APPENDIX.

In the introductory chapter I have already mentioned in a general way the diseases which are likely to be benefited by wintering in Egypt, and now I propose to consider the question a little more in detail, referring only to the most common diseases which I have met with amongst healthseekers in Cairo.

Phthisis.-Commencing with pulmonary consumption, it may be stated that cases of acute tuberculosis or acute phthisis are not sent to Egypt as a rule, because of their rapid fatality and because the state of the patient is so serious as to prevent the desirability of transport. The few patients I have seen with scrofulous phthisis associated with caries of vertebræ, psoas abscess, or fistula in ano, have generally done very well in Cairo, but some of them have died within a few months after leaving for Europe.

Perhaps I may be allowed here to quote the statistics of the influence of foreign climates in consumption published by Dr. C. T. Williams: 251 cases were sent to various places in the Riviera, south of Europe, north of Africa, and Atlantic islands. Twenty patients spent twenty-six winters in Egypt, and furnished "by far the finest land result" of the experiment; 65 per cent. improved, 25 per cent. remained stationary, and only 10 per cent. became worse. It is a matter for congratulation that the expense of the trip to Cairo and the ascent of the Nile is now so much reduced that the country is thrown open to large numbers

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of patients who have hitherto been prevented from coming. Out of 45 cases that I have seen with unmistakable phthisis, 69 per cent. improved, 20 per cent. remained stationary, and only 11 per cent. grew worse (including three deaths in Egypt).

My figures are, therefore, confirmatory of the results previously obtained by Dr. Williams. The three deaths which occurred in Egypt were cases in the last stage of phthisis, which died soon after arrival, and of course ought not to have been sent abroad. I can only repeat-what every one knows already—that threatened cases of phthisis, with or without a bad family history, can apparently be prevented from developing in a pure, dry, warm climate; that incipient cases can be improved and perhaps cured ; that chronic cases can remain stationary, so that their lives are definitely prolonged; but that advanced cases with disease in both lungs and a temperature every night above the normal cannot be cured by a change of climate, though their disease may, under fortunate circumstances, be arrested, and their days consequently may be enlivened and prolonged.

Perhaps the most satisfactory case to send abroad is the overgrown boy or girl with winter cough, insufficient expansion of chest, and general lassitude. Such patients require little or no medical treatment, gain weight and breadth of body and mind, and return to their work at home with healthy vigour. Next, if any cases of phthisis are to be sent abroad, they must be either those which, though anatomically advanced, are chronic or quiescent, or those in the earliest possible stage.

Now, in the case of these latter, the patients and their friends are least likely to think of the scheme, or even to suspect the disease. It therefore rests with the medical attendant, where he thinks fit, to order for his patient a continuance for some months of an equable warm climate, such as is provided by a summer in England, a winter in Egypt, and a second summer in England. When a patient

in whom phthisis is suspected goes or is taken by his relatives to a doctor to have his chest examined, it may generally be prophesied either that there is no ground for uneasiness, or that the disease has already made distinct progress. Incipient cases which gain weight and improve in other respects during a winter abroad, often need to be reminded that the measure should be repeated a second time.

Popular young patients must often be banished from Cairo during December and January, to desert life at the Pyramids, or at Luxor, to protect them from themselves and their acquaintance, and the snares of evening engagements.

Chronic cases of undoubted phthisis do very well in Egypt, for they improve in general health, digestion, and appetite, and can often take cod-liver oil, which was previously impossible. They are encouraged by finding that they gain a little weight, and become rid of troublesome cough and expectoration. This last symptom is an important one in Egypt, and one of the first signs of the patient's improvement.

An ordinary phthisical individual complains, when he first reaches Cairo, of cough and expectoration, and the stethoscope reveals a multitude of large and small moist sounds. When he is seen again a fortnight later, these sounds have partly disappeared, he still coughs, but is surprised and sometimes alarmed to notice that the expectoration has suddenly diminished. After another week or two, he reports that he only expectorates the first thing in the morning; he seldom coughs during the day, and the stethoscope again confirms the drying-up process which is going on in the lung, which seems to be the direct result of dry air inhaled. This is not so wonderful when we remember that the average winter humidity of the Cairo air is under sixty-six per cent. (Table I.), while that of London is above ninety per cent. It would be interesting to know whether the very dry air is inimical to the life and development of the tubercle bacillus. Two cases in which bacilli were seen in London and on arrival in Cairo, and could not be found before leaving Cairo and

upon returning to London, are possibly confirmatory of this suspicion.

Advanced cases of phthisis will often be much happier leading an indoor life in their own unsuitable climate than an occasional outdoor life in a more favourable one. This is especially the case if the patient has very limited means. He gains sunlight and sunheat during the day, and runs a chance of his disease being arrested; but against this he must balance draughts and irksome travelling, a paucity of fireplaces, food and habits to which he is unsuited, and exile from his home-comforts and best friends.

I have previously referred to the question as to whether it is advisable or not to send cases of hæmorrhagic phthisis to Cairo. I have not yet seen any ill result from doing so, and though I do not wish here to quote medical cases, I will give the results of the only two patients I have met, with alarming history of recent hæmoptysis. The first case, a friend, but not a patient of mine, aged 27, had copious hæmoptysis, recurring several times, followed by cough, purulent sputa, dyspnoea, and loss of weight (171 lbs.). He was sent to Pau, Nice, Mont Dore, and eventually to Egypt. He was so weak that he had to be carried ashore at Suez, and he could not walk for more than ten minutes at a time. After six weeks in Cairo, he went to Luxor for two months in January, 1888. In March his cough and expectoration had quite ceased, and he could be out shooting for three hours at a time. He gained. 19 lbs. weight while in Egypt, and spent the following winter at Cairo and Luxor, without cough, expectoration, or hæmoptysis, but still with old physical signs at the right apex.

The second case was that of a lady, aged 19, whose father, brother, and sister, had all died of rapid phthisis with hæmoptysis. She herself had had hæmoptysis for a year, with loss of flesh, night sweats, slight cough, and signs of incipient disease at one apex. After fifteen weeks at Cairo, she had gained 15 lbs. weight, and there was general improve