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THE OPEN-AIR CURE

THE following notes are based upon an experience gained in the last six years during which I have carried on an incessant, personal campaign with the bacillus tuberculosus, the scene of operations having included the snows of Switzerland, the veldt of South Africa, and the open-air sanatorium of merry England. Those who hope to find herein a brochure which will enable them to treat themselves or their friends without medical assistance will be disappointed. I will say at once and unhesitatingly that the first thing to be done by any one who finds or suspects that he is affected with tuberculosis is to seek the best medical advice which he can afford, and to undergo regular and systematic treatment under the guidance of an experienced specialist. I say a specialist, for, although consumption is the commonest of all serious ailments, the average practitioner is very seldom up in the minutiae of treatment, some very important, upon which the best authorities insist. A man cannot be a specialist in every branch, and consumption is a disease which eminently requires special treatment. Having insisted upon the necessity or, at any rate, the desirability of skilled medical advice and supervision, I will now say that, even with this, a very great deal depends upon the patient himself. It rests with him whether he will act upon his doctor's advice intelligently and conscientiously, or whether, in order to gratify some foolish whim, he will strain a phrase into a meaning which he well knows that it was never meant to bear. As an instance of this, I may mention the case of a patient who had been for some time upon a diet of beef tea, gruel, &c., and who, on being told by his doctor that he might have “a little fish and fruit,” proceeded to make a hearty meal of stewed eel, dressed crab, and walnuts. Moreover, an observant person will greatly help on his own recovery and facilitate the doctor's task if he can and will intelligently observe and note the results produced upon himself by diet, exercise, rest, &c. No two cases are exactly alike, and, however skilful a doctor may be, he must base his advice to a great extent upon results of which he can only learn from the mouth of his patient. The following is the routine of a well-managed open-air sanatorium in England in which I spent some months, and it may be taken as fairly typical : Between 7 and 8 A.M. the patient takes his temperature and pulse rate, and drinks, or rather sips, half a pint of milk. Breakfast 8.30. After breakfast an hour's rest, then half a pint of milk, after which exercise, nearly always walking, is taken, the distance and pace being according to the doctor's orders. 12.15 to 1.15, rest hour. 1.30, luncheon. After luncheon an hour's rest ; then exercise or more rest as ordered. 4.30, tea. 5.45 to 6.45, rest hour. 7.o, dinner. After dinner an hour's rest, then light exercise, music or rest till bedtime, about 1 o.o P.M., when a final half-pint of milk is taken. Generally the limits of the morning walk are strictly laid down by the doctor; and the disposal of the rest of the day, apart from meals and rest hours, is left more or less to the discretion of the patient. Great importance is attached to the “rest hour,” i.e., an hour's complete rest (even talking discouraged), before and after meals. Immediately after exercise the digestive organs are not in the best condition to perform their task; and as in consumption these organs are nearly always more or less impaired, they must be given every possible advantage. As to meals, although all sit down together as at a table d'hôte, the amount to be eaten by each patient is carefully estimated and arranged for by the doctor, and the serving is superintended by a nurse who is responsible that every one gets his due portion, and who notes and reports to the doctor when any one eats more or less than is expected of him. The meals consist of good, plain food. For breakfast: fish, eggs, bacon, ham, &c.; for luncheon and dinner : soup, fish, joint, milk pudding. The only drink allowed (except in special cases) is milk, with tea or coffee at breakfast. Three pints of milk are drunk during the day, half a pint at each meal, and half a pint before breakfast, during the forenoon, and at bedtime. Of course, in other sanatoria the details are not quite the same. The most important differences of which I am aware are that, in some establishments, no milk or other food is taken except at the three regular meals, and that, in some, instead of resting for an hour, the patients start out walking immediately or very soon after meals. As the latter procedure seems to answer, and as it gives a good deal more time for exercise, it certainly seems to me to be the better of the two.

In some sanatoria discipline is strictly maintained. Patients are obliged, under pain of dismissal, to conform to rules and to carry out the doctor's instructions. In others more, sometimes very much more, laxity prevails. These latter are to be avoided. It is most difficult, even for a strong-minded person, to attend strictly to business while his companions are diverting themselves hard by ; but, without such strict attention, no success can be achieved. In some sanatoria riding, croquet, golf, &c., are allowed, of course only for those who are convalescent. In others no exercise other than walking is permitted. At the sanatorium at which I stayed, and I believe at most others, there is now no “stuffing” or “overfeeding.” This phase of treatment was in almost universal vogue until recently, but it has been to a great extent given up. The practice was to make patients eat as much as they could possibly contrive to get down, and some heroic performances stand recorded. It has now been found better to regulate the quantity of food for each patient according to his capacity for assimilation, as indicated by certain physiological symptoms, and although many are required to eat beyond the promptings of appetite, the majority have no great difficulty in disposing of their allowance. The present regime certainly strikes one as being the more rational, yet it is an incontrovertible fact that a great many excellent cures were achieved by almost indiscriminate “overfeeding,” and it is at least open to question whether that treatment should not still be utilised in certain cases. To those who can take it well all nutriment is given in the form of plain food. For those of delicate appetite or digestion a part of the daily allowance is in the form of some milk preparation, such as plasmon or casumen. Some of these are of high nutritive value, a few teaspoonfuls, which can be dissolved in milk, being equivalent to a considerable amount of meat. They are practically tasteless and are easily digested. Meat powders are also useful but expensive. A most excellent article of food is cream. Fat is very necessary, but in most forms it is difficult to digest. In cream it is supplied in its most easily assimilable form, butter being probably the next, and, after that, bacon. The matter of diet is one in which the advice of an experienced medical man is most necessary. Without such advice one can only hope to arrive at a correct diet by exhaustive experiments, in the course of which the digestive apparatus is likely to be most seriously upset. Unfortunately, the number of doctors in ordinary practice who make any study of diet is very small, and many of them seem quite unable or unwilling to give any but the most general directions. Another point on which it is most difficult to guide oneself is that of exercise. It is probable that, in consumption, more deterioration of health, more relapses, and more deaths are due to over-exertion than to any other cause. Any one who has experience must know of many cases in which good progress was being made until some extra long walk or some unduly rapid or violent movement caused a set back. In certain stages of the disease the regulation of exercise is extremely difficult, and it is here that the intelligent co-operation of the patient is needed to assist the doctor in framing his instruction. The temperature and the pulse rate are carefully watched, both being observed and recorded by the patient immediately on returning from exercise. Some rise of temperature and acceleration of pulse rate is to be expected, and would occur even in the case of a healthy man, but, if either of these be abnormally great, there is indication of over-exertion." At the end of the rest hour the temperature and pulse rate are again recorded, and they should then have returned to their normal state, or nearly so. Although over-exertion can often be detected immediately by its effect on temperature or pulse, this test is not absolutely infallible, and it sometimes happens that no such indication is noticeable until two or three days have elapsed. Such cases are particularly dangerous, and it is likely that the person concerned concludes from the absence of unfavourable symptoms, or of any feeling of fatigue, that the walk, &c., was not beyond his power, and repeats or even increases it on the following day. Sometimes over-exertion produces a considerable increase of expectoration, but this is not always the case. Any increase of exercise should therefore be most carefully undertaken, and it is a good plan, after increasing one day, to return for the following few days to the previous limit, e.g., if one mile a day has been the allowance and this is to be increased to one and a quarter miles, the latter distance may be covered say on Monday. Then, on Tuesday and the following days, one mile or even a little less, until is is quite evident that the Monday's extra quarter mile has produced no ill effect. To do this requires great patience and self-control, but without these qualities progress is not to be expected. It is a good rule, whenever there is the least doubt as to the amount of exercise, to take too little rather than too much. An occasional complete rest for a day or two will often have very good results. Such a rest should invariably be taken whenever there is the slightest reason to surmise that overexertion may have taken place. The temperature of an ordinary healthy man is lowest (97.5 or so) at about 3 A.M. By 9 A.M. it has reached 98.4 (the point marked as “normal" on clinical thermometers), and it continues to rise until mid-day or later, when it may reach 99.2 or even higher. There is considerable variation in individuals, but it should be noted that the temperature must not be expected to remain always at the normal point. It is considered important that it should be well below this point in the early morning, and, for this reason, it is taken on waking or soon afterwards. The pulse rate also varies in individuals. Seventy beats per minute is considered about the average, and the rate is usually slowest in the early morning. When there is fever, i.e., when the temperature at rest is markedly above normal, no exercise is allowed. The patient is either kept in bed or reclining on a long chair. If the excess of temperature is slight, a little gentle exercise is usually allowed. At first walking exercise should be taken at a very slow pace and with frequent rests, the pace and the length of walk being very gradually and carefully increased as explained above. Care must be taken to avoid any exertion, such as lifting a heavy water jug, or any rapid movement such as running up even a short flight of stairs. Standing about is also bad. It uses up energy without producing any good results in the way of increased muscular development. When not taking exercise, a position as restful as possible should always be adopted. It is well to lie quite flat during rest hour and at other times if the temperature is not quite what it should be. Clothing, especially boots, should be as light as is compatible with a comfortable degree of warmth, and it is well to dispense with braces or other gear which restrict the free action of the chest. It is the general custom of sanatorium patients to dispense with headgear at all times. A most important point is that a comfortable degree of warmth should always be maintained. One often hears it stated that the patients in an open-air sanatorium quickly adapt themselves to their surroundings, and do not feel the cold even in severe weather. Those who make such statements are either singularly unobservant or are borne away by enthusiasm beyond the limits of strict veracity. It is true that a good many,

* It is impossible to lay down any rule as to what the temperature and pulse rate should be after exercise as they vary greatly in different individuals and in different types or stages of the disease. To attempt to de so would be mest misleading and mischievous.

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