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 iseases. 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.