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ANNIVERSARY ORATION
DELIVERED HEFORE THE
SOUTH CAROLINA  MEDICAL ASSOCIATION,
ANNUAL MEETING
IN   CHARLESTON,
HELD ON 31st JANUARY, 1853











 Br AMORY COFFIN, M.D.
        CHARLESTON, S. C:

STEAM POWER PRESS OF "WALKER AND JAMES,

          No. 3. Broad-Street.
1853.
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ANNIVERSARY ORATION
DELIVERED BEFORE THE
SOUTH CAROLINA MEDICAL ASSOCIATION.
AT THE
ANNUAL  MEETING
IN  CHARLESTON,
HELD ON 31st JANUARY, 1853.
By AMORY COFFIN, M.D.
■^■^^c
        CHARLESTON, S. C:
STEAM POWER PRESS OF "WALKER AND JAMES,
           No. 3. Broad-Street.
1853. 
 
ADDRESS.
               OBSERVATIONS

  ON THE INFLUENCE OF CLIMATE IN TUBERCULAR DISEASE.

   Gentremen:—The  subject of the address,  which  it has
 pleased you  to elect me  to deliver  to-day,  is The Influence
 of Climate in the Treatment of Tubercular Disease.  I have
 chosen it not only on account of its general interest, but be-
 cause to me  it  is also  of locil interest.  I have resided for
 some  years past  at  Aiken, a village  situated on the high
 sandy ridge which separates the head waters of the  Edisto
 from those of creeks which empty into the  Savannah river.
 Being so elevated, and the ground light and sandy, all  water
 is rapidly drained off, and the soil is as  sterile as the air is
 pure.  Vegetation seems to  progress  as if deficient in its
 elements,  with the exception of the lofty pines which scent
 the air with their terebinthinate fragrance.  It is, in fact, es-
 sentially a pine barren.
   Being easy of access, from its situation on the Rail-Road,
 it has, within the last few years, become  a place of much
 resort for pulmonary  invalids from all parts of the United
 States. It has long been favourably known as a retreat for
 convalescents from diseases of debility, and invalids  suffer-
 ing from immedicable chronic diseases, from Charleston and
 the sea-coast of our own State in  summer.  Thus  I have
 been favourably situated for observing the influence of cli-
 mate as an agent  in the treatment of Tuberculosis.  I have
premised these few remarks, which you will excuse, simply
for the purpose of rendering more intelligible the relation in
which I stand towards  my subject.
  The general interest attached to it has  been of late years 
4
ADDRESS.
greatly on the increase,  and this is owing to two principal
causes.   The first of these is  the greatly increased  preva-
lence of consumption in our  larger cities, from the many
depressing causes following in the wake of civilization.   In
the Northern cities this  is especially the case.  It has even
been supposed  that England, herself,  the hitherto favoured
home of phthisis, is fast yielding  this unenviable pre-emi-
nence to the  more northern of these States—New-England
especially.   The second, is the greater facility with which
change  of climate is  now effected and  the diminished  ex-
pense attending it.  What was formerly only  within reach
of the wealthy, can now be attained by those in more mode-
rate  circumstances.   And yet there seems to be on the part
of a great many physicians,  who are led  to advise their  pa-
tients to seek change of  air for the  benefit of their health, a
great want of information as to the particular localities in
which the invalid will  find  the climate  best suited  to  his
complaint.
  In  England,  notwithstanding the existence  of  the works
of Clark, and  other eminent writers on  the subject of cli-
mate, we find Malta, Madeira, Montpelier, Florence, Rome,
Naples, alternately recommended and decried.
  After a few years enjoyment  of popular favour, these
places  find  themselves deserted,  with nothing left but  the
numerous English graves to mark  the reputation they once
enjoyed.
  So great has this disappointment been, that  the principal
object of those who have written on the subject of climate of
late  has been to turn the attention of physicians, and their con-
sumptive patients, to the advantages of the southern coast of
England over foreign countries.  The bend of the coast from
Hastings to Torquay,  the  Home Madeira as it has been
called,  protected as it is by  projecting land to the west, en-
joys a mild and equable climate compared with that of the
rest  of  England.  And  yet we cannot, on reflection, but  con-
clude that absolutely, and not comparatively considered, the
influences of this section would be favourable only in a few
instances. It is too relaxing, too much exposed to sea breezes,
or to what experience has proved  to be  the  very worst in 
ADDRESS.
5
tubercular disease, the  mixture of land and sea air, which
pessesses the disadvantages of both, without the favourable
influence of either  alone.  We  venture, confidently, to pre-
dict that in a few years  a reaction will take place, and these
resorts  will fall into unmerited neglect.  I say unmerited,
because, doubtless,  as  we shall see hereafter,  there are a
certain number of cases to which  such  a climate is benefi-
cial.
   Again—the natural honing of consumptives for the warmer
climates of the South of Europe will arise.   They will not
be satisfied with any thing short of Italy.  This will, in its
turn, influence their medical advisers, and again indiscrimi-
nately will  they be shipped  to  die  in  foreign lands, away
from friends, from home comforts,  and all those little atten-
tions and kindnesses which  smooth the gradual passage  of
the consumptive, especially, to the grave.  And here is indi-
cated the great, the serious error,  which is the cause of all
this disappointment, and which has caused the  efficacy  of
climate in the treatment of Tubercular disease to be called
into question, namely:  want of discrimination of the cases
to which this  treatment should be  applied, and want of dis-
 crimination in the selection of the climate applicable to each
 particular case.
    Certain  places obtain a  name  as  favourable resorts for
 consumptives—such as Havana, the Bermudas, Florida, Ai-
 ken, and some parts of Georgia—possessing little in com-
 mon as regards climate, but a certain elevation of tempera-
 ture.   A physician  is consulted by a patient who finds his
 health declining, his flesh and  strength  diminishing, and a
 certain little unpleasant cough recurring, and growing more
 and more obstinate at  every return of cold weather, or per-
 haps a slight spitting of blood is the  first symptom that
 alarms him and induces him to seek medical advice.  The
 physician examines his lungs and finds signs of incipient  tu-
 berculization.  He  advises his patient in general terms to
 seek change of air, or  if a Northern man to  go South—and
 either leaves the selection of the locality to the patient, who,
 perhaps, knows as much about it as he does himself, or more
 frequently  mentions the one of the above places whose name 
6
ADDRESS.
 is most familiar to him.  Hence, as I have said, a most fruit-
 ful source of disappointment—a  want  of  philosophic dis-
 crimination—a vague and empirical manner of prescribing,
 which the very same physicians, perhaps, good and eminent
 men  in their way, would disdain to practice, when adapting
 other and pharmaceutical modes of treatment  to other dis-
 eases.
   When we are called on to prescribe for a  case of disease,
 in order to arrive at a correct diagnosis, we carefully  consider
 all the circumstances which  surround  the  patient, investi-
 gate  the causes which gave rise to the affection, the temper-
 ament which influences its character, and the thousand and
 one little  details which a careful examination brings to light,
 and which are necessary to form to our mind's eye a finished
 picture of that individual  case.  We then  proceed, in the
 best manner we are able, to advise and apply such remedies
 as our judgment and skill prompt  us  to.  We do not con-
 tent  ourselves  with prescribing for the name of a  disease.
 Why  should we not then be equally circumspect in prescrib-
 ing hygienic  change of air in pulmonary consumption.  If
 there be any virtue in it, and that there is when judiciously
 employed, my own observation alone  would justify me in
 asserting, it must be administered with  a due regard to all
 the circumstances connected with each individual case.
  Let me then, first, invite your attention to the nature of
 the disease we are  called  on to  combat by this powerful
 agent, and to the varieties it may present.
  Tuberculosis, one of the dyscrasiae, is  generally allowed
 to be  a disease of debility.   The causes which gave rise to
 it, are, in  almost every instance, of a depressing character—
 they are such as sink the system below par.   They  may be
 moral in their nature—such as disappointed affection, anxie-
 ty of  mind, prolonged watching and attendance on the sick,
 over-eagerness in the pursuit of gain, (especially when fol-
 lowed by disappointment,) either from the desire and neces-
 sity of obtaining the means of life,  or  from a much  more
 common cause, and one  that is becoming  daily more preva-
lent,   the  sheer  unmitigated love of lucre—or  they may
 be physical, such as imperfect assimilation  and nutrition, 
ADDRESS.
7
brought on  by the use of food either intrinsically indigesti-
ble, or rendered so by the improper mode of preparing it, or
by the manner in which it is  consumed; or, again, some
previous disease, either debilitating itself, or too debilitatingly
treated.  Even in those cases, not so numerous as they were
once supposed, where hereditary transmission is traceable,
some depressing circumstance is usually found to be the im-
mediate cause of the local development of the disease.
  Its local expression in  the lungs is  favoured, there is  no
doubt, by the action of cold and moisture on the skin and
bronchial mucous membrane.   Indeed I have lately seen it
asserted by  an experienced English physician, that tubercu-
lar deposit in the lungs is always preceded by bronchitis.
  The disease may then be said to consist of two elements—
the general diathesis and the local pulmonary affection, and
these may exist in very various proportions to each other.
   We often find, and principally in hereditary cases, patients
whose general appearance, form of the  chest, figure, com-
plexion, &c, indicate a general tubercular tendency, but in
whom we will be able to discover only the signs of a few
scattered tubercles in the lungs.
  On the other hand, we as often see cases in which,  with
an otherwise good and sometimes even robust constitution,
pulmonary tubercles have  been developed by some  one of
the forementioned causes, without there being the least natu-
ral tendency to the tubercular dyscrasia—cases of " acciden-
tal phthisis," as Dr.  Pollock terms them.  These  are  both
theoretically and practically the most amenable to treatment
and hygienic influences, as it has been asserted by some of
the highest  authorities on the  subject, that the tendency of
the local disease  is towards a cure, which would be effected
were it not for the constant renewal of the sources of irri-
tation.  Between these two extremes we have every possi-
ble variety of proportion, but in the great majority of cases
we are obliged to combat these two  elements at once,  and
experience has shown how little drug-medication has in  ar-
resting their progress.  None at all, indeed, as long as the
patient is still exposed to the atmospheric influences which
favoured the development of at least one of them.  He must 
8
ADDRESS.
 then be brought  away  from them, and placed in a climate
 which is rather tonic in  its nature, unirritating to the lungs,
 and which will allow him to pursue the most freely, and for
 the greatest length of time, those amusements and exercises,
 which while they strengthen his body, divert his  thoughts
 from himself and his symptoms.
   Of such climates we may count three classes.
   1st.  The  warm and  moist or insular.   Under this  head
 may be comprised the climate of Havana, and that of the
 beautiful  islands of the Caribbean Sea,  the peninsula of
 Florida, and the Bermudas, including the sea voyage thither,
 in this hemisphere corresponding to that of Madeira, Malta
 and the Italian peninsula in the eastern.
   2d. Much attention has been drawn of late years to the
 advantages derivable from the influence of a cold dry at-
 mosphere, such as may be found among the green and white
 mountains of the northern States, upper Canada, or nearer
 home in those sections of our own State and North Carolina,
 which lie  in or near the  Blue Ridge, such as Greenville, Pen-
 dleton and the old Buncombe, now Henderson county of
 North Carolina—in Europe, Sweden and Norway.  And
   3d. The comparatively mild and dry or pine barren cli-
 mate.
   Until within a few years back the warm and moist insular
 climates have been those most preferred  by physicians and
 patients.   Not acting much on the skin, but relaxing the
 bronchial  mucous membrane, and inducing a freer secretion
 therefrom, they in this manner relieve pulmonary congestions,
 give the lungs a better opportunity  of recuperation, and are
 thus eminently serviceable in cases of incipient consump-
 tion, and those cases we  have before alluded to as accidental
 phthisis—where  the  general  tubercular diathesis is slight
 compared  to the  local affection, where, in an otherwise heal-
 thy constitution, tubercular development has been induced by
 temporary depressing  causes as disappointment, anxiety or
 prolonged  watching.
  The  patient relieved of his dyspnoea, and thoracic pains
 and stricture, feels bouyant and light, interested  by change
of scene, his attention arrested by the charms  of  tropical 
ADDRESS.
9
scenery, he forgets the home cares, the cause of his disease,
and the healing power of nature progresses unopposed in its
work of cicatrizing small cavities, or of rendering indolent,
tubercular deposits.
  Elderly and  feeble persons, too, whose power of develop-
ing heat is small, who enjoy more than any thing the bright
sunshine, and are depressed by even  moderate cold, have
their comfort promoted and their life prolonged by resort to
a climate of this class.
  But for cases which have proceeded  further than mere in-
cipiency, where the tendency to softening  is greater, where
the constitution participates more largely in the disease, and
especially for  patients from high northern latitudes, these
climates are too  relaxing,  too debilitating.  The  increased
bronchial secretion,  instead of being only sufficient to relieve
pulmonary congestion, is carried to such an extent as to ex-
haust the patient.  Digestion, the integrity of which is so
essential, begins after a while to suffer, assimilation is defi-
cient, then ensue further debility, fresh deposit of tubercles,
softening, hectic, and so on to the end.
  It is only recently that the attention of physicians has been
drawn  to the advantages derivable in some  cases  of con-
sumption, from a climate of an exactly opposite character—
a cold dry air ; so cold indeed that all the moisture of the
atmosphere is congealed.  The air is  completely and abso-
lutely dry.  Such a  climate is found in the greatest  perfec-
tion in some parts of upper Canada.
  The bracing and invigorating effects of a cold frosty morn-
ing, are familiar to all of us.   The circulation is quickened,
physical activity is heightened, the appetite is increased, and
respiration, digestion and  other functions  seem, as it were,
to proceed  with greater  vitality.   This heightened  action
which is apparently only an answer of nature to an increased
demand made upon her, has been made the foundation of a no-
vel practice of sending consumptives to a more northern and
colder instead of a more southern and  milder region.  Ex-
perience is  yet wanting by which the practical efficacy and
success of this plan can be tested,  but to judge  of  it theo-
retically, I  should say that if it is to  be  beneficial  in anA 
10
ADDRESS.
cases, it must be so in those of a character opposite to such
as we have already  considered  as improveable by the first
class of climates.  Such for example where the local disease
is not  extensive, where the general constitution requires
strengthening and bracing up, and more particularly where
digestion  is at fault—where indeed  depraved or imperfect
nutrition  is the prime cause and origin of the disease.  In
such cases we can easily conceive that the tonic action of a
dry cold, and the thereby induced desire for exercise,  would
be  highly serviceable.  But the  proportion of such cases to
the whole  number of consumptives is small,  and the stage
of the disease to which such a climate  is applicable is com-
paratively limited, for although in such cases the progress is
slow, and the period  during which some  change  of  air is
likely to be of service, is more protracted  than in the first
class of cases, yet there  arrives a time when the economy
has not vitality enough left to react, when nature can no
longer respond to the call made upon her.
  And then we must remember that although moderate cold
acts as a tonic stimulant, extreme cold, even though dry, has
a sedative and depressing effect,  particularly on previously
enfeebled systems. Females and old persons will not bear this
variety of climate well.  Their calorific powers are not suf-
ficient to bear up against the cold, and instead of acquiring
health and strength by active out-door exercise, they would
feel more inclined to sit by the fire and mope.
  It is best suited to male adults who  have constitution and
strength enough yet to shoulder  a  gun  in  pursuit  of game,
or mount  a horse and enjoy a brisk canter of a frosty morn-
ing.
  The third variety of climate,  the pine barren climate, is
much milder, though  sufficiently cold to be  tonic and ex-
tremely dry, but its dryness  is owing to the fact of the great
scarcity  of water,  and  not  to its  being  congealed by
frost.
  The winter  temperature is somewhat lower than that of
the coast, the cold not being moderated by the vicinity of the
sea, but yet the thermometrical  average is sufficiently high
for it to be classed as comparatively mild, and its great dry- 
ADDRESS.
11
ness makes  its effect very different from that of the  insular
climate already described.                               _.,
  I would say that its principal perceptible effect was a deT
rivation from the lungs to the skin, and  sometimes  to the
abdominal organs, this latter not in the shape of diarrhoeas,
but rather of hepatic and splenic congestion, which, if Roki-
tausky's views are correct, would induce that state of venos-
ity which he  considers antagonistic to Tuberculosis.  This,
however, is only conjecture; but the increase of cutaneous
action is very marked, and the relief thereby afforded to the
lungs is proportionately great. With  an  air comparatively
free of vapour for the oeration of the blood, which process is
consequently more easily and readily performed, and the de-
termination of this  fluid to the surface,  lessening internal
congestion and stasis, we often see the dyspnoea considerably
lessened and gradually disappear, the secretion become more
scanty, and the sputa of a lighter colour, and less purulent
character.
  In the more favourable cases,  while the patients comfort
is thus  promoted, the disease assumes a less active, a more
chronic character.   The drain on  his strength being lessen-
ed by the diminution of the purulent secretion,  the  patient
may gain flesh, and  the  progressive gain of flesh is  one of
the best symptoms.
  The climate is not too warm to counter-indicate or render
disagreeable the  use of Cod Liver Oil, and  nourishing and
fatty food—nor too cold  to  prevent all but the most  feeble,
and those in whom the disease has progressed to an incura-
ble point, from taking sufficient exercise to  assist in the di-
gestion of them.   To such a climate may  be sent with a fair
prospect and hope of benefit, such  cases as in the proportion
of the two elements of the disease, the general taint  and the
local deposit lie  between the two  aforementioned  classes—
such as  in whom, with general  laxity of constitution, the
disease has sufficiently advanced to make a decided impress
on the lungs, but yet not an ineffaceable one.   Local disease,
there is either in the shape of crude tubercle or small cavi-
ties, but the  tendency to progress is exceedingly slow and 
12
ADDRESS.
chronic, or if softening has taken place to a greater extent,
yet it has not been so rapid as to cause an exhausting drain
on the patient's strength.
  In  them, usually, no  hereditary contamination  can  be
traced, but the development of the disease has been assisted
by some of the  accidental causes, mental or physical, pro-
longed error in diet  or clothing, acting on not very strong
constitutions.
  If such patients, especially those from nothern latitudes,
are placed  under the genial influences of one of these  pine
barren climates, made to take horseback exercise in  propor-
tion to their strength, have their diet and clothing regulated
for them by those who understand the importance  of partic-
ularity in these matters, they are  almost sure to exhibit, in
the majority of cases,  for some  time at least, the  signs of
improvement I have  before enumerated   How long  this im-
provement  is to last, whether progressive and permanent, or
only temporary, will depend much on the force of resistance
and power  of repair of the constitution.
  Do not understand me as wishing to assert that  climate
will effect  wonders  in  the  cure of consumption.   We .ill
know how  painfully numerous are still its victims notwith-
standing change of air or Cod Liver Oil.   All that I wish to
maintain is, that much may be done towards the  prolonga-
tion of life, much towards promoting the comfort of suffer-
ers, and  something towards lessening the number of those
who  fall a prey to this terrible  scourge—the  more terrible
because its victims seem by some strange fatality to be cho-
sen from among the most interesting, the brightest, the  best
beloved of  families—and this may be effected by a careful
choice of climate, as best suited to each particular case.
  In favour of these pine barren climates, may be adduced
the rareness of consumption among the natives, and  what
has often astonished me, its exceedingly slow progress when
it is established—and this, notwithstanding the use of un-
wholesome indigestible food, badly cooked, dwellings open to
all the winds, great carelessness in dress, much exposure to
bad weather, and much poverty. 
ADDRESS.
13
  It may be said that  this exemption is owing  to  the pre-
servative influence of Fiisel oil, which is constantly and ex-
tensively consumed in the shape of bad whiskey.   Possibly
so—but yet we have evidence of the same fact in analogous
climates, where this article is not so freely used.  Dr. Has-
pel, in his work on the diseases of Algeria,  says that he was
struck with the infrequency of phthisis in North-Africa, only
having had three  cases  out  of 1480  patients, and but  one
death in 138  was from this disease.
  He asserts that pneumonia never, under  his observation,
degenerated into tuberculosis, and he  thinks that there is a
kind of  antipathy between the climate  and  the generation
of tubercle in the lung, which goes far to confirm the belief
of the antagonism between malarious diseases,  very preva-
lent in that section, and phthisis.
  If there  be any foundation for this doctrine of the antago-
nism of disease, and every  year seems to  accumulate the
proofs in favour of it, there  is more probability of  its exist-
ing between  marsh diseases and phthisis than any other two
classes of disease.  But, in these pine-barrens, we have what
would be malarious districts, if they were not prevented from
becoming so  by the  absence of moisture.   This one of the
conditions necessary for the production  of  malaria, but not
necessary  for  the antagonism of phthisis is wanting.  In
proof of this, I may  adduce  the  fact, that after the heavy
rains of the last summer, intermittent, remittent and pseudo-
typhoid fevers and dysenteries prevailed extensively in these
usually perfectly  healthy sections of country; so that pa-
tients may be subjected  to  all the other influences without
having  to  undergo the depressing  effects of malarious dis-
ease. To benefit by this  variety of climate, the patient must
have lung enough left to breathe  its dry, balmy air; stomach
enough  to digest good  wholesome  animal food,  juices  of
meat, &c.  ; and, if thought advisable, to  resist  atmospheric
vicissitudes,  and assist respiration  by the  ingestion of the
requisite quantity of Cod-liver oil; and, above all, general
health,  and strength enough to lead an out-door life and take
a sufficiency of Sydenham's  specific, horse-back exercise. 
14
ADDRESS.
  Further, he must have courage  and patience enough to
pursue this course, and subject himself to such climatic in-
fluences, if not permanently, at least  for  a series of years.
He must not expect to eradicate entirely, in a few months,  a
disease which seizes so deeply on the constitution.  The ne-
cessity for this has  often  struck  me while watching the
course of our Northern invalids.  They arrive usually in the
fall, or the commencement of winter, and  improve during
their stay.  On  the first arrival of warm weather, feeling
better, they are anxious to return home.  The  next autumn
they come back again,  rather worse than when they  left,
proving that a Northern summer does not constitute a South-
ern climate.   They rally, perhaps, but not as rapidly, nor as
thoroughly as at first.   Again they seek their home, and we
either hear no more of them,  or that they will  not return
again.  Consequently, if such patients as we have described,
find themselves  doing well  under  change of climate,  they
should continue so as long, and as uninterruptedly as practi-
cable.   But, for those cases where softening proceeds unin-
termittingly, where the constitution is worn down by large
suppurating cavities, by consequent hectic, by colliquative
diarrhoea and  exhausting night sweats, there is but one cli-
mate to be recommended, and that is the aggregate of cir-
cumstances which are comprised under the  name of home,
with the long-enduring, never-wearying love and attention
of friends and relatives, the kind nursing,  the  many little
amenities and the accustomed comforts which cannot be
purchased.  'Tis cruel to send such abroad.  In the expres-
sive words of  Dr. Pollock, I  may say—
  " Could the home physician be ever placed in the position which
has  often been ours, that of being called on to perform the  last sad
duty which science owes to humanity, by numbering the days which
yet  remain ; and, face to face with the patient, calculating with such
exactness as we  may, whether the powers of life will bear  removal
home, and be obliged to decide  in  the negative, such sufferers would
rarely arrive to humble the  pride, and wring the hearts of those who
practice our profession abroad."
  And now, in taking leave of my subject, I would merely 
ADDRESS.
15
say that these remarks have been made rather in the spirit
of one who would invite attention to this important subject,
than as considering them  possessed of any interest them-
selves.  They are  such as have often  passed through my
mind during the  long solitary rides of a country practice.  I
had last year but little time to  put them into such finished
shape as would be worthy of your attention.