUR CONSUMPTIVES? BY WILLIAM W. VAN BAUN, M.D., PHILADELPHIA, PA. As the late fall months creep on, the question of where shall the consumptive be sent becomes of increasing importance. The uni- versal recognition of the value of an out-door existence for the victims of phthisis pulmonalis calls for the decision of this question in every case where such an expenditure can possibly be thought of by the unfortunate or their friends. The proper location for an in- cipient case seeking cure, or one well advanced searching for ameli- oration, involves a multitude of nice points, each of which must be taken up and considered carefully, the right importance being at- tached to each. Nothing can atone for a want of prudence at this critical period. It is not sufficient to say to the wealthy patient, go to Southern France, to the Italian Riviera, to Egypt or to Southern California; or to those of more moderate means, to the Carolinas, to Florida, etc. This is not advice; it is merely sugges- tion. It is unfair, as it leaves the patient nearly as helpless as at the beginning of the interview. With this information, they will go groping for a poorly-understood “something,” searching in vain for an ideal climate that will only be realized in paradise. When a patient applies to his medical attendant, and puts his health, his prospects and his life, or the life of his loved ones, in his hands, and is willing to faithfully abide and be governed by his decision, it is a superb trust between man and man, and avoidable ignorance is an unworthy return for his confidence. Consumptives should be given a well-thought-out, clear-cut route, with an objective point to go to or to work towards, and where they are to remain. The place being selected with a view of thorough adaptation to their social condition in life and to the requirements of their physical, moral and intellectual nature. A rough, out-door ranch life on plateau or mountain side may be just the thing for a boy budding into manhood, who has been caught at the right mo- raent and has been sent at once to ideal hygienic surroundings; but to advise the drooping society lily, whose very life is her “set” and its doings, to transplant herself in the same ruthless fashion, would simply be to overleap the mark and be compelled to acknowl- edge defeat, to fret and worry. A more judicious, half-way course will accomplish results not so great as in the first instance of a happy, contented, out-door life, but such as will hold good promise for the future. The first step in deciding the question “Where shall we send our consumptives ? ” will be to ascertain what are the ideal condi- tions to be looked for in selecting a location. We will want, if possible, a country having a scanty population, a fair altitude, a mild, equable temperature, a low degree of moisture, and possessing in the highest degree a pure atmosphere—an atmosphere free from micro-organisms. Alone, any one of these conditions will be capa- ble of producing but little curative benefit; it is the ensemble that is needed. Can it be found ? If we could secure an absolutely pure atmosphere in a country capable of sustaining life and health at a minimum expenditure of force and effort, our search would be at an end, and we would simply have to busy ourselves by endeavoring to discover an efficient way to keep the atmosphere pure in the pres- ence of the consumptives who would gather at the phthisical Mecca. Phthisis is essentially a disease of civilization. Where the masses are, there phthisis is rampant, no matter where the country may be nor how abundantly nature may have heaped upon it her richest blessings. It is a fact beyond dispute that many of our Western towns which, a few years ago, enjoyed enviable reputations as remarkable health resorts for consumptives, are to-day absolutely without repute. This is due to the trend of civilization massing great numbers of people at these centres; and they have given over the good work of rescuing the victims of the white plague,* and, in their turn, have become veritable breeding-sinks of consumption. It is clear that if consumptives are to recover, they must be removed from the sphere of dense population. Altitude.—High altitude has been much vaunted by writers, and no doubt many individual cases have been greatly benefited ; but, on the whole, it is an unsafe experiment, especially with patients of neuralgic tendencies, with weak hearts, or those who are in a well- * It is estimated that 35,000,000 of people die in the world annually, and of this number 5,000,000 are due to consumption alone. advanced stage of the disease. These are rarely benefited, while cases in the incipient stage frequently get along very well. Patients who have been living at high elevations, such as Colorado and sim- ilar places, and have established a new equilibrium between their cir- culatory and respiratory systems, can seldom venture again with safety to the seaboard. If patients are sent to such localities, and they do well, then they must be made to understand that in order to obtain permanent results, they must make their new abode their home for life. Temperature.—A mild, equable temperature is always desirable; it is, by far, the most pleasant climate for the well to live in, and especially so for those whose vitality is depreciated. As the character of climate is usually a matter of selection, it is unreasonable to send patients searching for lost health and vigor to the Adiromlacks for the winter. Naturally, something can be said in favor of so doing, but to condemn a partient to a long, cold, deso- late winter season at this mountain resort verges on cruelty, and few natures are able to endure it. If it were not so, Iceland, Faroe Islands, the Hebrides and places in Norway would be the world’s lung sanitarium. It is a remarkable fact that consumption is ex- tremely rare in these localities. On the other hand, turning to the opposite, the hot, dry plains of New Mexico and the Desert of Sahara are a source of intense distress to many. It will be well to remember that in Colorado, New Mexico and California, especial 1}’ at points of any considerable elevation, the variation between the noonday and the midnight temperature is very great. A straw hat and light jacket will do at noon, but a heavy Eastern ulster will be none too warm late at night. Notwithstanding this fact, the climate of these States is immeasurably superior to our own for the con- sumptive for at least nine months of the year. A Low Degree of Moisture.—Intense dryness, if associated with alkaline dust, will unquestionably act as a local irritant to the air- passages. In'the majority of cases this irritation is well borne, but in some the annoyance is so great that they, like the Wandering Jew, must push on to other worlds. Countries presenting long-continued wet seasons are, of necessity, to be avoided. Purity of Atmosphere is a prime requisite. If this can be found, will it be possible to so maintain it, since each case of consumption is in itself a source of contamination ? Strictly speaking, there are but few places on the earth, if any, where there is an absolutely pure atmosphere, where life could he maintained pleasantly. Even such ideal places would soon lose their prophylactic quality when colonized with a diseased lung population. A climate suitable alike for all cases of phthisis pulmonalis does not exist. The individuality of the patient must be consulted, and the selection of a location for him to resort to in search of health must be based upon his personal requirements, governed by the principles of selection laid down above. The winter health resorts for consumptives in the Eastern States, with the noted exception of New Jersey’s famous pine belt, which in- cludes such favorably-kuown places as Brown’s Mills and Lakewood, need no consideration. It is safest not to suggest them. Patients who cannot leave home for more than two or three weeks at a time, and, necessarily, are not able to go far away, will not get sufficient benefit from their outing to justify the risk they run in changing their mode of life in a cold climate at mid-winter. If a patient has command of full and plenty, and is a good sailor and an old traveller, understanding well the art of taking the trav- elling mixture of exasperating annoyances and exquisite pleasures, the Mediterranean circuit will offer many attractions. Patients should be instructed to take a steamer direct to Genoa or a long yachting cruise via Gibraltar. To send invalids at this season of the year to the French or Italian Riviera over the usual route, via Great Britain and the Continent, is to expose their weak health to un- necessary risks. In Europe at present, excepting Switzerland, it is practically impossible to travel with a decent regard to comfort in way of light and warmth on second-class railway compartments, and first-class offer but little improvement. The accommodations are utterly inadequate during the winter months—in fact, they are so at any time, according to American ideas. The fashion of long voyages and winter cruising for health or pleasure, or both, is on the increase in America as well as in Europe. If a patient is in the stage of incipient phthisis, and is in a fairly good physical condition, possessing to a high degree the faculty of self-amusement, a long ocean voyage has much to commend it. It also has many drawbacks—the cramped sleeping apartments, the housing with other consumptives, the injudicious eating that is so prevalent; excessive consumption of food is so universal on our great liners that it actually fails to attract attention. There is really nothing else to do. Shipboard, as a rule, is a very dull place; amusements are few, and the reading habit does not belong to all. If one does possess it, the jar of the machinery fatigues the eyes, or the stomach is jnst sufficiently disturbed to divert the attention; so it all comes back to doing principally one thing, and that is eating —eating until the digestion is ruined. Another marked objection to sea voyages is the limitation of free exercise in the open air. If one has at command a well-appointed yacht, handsomely fitted up, ladened with every necessity and luxury, with which he may touch at places of great natural beauty and of historical or romantic interest, the traveller will certainly find change, relaxation and mental stimulation all pleasantly combined in sailing the Mediter- ranean. The sea acts as a tonic, and there is at hand everything to gratify the artistic, literary or antiquarian tastes of its possessor. Still, even under such conditions, there are imperfections; the choicest spots bordering the Mediterranean and the sea itself are subject to sudden and severe, though usually brief, storms, and the winds are apt to be decidedly chilly, even as late as April.* Again, a pleasure- seeking party is apt to be forgetful of the weakened endurance of the semi-invalid, and, on the other hand, the invalid is not likely to remain sky-gazing, even if it is “ever so blue.” while the rest of the party are taking a “scamper through Pompeii” or are climbing up to Vesuvius’s crater. Every inclination and surrounding goads the chafing spirit to burst the bonds of restraint and join the more hardy, happy group. Much mischief often results to those in pre- carious health availing themselves of these brief and precious oppor- tunities on shore to see all and to do all that the most venturesome and ambitious in the party is attempting, and it is harder still for those in health, after four to ten weeks of luxuriously-indolent life at sea, to realize that they are not in condition for immediate violent exercise, and that there is a limit even to their endurance. If the patient is in poor health, or is of an impulsive tempera- ment, the ocean voyage is to be interdicted. Those cases of early consumption who are making the search for health their life’s business will find the Mediterranean seacoast ex- ceedingly beneficial. The southern coast of France and the Italian shore, in its entire length washed by the surf of the Mediterranean, has been sought after for centuries. The coast of Greece is com- paratively free from consumption, while in Cyprus phthisis is said to be almost unknown. The shores of Asia, particularly the Armenian plateau, the coast plains of Syria, and even the table-lands of Persia, are regions where the experienced traveller can ply his vocation to * British Medical Journal, May 30, 1891. 6 his heart’s content, as they are all countries remarkably free from phthisis. Egypt is vaunted by some, but this must be accepted with allowance; results can only be looked for in the upper and central portions, and these regions are not suitable for Americans. The north shore of Africa, especially parts of Algeria and Morocco, are being much resorted to, and at present the Germans are advocating certain sections of the Desert of Sahara. Turning to our own country, what has it to offer? Where are the sections presenting in the highest degree the conditions for which we are looking ? If we turn for advice to the pamphlets and the literature actively circulated on this subject, we are impressed at once that the writers have been wielding their pens with a single purpose—the booming of the particular section of country in which they are personally interested. We become unpleasantly aware that the authors have not been restrained nor hampered by any consider- ation of truth or modesty from proclaiming the real or fancied per- fections of the land they are writing up. There are four States claiming pre-eminently the attention of cli- matologists ; they are: Florida, Texas, New Mexico and California,* and it is here we must look for remedial and curative results. Florida is the nearest and most fashionable winter resort for the Northern and Eastern States. On the whole, it does not offer much for consumptives, but its climate is mild and rather humid, and is a vast improvement on that of the severe winters farther north. There are a few places inviting special attention : First, Jacksonville, for cases seeking amelioration only, who are too far advanced for cure. This city is particularly useful ou account of being easy of access and of its excellent hotel and boarding accom- modations. It has a large population and is a great gathering-place for phthisical patients. This fact is a good and sufficient reason why incipient cases should avoid going there. Lake Worth is a delightful, semi-tropical resort growing rapidly into popularity. It is situated upon a strip of land between the ocean and the lake from which it takes its name. It is a quiet resting-place, offering plenty of out-door pleasures, but it has no social advantages. To those whose existence is largely dependent upon excitement and bustle, Lake Worth will not be acceptable. Its climate is mild, balmy and humid. It is difficult of access. Key West is on an island at the extreme southern end of the pen- * For a practical review of the claims of Colorado as a health-resort, see article “The Climate-Cure of Colorado,” by Eugene F. Storke, M.D., The Medical Current, September, 1891. 7 insula, and possesses what is claimed to be the “ warmest and most equable climate on the eastern coast of the United States.” It has occasional fogs and mists. It is reached by a line of fine steamers sailing from Xew York. It is an ideal stopping-place for patients too weak to undertake the overland route to the South and West. Here they may rest a number of weeks until their recuperative power asserts itself, when once again they can embark for Galves- ton, pressing on to the more distant points of San Antonio, Xew Mexico and California as their strength may permit. Tarpon Springs, on the western coast of Florida, is the gem of the so-called American Riviera. It is the most desirable place in the State of Florida for bronchial and lung cases. It is easy of access and has excellent hotel accommodations. The population is not large and is made up of cultivated Eastern and Northern people, whose energy has gone far to make it the most attractive city in the State. There is abundant social amusement, and the fishing and hunting are uncommonly good. A beautiful lake is in the immedi- ate locality, which is supplied with boats for exercise and steam- launches for pleasure-parties ; everything is done that is possible to induce the patient to live out of doors. The climate is mild and equable, with a great wealth of sunshine and pure, balmy air. It is situated below severe frost-line and does not have mists nor fogs. Travelling westward, Texas, with its quaint old San Antonio,* opens up an inviting field for the consumptive. The city and the adjacent country are in what is known as the dry or “ health belt,” and enjoy a deserved reputation as winter resorts for invalids. San Antonio has an altitude of 800 feet, with surrounding hills attain- ing the height of 1100 to 1500 feet. The atmosphere is pleasant and almost entirely free from humidity excepting during the short rainy season. The air is soft, dry, balmy and refreshing, and is beneficial to all pulmonary complaints. A very great advantage possessed by Texas over California, Colo- rado and Xew Mexico is its equable daily temperature. San Antonio is a delightful place socially for ladies, and, on account of the excellent hunting and fishing in the vicinity, a most desirable resort for gen- tlemen. The city, unfortunately, has no “system of sewerage,” and the drinking-water is obtained from springs within the city limits and from Artesian wells.f * See able and conservative pamphlet on the city of “San Antonio and Southern Texas as a Pulmonary Sanitarium.” Bv C. E. Fisher, M.D. f Winter Resorts of North America. By Aim6e Raymond, M.D. Medical Record, October 17, 1891. New Mexico presents three points of distinctive prominence— Los Vegas, Santa Fe and Albuquerque. The altitude of all is very high, the first two reaching, in round numbers, 7000 feet; they are, practically, too high for the majority of cases, especially those having heart, nervous or neuralgic affections. Albuquerque, at 5000 feet about sea-level, is warmer and better adapted to lung cases. It makes a good stopping-place for con- sumptives on their way to California, but is a poor place for those in whom the disease is well advanced, as they never do well. Albu- querque is a city of 10,000 inhabitants, and yet there is the same astonishing disregard of sanitation as characterizes the rest of New Mexico and the majority of Southern and Western resorts. This fact presents a weighty reason why these centres of population should be avoided. The climate of this part of New Mexico is mild and equable and is not surpassed by that of any part of America. Camp life is to be strongly recommended in this country, espe- cially in the neighborhood of Raton and Springer, in Colorado, and along the railroad from Watrous to Los Vegas, the Pecos river country to Glorieta and around Santa Fe. In sending patients to Colorado, New Mexico or California it is very necessary to impress them thoroughly with the fact that in these States the days are hot and the nights cold, so that they may go thor- oughly provided with clothing. It will be a good ride never to locate a patient in New Mexico in whom phthisis pulmonalis is well advanced. Caeifornia’s climate varies greatly, owing to the difference in elevation and latitude. It is imperative to select for patients going into this State a definite location, so that they will not go wandering all over the country searching for that they know not of. The State presents many excellent places for consumptives, especially in the southern section and above fog-line. San Diego has many charms. It is dry, equable and invigorating. It is quite a large city, and yet most lung cases do well within its limits. The rainy season, as in most California health-resorts, begins in the latter part of October and continues until about the middle of April. This rainy season is peculiar; it is not a continuous down-pour, but is interspersed with bright, warm, sunshiny days, and the rain is most likely to occur at night. There are but few really harsh days. Those in position to judge assert that the climate of San Diego is superior to the best that the Mediterranean circle has to offer. 9 It will be good advice to warn patients to avoid Los Angeles. The weather here is apt to be changeable, foggy and raw, with consider- able sea breeze ; the nights are very much colder than the days, and the extensive irrigation of the surrounding country gives rise to in- creased humidity. Santa Barbara, one of the oldest of California health resorts, is charmingly situated in a sheltered nook on the coast, with a chain of mountains to the north. It has a fine, crescent-shaped beach, which overlooks adjacent islands, making a delightful marine pic- ture that is both pleasing and restful to the wanderer far from home searching for health. The air is pure and bracing, with a degree of moisture that invigorates and refreshes. It is a great resort for lovers of out-door sports. There is an abundance of riding, driving, bathing, fishing, shooting and hunting (everything from birds to grizzly bears). San Bernardino nestles charmingly in a valley of fruit, 1500 feet above the level of the sea, not far distant from snow-capped moun- tains. The atmosphere is pure and invigorating, and it is very much drier than at the coast. The rainy season occurs during the first three months of the year. The city has the rare ad vantage of being thoroughly sewered. Pasadena offers many attractions. It is a lovely place, with much to interest the invalid. Its situation is well adapted for the early stages of phthisis. Its drawbacks are occasional fogs and raw, chilly days. The houses are not constructed for damp, penetrating weather. Frequently while it is uncomfortably hot on the streets in the sun, it is unpleasantly raw and chilly in the poorly-heated houses—a condition peculiarly trying to half-sick patients. The Sierra Madre Villa, some three or four miles in from Pasa- dena, on the foot-hills of the Sierra Madre mountains, at an altitude of 1600 feet, is a delightful resort and one that will give the best possible results. Its climate is of the same general character as that of Pasadena, with the advantage of its higher elevation holding it far above the fogs in almost perpetual sunshine. Higher up the mountains in this vicinity is a sparsely-settled country covered with ranches, on which patients can secure the ben- efit of an out-door life in a pure, healthy atmosphere, above fogs and having the minimum amount of moisture, at any elevation that will best suit their individual case, and still be living within the reach of centres of advanced civilization. This part of California is the only region in the world presenting, 10 within thirty miles, a chain of superb hotels, innumerable good ranches and excellent camp-sites, giving the invalid every possible condition and altitude, ranging from the level of the sea at the shore to high up on the mountains—5000 or 0000 feet. The one great lesson the patient must learn, and go prepared to meet, is the vast difference in temperature between sunlight and shade and between day and night. This temperature change, the long distance from the eastern seaboard—involving a tiresome and trying journey—and the fact that the houses are not constructed with an idea of furnishing solid comfort in raw, cold, chilly weather, makes up the list of objections, offsetting the advantages of a climate that is as near perfect as can be found. The places I have enumerated are the choice spots of the earth for bronchial and lung cases. The objections to these places have been dwelt upon somewhat at length, not in the spirit of hyper- criticism, but with the intention of bringing out the fact that there is no such thing as a perfect climate in this world, and, by dwelling upon their imperfections, to enable patients to go into these new regions advisedly. If their experience turns out better than they anticipated, they will endure the disappointment with a fortitude that is difficult to maintain under reversed conditions. Finally, no matter what the attractions of a health-resort may be, remember, hotels and first-class boarding-houses do not make provision for those who are seriously ill, and never be tempted into the cruelty of sending a patient in the last stages of consumption in search of possible benefit when the prospects are such that danger of death far away from home is imminent; and, above all, insist upon patients placing themselves under the direction of a competent physician, and have him report to you or to their family at stated intervals the real condition of the invalid. One of the most dread- ful delusions of this insidious disease is the overweening confidence of patients that they are steadily and rapidly improving, when, really, Death is just about claiming them for his own. Innocently and unwittingly they deceive and mislead their friends in their communications, and frequently, through this false judgment of their true physical condition, they die, unnecessarily, far away from home, without the solace of the ministering love of their family. This little precaution will often save all parties concerned the bitter experience of the saddest side of health-resort life.