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Tuberculosis





Tuberculosis, in spite of all our efforts against it, remains in
Defoe's striking phrase the "captain of the men of death." Pneumonia
has preempted its place in the statistics of mortality, but this
is to a considerable extent because tuberculosis at the end
masquerades as an acute pneumonic exacerbation. Not less than one in
eight, probably more, of all those who die, die from tuberculosis. It
is the most serious of diseases. In spite of its eminently physical
character it probably affords the best possible illustration of the
place of mental influence in therapeutics. We have had any number of
new cures for tuberculosis, introduced by serious physicians who were
sure from the results they had secured that they had found an
important new remedy. After a few years each of these cures in
succession has been relegated to the limbo of unused remedies because
found inefficient. At the beginning they produced a beneficial
influence because of the suggestion of therapeutic efficiency that
went with them. When this suggestion failed because the physician who
administered the remedy lacked confidence, the real place of the
supposed specific as merely another mind cure was recognized.

Indeed, many of the remedies that have been introduced have not been
merely harmless drugs, but not a few of them have probably had rather
a detrimental physical effect than a beneficial influence. In spite of
this, the influence on the patient's mind has been sufficient to
neutralize whatever of harmfulness there might have been and to arouse
new courage and new energy. The consequence of this has always been
that the patient was tempted to live more in the open air and to eat
more. These are the two efficient remedies for tuberculosis. With
the additional life in the open air and increase of food his appetite
grew, for nothing so adds to appetite as the exercise of it, and with
the gain in weight there was a cessation of cough, a reduction of
fever, a disappearance of night sweats and a definite increase in
resistive vitality which gradually helped to overcome the disease.
Manifestly, then, the use of mental influence in tuberculosis is very
significant.


PROGNOSIS AND SUGGESTION

The most important element in any treatment of tuberculosis must be
the neutralization of unfavorable suggestions which are weighing upon
the patient and preventing him from using even the vital forces that
he has for resistance against the disease. The popular impression of
tuberculosis, happily waning, is that it is an intensely fatal
disease.

Though this is true in general, tuberculosis is by no means a
necessarily mortal disease in individual cases, and, indeed, a great
many more patients recover from tuberculosis than die from it. Papers
read at the International Congress on Tuberculosis, in Washington, in
1908, showed from careful autopsy records that practically all adults
either actually had had at the moment of death, or had suffered
previously from tuberculosis. If there are not active lesions then
there are always healed lesions of tuberculosis in the body of almost
every human being who has passed the age of thirty. Most people have
quite enough resistive vitality to enable them to recover from the
disease. It is only those who are placed in very unfavorable
circumstances during the initial stage of the disease, or who have
some serious drawback against them, who succumb to it. The fact that
the bacillus finds a lodgment in so many individual tissues shows that
it is not insusceptibility that makes the difference between
people, since we are all susceptible, but it is the lack of resistive
vitality, and that most of us have, under ordinary circumstances, and
all of us can have under favorable conditions, quite sufficient
immunizing power to prevent serious developments.

Even in advanced cases it is perfectly possible for the progress of
the disease to be stopped and for many years of useful life to be
gained. Probably patients who have gone beyond the incipient stage, in
whom there has once been a breaking down of pulmonary tissue never are
entirely cured, but they may be so much improved that all their
symptoms disappear and they are able to follow an ordinary occupation
for many years. There is no disease in which the unfavorable prognoses
of physicians have been more frequently disappointed than in
tuberculosis. In any city hospital dispensary one finds many cases of
tuberculosis turning up as relapses of previous conditions, with the
story that when they were seriously ill before, some prominent
physician, since dead, said they had only a few months to live. The
fact that the physician who made the unfavorable prognosis has since
died himself adds greatly to the zest with which patients tell their
story. Neither the severity of the symptoms nor the amount of lung
tissue attacked is quite sufficient to justify an absolutely
unfavorable prognosis in the majority of cases of pulmonary
tuberculosis.


No Incurable Cases.--Above all, it cannot be insisted on too
emphatically that there is never a time in the course of the
tuberculosis when a physician is justified in saying to a patient
suffering from any form of tuberculosis that his case is hopeless. One
is never justified in saying "You are incurable." Practically every
town of any size in this country has a number of cases in which
patients were told by physicians that there was no hope, and yet they
have recovered to chronicle as often as they get the chance the fact
that they have outlived their physician. To say that no case of
tuberculosis can be confidently declared incurable will seem to many
an exaggeration. There are patients in whom the prognosis is so
unfavorable as to be almost hopeless. There are never cases of which
it should be said there is no hope. When patients are told, as they so
often are, that they are incurable, absolutely no good is done and
harm is inevitable.


Heredity of Resistance.--When the disease has developed very rapidly
in patients in whom there is no previous history of tuberculosis, and
in whom there is no history of previous cases in the family, the
outlook is always serious. These cases come as near being incurable as
any the physician sees. But the most apparently hopeless of these will
sometimes recover, contrary to all anticipation. In spite of the
opposite impression so commonly accepted, the most helpful element in
these cases is the presence of a trace of tuberculosis in the family
history. This always means the existence of some immunity against the
disease and there may be a turn for the better even when the case
looks absolutely hopeless and when it seems to just be verging on its
fatal termination. Probably the most discouraging are the cases in
which miliary tuberculosis is at work and conditions are about as
unfavorable as possible. There are cases of this kind on record,
however, with the most startling contradiction of anticipation, in
which undoubted miliary tuberculosis produced high fever for weeks and
even months, then gave rise to pleurisy, to peritonitis, to various
cutaneous abscesses and to abscesses of bone, in which patients lost
one-third of their weight or even more, and yet after the
external lesions began to discharge freely, recovery occurred.


Slow Cases.--As for slow-running cases in which there is a distinct
history of tuberculosis in the family, not even the most experienced
physician can state with any certainty that a fatal termination is
inevitable and that recovery cannot occur. Some of the most expert
diagnosticians have been deceived in these cases. After half a dozen
physicians have given a man up, some gleam of hope has buoyed his
feelings and a turn for the better has come. Men with cavities in
three lobes, even in four lobes and occasionally it is said in all
five lobes, have survived acute stages, have recuperated to a
considerable degree and have been able to return to work or at least
to take up some useful occupation for a time. Where the lung lesion
progresses slowly it is surprising how small an amount of healthy lung
tissue is needed to support life. Only those familiar with many
autopsies on the tuberculous can appreciate this. Ordinarily we are
apt to think that when more than half the pulmonary tissue is involved
so as to be of little or no use for respiratory purposes, death must
be inevitable. On the contrary, one-fourth the ordinary lung capacity
will serve and all of one lung may be quite out of commission and only
a portion of a single lower lobe be available, yet the patient may
survive for a prolonged period.


The Specter of Heredity.--The most serious contrary suggestion that
patients suffering from tuberculosis are likely to have is that their
affection is hereditary and that, therefore, there is little hope of
its cure. It is in the family strain and cannot be obliterated. This
idea, fortunately, does not carry the weight it used to. It should,
however, have no unfavorable influence at all and this needs to be
emphasized. We discuss the subject more fully in the chapter on
Heredity. We know very definitely now that the hereditary element in
tuberculosis is so small that it is quite negligible. There are good
authorities who do not hesitate to say that heredity plays no role in
the causation of tuberculosis and does not even produce a
predisposition. Some remnant of the old superstition (for
superstition, from the Latin, superstare, means a survival from a
previous state of thinking, the reasons for which have disappeared)
always remains, and predisposition is the last rule of outworn
opinion.

We know now that contagion is the important element. The possibilities
for contagion vitiate all proofs of the predisposition idea.
Especially is this true when we recall that thirty years ago
practically no one took proper precautions to prevent the
dissemination of tuberculosis, and very few took them even fifteen
years ago. Even at the present time many tuberculosis patients cough
around the house with open mouth, spreading tubercle bacilli all
around them. We are caring for the sputum, but many other avenues for
the diffusion of the disease are open. Children acquire the infection,
overcome it, but retain the seeds of it in them and then in some
crisis in life, as after puberty, or when they are over-working and
over-worrying, or during the first pregnancy, an opportunity is given
to still living tubercle bacilli to find their way out of sclerotic
confinement. Other forms of contagion count in the absence of a case
in the immediate family. We can trace the contagion only too easily,
even if there is no consumptive member of the home circle.
Scrub-women, laundresses, those who are careless in their attendance
upon the tuberculous, workers in dusty places or in factories, where
there are others who cough, all these get the disease.
Predisposition counts for so little that it is a vanishing factor.

Patients can be assured at once then that they need not worry that the
hereditary factor will make their affection less curable. On the
contrary, our recent careful studies in tuberculosis show just the
opposite of the old false impressions. The children of parents who had
tuberculosis are much more likely to possess resistive vitality to the
disease than those whose parents never had it. As we emphasize in the
chapter on Heredity, the nations that have had the disease the longest
among them are the most resistant to it. When the affection is newly
introduced into a tribe or race it carries off a great many victims.
This immunity, however, is not a function of heredity or of the
increase of resistive vitality by the inheritance of an acquired
character from the preceding generation, but tuberculosis takes the
non-resistant, weeds out all those who have not some immunity against
it, and consequently those that are left possess some immunizing
power. Tubercular heredity, then, instead of being a source of
discouragement should rather be a source of hope. It is surprising to
note what a relief to many patients' minds is the explanation of this
newer view of heredity in tuberculosis; it lifts a burden from many
and makes them eat and sleep better for days.


ANNOUNCING THE DIAGNOSIS

Friends and especially near relatives sometimes come to a physician
when there is suspicion that a young person is suffering from
tuberculosis and ask that, if there is a ground for a positive
diagnosis, it shall not be communicated to the patient. They usually
urge that they fear the discouragement will kill the patient. The
young are not so easily killed and the reaction on being told the
truth and the facing of it bravely is such a magnificent help in
therapeutics that the physician should always refuse for the patient's
sake alone, quite apart from any ethical obligations in the matter, to
enter into any such arrangement. The assurance may be given that the
patient's condition will be so stated that, far from the patient being
discouraged after due consideration, he or she will look forward with
confidence to overcoming the affection.


EARLY DIAGNOSIS

Mental treatment is most valuable in the very early stage of incipient
cases of tuberculosis. The time is past when the diagnosis of
tuberculosis was made only after the recognition of definite physical
signs in the lungs and a considerable loss in weight.

In the Medical News for April 9, 1904, I called attention to the
question of "Early Diagnosis of Tuberculosis" from the pulse and the
temperature in these cases, and pointed out that a disturbance of
temperature need not necessarily be a febrile temperature of over 100
degrees, but that any increase of the normal daily variation of
temperature, usually considered to be about a degree and a half,
should suffice to arouse serious suspicion at least. If the morning
and evening temperatures differ by two degrees, this would indicate
the presence of some pathological condition, usually tuberculosis. If
in addition to this and the pulse disturbance there is any localized
area of prolongation of expiration, then tuberculosis is almost
certainly present, even though there may be no other physical signs,
no cough, no tubercle bacilli in the sputum, nor any other signs of an
active process.

It is in these cases particularly that patients can be benefited. Very
often they have a slight hacking cough, frequently repeated, with some
disturbance of appetite and of digestion and sometimes some loss in
weight. Indigestion is recognized now as one of the early stages of
tuberculosis. The cough in these cases, as has been said, is often
spoken of as a stomach cough and is supposed to be due to the nervous
reflex from the pneumogastric nerve carrying irritative impulses from
the stomach to the lungs. It is much more likely to be due directly to
irritation of the terminal filaments of this same nerve in the lungs
themselves.


FAVORABLE MENTAL ATTITUDE

The most important element in any cure or successful treatment of the
disease is a favorable attitude of the patient's mind. He must be told
at once that consumption takes away only the "quitters." People who
give up the battle or who, though still hoping, do not hope
actively--that is, do not make the exertion necessary to get out into
the open air and to eat heartily--inevitably succumb to the disease.


Eating.--Eating is often more a question of exertion than appetite or
anything else for consumptive patients. They have no active appetite
and they simply must force themselves to chew and swallow. Their
fatigue from chewing is, indeed, likely to be so disturbing that it is
advisable to furnish patients as far as possible with such food as
requires no chewing. Milk and eggs and the thin cereal foods, like
gruel, and rather thin puddings are the best for this purpose.
Patients must be persuaded that they must take these whether they care
for them or not. Occasionally they may cough after a meal and vomit it
up. The rule in the German sanatoria for consumptives is that whenever
this happens they must, after a short interval, repeat the whole meal.
Only rarely does it happen that a tuberculous patient vomits without
some such mechanical cause as coughing. They must be made to
understand that any food that stays down does them good no matter how
they may feel toward it.

The actual state of affairs as regards their future must be put before
them. It is a question of eating or of death. They face these two
alternatives. Eating is objectionable but, as a rule, death is more
so. The kinds of food they do not care for, if they are good for them,
must be insisted on. Most people who think that they cannot take milk
can do so, if it is only presented to them insistently, with at first
such slight modifications of taste as may be produced by a little
coffee, or tea, or vanilla, or by some other flavoring extract, which
modifies its taste. Butter and the meat fats will be taken quite
readily if it is only once made perfectly clear to patients that they
must take these or else lose in the conflict with the disease.

It deserves to be repeated here that in many of these cases the
disinclination to eat is due to the fact that patients find it almost
intolerably wearying to make the effort necessary for mastication.
This is particularly true if they are asked to eat meat frequently,
and especially if asked to eat underdone beef, which usually
requires vigorous chewing. Such meat is excellent for them once a day,
but it may be made much easier to take by chopping or scraping so that
practically no exertion is required. Besides, it is by no means
necessary that these patients should eat much meat nor that they
should have to chew laboriously at their food. Raw eggs may be the
basis of the diet, especially eggs beaten up, and these will be found
not only to be very tasty, but eminently digestible. Their vegetables
may be taken in purees, so that they require very little chewing
effort, though patients must be warned to mix starchy substances well
with saliva so as to facilitate their digestion. Their bread may be
taken in the shape of milk toast, or in some other soft form--bread
pudding for instance. All this helps, without demanding too much
effort, to prevent loss of weight and to regain it when it has been
lost.


Air and Comfort.--Next to food, the most important adjuvant is fresh
air. Often patients find many objections to this. It is too cold for
them; they are shivery and become depressed. Most patients need to be
dressed much more warmly than is the custom at present, and hands and
feet should be covered with woolen gloves and socks and even a woolen
hood worn around the head if necessary. There is usually too much
covering worn on the chest and too little on the extremities. With
fleecy wool garments next the body and sufficient clothing, properly
distributed, many a patient who complains of the cold will at once be
more comfortable. They must be made to understand that fresh air is
absolutely essential. Every extra hour they spend in the air is that
much gained; every hour they spend inside is just that much lost in
the curative process. If they are uncomfortable, however, they become
discouraged, and a discouraged tuberculous patient never resists the
progress of his affection. Not only does he not improve, but he
inevitably retrogresses. It must not be forgotten, however, that the
thin anemic patients who complain bitterly of the cold, when they
first take up the habit of living outside, will grow used to it after
a time and then will from habit and the accumulation of a ten-pound
blanket of fat be able to stand the cold much better than many healthy
persons.


Stimulating Examples.--Tuberculous patients need to have their courage
kept up. It is true that the toxin of the tubercle bacillus has the
definite effect of stimulating its victims so that they are likely to
be hopeful, but very often this hopefulness is vague and does not
tempt them to eat and to live in the open air, the two things that
make their continued resistance to the disease possible. I find that
the knowledge of how bravely and how successfully other sufferers from
the disease resisted its invasion and succeeded in doing a good life's
work is the very best tonic that sufferers from tuberculosis can have.
Needless to say, there are any number of examples of heroes of
tuberculosis who put to shame perfectly healthy people in the amount
of work they succeeded in accomplishing in spite of the drawbacks of
their disease. The unfavorable suggestion of the number of deaths from
the disease must be overcome by the contrary suggestion of the brave,
busy lives lived by those who suffered even the very severe form of
the disease and often accomplished the full term of existence in spite
of their handicaps from tuberculosis.


Robert Louis Stevenson.--The best example in recent years is
undoubtedly Robert Louis Stevenson. In spite of tuberculosis in severe
form which prevented his living in the ordinary climates for the last
twenty years of his life, he succeeded in doing an amount of work that
is simply marvelous and in influencing his generation more
widely than most of the perfectly healthy writers who lived in his
time. There are over, 2,000,000 published words to the credit of
Stevenson, and, when we recall that most of this, owing to his
critical care, had been written over and over many times, some idea of
the vast amount of work he accomplished will be realized. Perhaps the
climax of his cheerful nature, the utter lack of discouragement in the
face of what is usually the most depressing possible incident, is to
be found in his famous letter to a friend telling him, as he lies in
bed, that he cannot write at any great length now but that he will
write a long letter next week if "bluidy Jock," his playful name for
hemorrhage from the lungs, would only let him.

One of the most striking illustrations of his insatiable appetite for
work and his complete refusal to admit that he was being conquered by
the disease has been recently told with regard to his unfinished
novel, "St. Ives." He had been suffering from certain severe symptoms
and had been forbidden to do anything at all, even to dictate brief
notes, or anything else that would make any extra work for his
respiratory organs. The ideas for chapters of "St. Ives" were in his
head and would work themselves out in spite of the doctor's
prohibitions. He would not let the thought of his disease overcome
him, and so he dictated these chapters to a secretary in the sign
language, which he had learned so as to be able to communicate under
such conditions. I know nothing that is more likely to make people
realize how a brave spirit can overcome every discouragement of body,
and how much such a spirit is its own reward, since it secures for its
possessor a prolongation of the life of the body that would surely be
worn out by depression, by discouragement, and by worry. Undoubtedly
Stevenson's interest in his work literally gave him new life. It did
use up some nervous energy, but if his mind had been occupied by
thoughts of his disease, and its probably fatal consequences, much
more of his precious store of nervous energy would have been exhausted
in anxiety and worry.


J. Addington Symonds.--After Stevenson probably the most striking
example among modern literary men is John Addington Symonds.
Comparatively early in life he found that he could not live in England
owing to the inevitable advance of tuberculosis when he tried to do
so. He took up his residence then at St. Moritz and other places of
rather high altitude in Italy and continued his literary work. When we
see the row of books that we owe to Symonds' literary activity it is
surprising to think that he, too, like Stevenson, had to watch his
temperature, that every now and then there were discouraging
developments and incidents in his tuberculosis, and that a return to
the ordinary habitations of men away from the friendly altitudes of
the Italian Alps was always followed by a recrudescence of his
symptoms. Symonds' work was not merely literary, but his books are
valuable historical monographs on many subjects requiring much reading
and diligent study and consultation of authorities. There are few men
in perfect health and with abundant leisure who have succeeded in
accomplishing as much as did this hero of tuberculosis.


Thoreau.--There are other distinguished literary men of the
nineteenth and twentieth centuries the stories of whose tuberculosis
has a special interest and tonic quality. One of these is our own
Thoreau, another is Francis Thompson, the English poet, whose recent
death has brought him even more publicity than did his great poems
while he was alive. Both of them are typical examples of another phase
of tuberculosis that is interesting to realize. It is probable
that if Thoreau had lived the ordinary, practical, everyday life,
which those who lived around him thought he should, he would have died
of tuberculosis before he was thirty. He had no use for money beyond
his present needs and when he had made enough to keep himself very
simply he refused to earn any more. He had not time, as he said, to
make money. He wanted to live his life for itself and for the
interests higher than the material that there can be in it.
Accordingly, he set himself to learn all about the birds and beasts
and the trees and plants and the waters and their inhabitants around
his country home. He introduced the modern taste for nature study in
its most beautiful way. He spent most of his time out of doors.

Undoubtedly this out-of-doors life prolonged existence for many years
beyond what would have been his term. His biographers say that
probably his being out of doors in all sorts of weather laid the
foundations of "the cold which settled on his lungs" and eventually
carried him off. Those of us who know anything about tuberculosis, as
it has been studied in recent years in the tuberculosis sanatoria, are
not likely to agree with such an opinion. Our patients in the
Adirondacks live outside ten or twelve hours a day and then sleep with
their windows open with the temperature sometimes down to zero during
the severest winter weather. Rain and dampness are not allowed to
interfere with the open air program. Colds that "settle on the chest"
so that people die from consumption are not due to exposure to cold
but to the bacillus of tuberculosis. Where this once gains a foothold
the one hope of prolongation of life is out-door air and the more cold
and stimulating that out-door air is, provided he can stand it without
discouragement, the better for the patient. Thoreau is an example of a
man whose life was prolonged by his out-door habits and by his refusal
to live the humdrum, practical existence of other men, just to be like
those other men and measure his supposed success by their standards.





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Previous: Coughs And Colds



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