CHAPTER II

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 {351} 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 {352} 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 {353} 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 {354} 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 {355} 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, {356} 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 {357} 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. {358} 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.

CHARACTER AS A THERAPEUTIC ASSET

Recent interest in tuberculosis has taught us that the best possible asset for a tuberculous patient is character. Resistive vitality in the physical order and character in the moral order seem to be co-ordinate factors. If a man will not give in in the fight, if he insists on struggling on in spite of difficulties, discouragement and an outlook that seems hopeless, then he will almost without exception get over his tuberculosis, if there is any favorable factor in his environment. We talk much of immunity inborn and acquired to the disease, but it seems to go hand in hand with a certain capacity to stand the debilitating symptoms of the disease without allowing one's mind to become depressed or one's disposition rendered despondent by them.

Courage and Constancy.--The career of Dr. Trudeau to whom we owe so much of our knowledge of tuberculosis is a striking example of the power of character to enable even an apparently delicate organization to withstand the ravages of the disease. This is all the more striking because he was an advanced case when he finally reached an environment in which he could make head against the disease. The story of his own personal struggle for life at Saranac, in which he both learned himself and taught others what the modern {359} treatment of tuberculosis should be, is one of the best therapeutic documents of modern times. Under circumstances that were quite apt to be discouraging to anyone of less character than he, with the bitter cold of the Adirondacks around him and quite inadequate heating facilities, so that even old-fashioned lamps were in requisition for heating purposes, he yet succeeded in winning back his own way to health and showing others how it could be done. The struggle had to be kept up for long, it had to be renewed again and again, our greatest American authority on tuberculosis had to learn in his own person all the clinical details of the disease, but in the midst of it all he succeeded in accomplishing a life work that will stand beside that of any man of his generation and will probably mean more in the history of American medicine than that of any of his supposedly more distinguished colleagues in our large cities and large teaching institutions.

This is the sort of man whom tuberculosis does not take in spite of every advantage that the disease may seem to have. Two others of our American authorities on tuberculosis had almost the same experience.

Persistence.--Recently I have been in correspondence with a young man who illustrates the same power quite as strikingly. He went to Florida and soon found that the unfortunate fear of tuberculosis that has so unwarrantably come into many minds in recent years made it extremely difficult--indeed, almost impossible--for him to live under such circumstances as he hoped for when he went there. In any boarding-house he went to just as soon as there was question of his having tuberculosis the landlady would either insist on his leaving at once or else plead with him to take his departure, lest her other boarders should desert her. He was coughing, he had some fever, his disease was advancing in the midst of all this disturbance, physical and mental, and the outlook seemed hopeless. His picture of this selfishness of humanity, scared about nothing (for there is practically no danger if tuberculous patients take reasonable precautions, as even nurses in sanatoria do not acquire the disease, though living in the midst of it), constitutes one of the most poignant indictments of human nature in its worst aspect that I have ever had presented to me.

Finally he made up his mind that there was nothing for him to do but to tent out and live by himself. Fortunately he was able to do that and just as soon as he was settled under circumstances where human nature did not bother him, nature began to do him good. He feared that he would die during the first month in the tent, for he was having fever up to 102-1/2 and sometimes more every afternoon; but he laid in a store of provisions which with the milk and eggs delivered to him every day enabled him to stay in bed for a week, opening up the flap of the tent in the middle of the day. Then he went out and got another stock of provisions and stayed in bed for another week. His thoughts were gloomy enough, he had only some old illustrated newspapers to give him a few fresh thoughts every day, he had no one to visit him, but he hung on and kept up his habit of rest and forced feeding in spite of disinclination. At the end of two weeks he had no temperature in the afternoon. At the end of the third week he made for himself a reclining chair and sat in the sun outside of his tent wrapped in a blanket. At the end of four weeks he had gained five pounds in weight. From that on all was plain sailing. It was his character that conquered his tuberculosis.

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SUGGESTION AS TO SYMPTOMS

Besides the value of suggestion for the general condition in tuberculosis many of its symptoms can be treated best by changing the mental attitude of the patient towards them and giving him a proper appreciation of their significance. Most symptoms are likely to produce exaggerated reactions, especially in patients who are over-solicitous about themselves. Not a few of the symptoms are really nature's attempts at compensation, or the result of conditions which show a natural disposition to bring about a cure. Fever, for instance, produces lassitude and great fatigue on exertion, and patients are prone to think that this means weakness or exhaustion. It is really only an indication of the necessity for rest, and is brought about by nature's refusal to supply all the demands of the muscles for nutrition, at a time when the febrile condition is burning up a lot of extra material. Far from being a disadvantage, weakness is a decided advantage in this condition.

Hemorrhage.--Probably no symptom that occurs in connection with tuberculosis is more influenced by the mental attitude than hemorrhage. It is a most disturbing incident. Even in quite small amounts it upsets the patient seriously and, of course, in large amounts it is a source of profound disturbance even to the most placid of patients. Excitement always adds to it. Probably no physical means that we have at command can be depended on to control it. Ergot used to be popular, but such physiological action as it exerts, so far as we know the drug, would seem to be likely to do as much harm as good.

Other remedies have gradually lost favor in the hands of those who have had most experience with the symptom and gallic acid and supra-renal extract, the older and newer remedy, are now little depended on. Two things are important--to secure lower blood pressure and lessened pulmonary activity. For these opium in some form is undoubtedly the best drug; and then a placid state of mind on the part of the patient must be secured as far as possible. The scare in these cases, in so far as it is relaxing, is rather favorable than unfavorable for the patient. In addition, it is necessary to insist on absolute quiet and silence and then to allay all reactionary excitement. It is important to make patients realize that while hemorrhage is a serious complication, it is by no means so serious as is usually thought.

Many cases of tuberculosis that eventually run a slow course are ushered in by hemorrhage, or have it as a very early manifestation. It is surprising how many people have had hemorrhage as a symptom and live to tell of it thirty or forty years later. This was not due to any mistake of diagnosis, for a generation ago tuberculosis was more likely to be missed when actually present than to be diagnosed when absent. Indeed, this tendency for the cases in which hemorrhage occurred to run not so fatal a course as others was a fact that seemed to an older generation of physicians to require explanation. They suggested that possibly the hemorrhage swept out with it some of the virulent elements from the lungs and so lessoned the infection. From what we now know this is a doubtful explanation, but it seems not unlikely that a frank hemorrhage might reduce the amount of toxins in the circulation and so in an early stage of the disease give nature a fresh start in resistive vitality.

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What is much more likely, however, is that the occurrence of early hemorrhage made it easier for the patients to appreciate the seriousness of the affection and brought them to accept advice as to proper precautions. Under ordinary circumstances it is difficult and used to be even more so in the past to make the patient understand at the beginning of the affection the necessity for giving up indoor occupations and living the outdoor life with the care for nutrition that is so important if the case is to be improved. Hemorrhage scared them into submission. In the old days it was the first positive symptom of consumption. Now we have many others, and instead of following the advice of over-solicitous relatives that we should not tell patients what is the matter with them, we tell them frankly and secure such care of the health as will bring about improvement. Probably nothing illustrates so well the necessity for thus influencing the patients' minds into caring for themselves as the fact that the hemorrhagic cases, as a rule, do better than the others. All of this can be used to make the minds of patients much less disturbed than they would otherwise be by this alarming symptom.

Cough.--In the chapter on Coughs and Colds we have outlined how much coughing may depend on suggestion, or habit, or on the tendency to yield to slight bronchial irritation when there is no real necessity for it. Most tuberculous patients cough much more than is necessary. This is always somewhat dangerous for them since it disturbs their lungs, has a tendency to distribute tubercle bacilli in their lungs, or in the air around them, and may by efforts at expulsion lacerate affected blood vessels and produce hemorrhage. Whenever cough is productive it should be indulged in, for it removes material that should not be allowed to accumulate. Unproductive coughing, however, can usually be controlled by training.

It is particularly at the beginning of phthisis that the control of coughing by suggestion is important. There are many little coughs, "hacks" as they are sometimes called, frequently repeated by those in a very early stage of pulmonary tuberculosis and which are consequent upon irritation either of pulmonary nerves or of pulmonary tissues, but that are quite unnecessary, as a rule, if a little attention is paid to suppressing them. As a warning sign they are excellent, but the patient should be taught not to indulge in them. Coughing tends to prevent nature's curative reaction and the contraction of pulmonary tissues which may take place around a lesion. In beginning consumption, even where there is but slight infiltration, we know from the observation of the movements of the diaphragm either by the X-ray or directly by Litton's method that its excursions on the affected side are shortened. Coughing is in direct opposition to this setting of the lung at rest and therefore should be controlled; however, as our drug remedies are likely to disturb the stomach, whose healthy function is so important in these cases, the use of the mind in the control of the cough is of the greatest value.

Thoracic Discomfort.--Complaints are often made by the tuberculous of pains in the thorax. Ordinarily the discomfort is supposed to be due to the lung condition, and it is assumed that it is either actually in the lung itself or in the pleura, or communicated from them by reflex to the muscles. In most cases, however, patients complain of pain on the side that is either not affected at all or least affected. If they have been told that the other side is suffering most from tuberculosis, they are prone either to think that now the {362} well side is being invaded or else that their physician is making a mistake, and both thoughts are seriously discouraging. The reason for the pains on the well or the better side, however, are easy to understand. As far as possible, as can be readily demonstrated by the X-rays or seen in the observation of the so-called Litten's phenomenon--the excursions of the diaphragm--nature puts the ailing lung at rest and the diaphragm moves much less on that side than on any other. In order to make up for the lack of breathing in this side the other lung does compensatory work. This over-stretches the muscles of the thorax on the well side and causes some over-work in them. The consequence is a tiredness which may become fatigue; in damp weather this may be even painful. Just why damp weather has this particular effect on muscles is not surely known. Muscular action is probably accomplished with more difficulty in damp weather because of the relaxing effect of moisture on tissues and circulation. Reassurances may be given them, then, that will keep them from thinking seriously of the significance of these pains except as an index of nature's compensatory efforts. The painful conditions instead of causing discouragement will, then, be a source of encouragement. It must not be forgotten that rubbing with some gentle stimulant, soap, liniment, or the like, will greatly improve the thoracic muscles in these cases, but the rubbing must be done gently and by someone else beside the patient, for it is only beneficial if done from before, backwards, in order to help the return venous circulation which runs in that direction in the external respiratory muscles.

Altitude.--There is a marked difference between the amount of water which finds its way out through the lungs at varying altitudes. At sea level an ordinary patient will lose during the night about 300 cc, that is, something more than half a pint of water, through his respiratory tract. At an altitude of 5,000 feet, however, this amount is almost doubled, and at 10,000 feet is almost trebled. At 2,000 feet it is half as much again as it is at sea level. This copious giving off of water has a marked effect on the lungs. It constitutes one of the reasons why altitude is a favorable element in the treatment of tuberculosis. Only beginning cases of tuberculosis, however, are able to stand the additional work thus put on them, though a slight elevation, up to 2,000 or even 3,000 feet, rather seems to be of benefit to all cases. How far-reaching the effect of this extra loss of fluid is, is appreciated from the concentration of blood which takes place and which produces a blood count of 8,000,000 red cells at a mile of altitude in patients who, at the sea level, have no more than 4,500,000. Such patients, of course, need much more water and fluids generally to be comfortable than when living lower down.

Suggestion and Treatment.--There are many accessory suggestions with regard to food that serve to confirm the patient in the idea that abundance and variety of food must be taken if the battle with the disease is to be won. To patients who find milk difficult to take, it must be explained that a copious amount of fluid in the system is needed in order to make coughing easier. So milk serves a therapeutic as well as a nutritional purpose. In the same way it may be explained that fats, such as bacon and cream, help to keep the bowels from becoming constipated and constipation inevitably disturbs the appetite.

Explanations as to the advisability of being out of the city and in a portion of country not very thickly populated, in order to avoid the possibilities of secondary infection with other respiratory diseases and bacteria of various {363} kinds, will make a patient understand the necessity for leaving town. It may be helpful, also, to insist on the value of living at some elevation above sea level as an aid to expectoration.

Cough is the symptom that many of these patients fear most, and a promise of any amelioration of it by a simple change of location helps them to make the sacrifice of city life for a while. Some patients who have been benefited by a stay in a sanatorium come back with a relapse of their symptoms. They dread to return to the sanatorium and think they can care for themselves as well at home, since they know what the regulations are, though it may be evident to the physician that they are losing ground in their city environment. It is well worth while to give them a careful explanation of what we know of the effect of altitude upon consumptives who have sufficient reactionary power to stand it.

_Negative Suggestions_.--Some suggestions are valuable for the prophylaxis of complications. For instance, tuberculous patients must be warned not to indulge in breathing exercises without the express consent of the physician. So much is said in popular literature as to the value of breathing exercises that many a patient suffering from tuberculosis thinks that, not only may they be indulged in with impunity, but that they will surely do good and can do no possible harm. Nothing could be more erroneous. Many localized lesions have been diffused in this way and there is always danger that the strain will cause hemorrhage. Patients must be warned also to avoid any possible condition in which they might have to over-exert themselves. Because of the dust inevitably breathed during automobile riding, this pleasure must be denied to tuberculous patients as a rule, but even when they have recovered sufficiently so that this may be permitted they must be warned not to take long rides into the country lest the breaking down of the machine should place them under the necessity of walking a long distance. This idea should also be emphasized for rowing excursions, or trips by motor boat, for occasionally they lead to serious and exhausting exposure.

One negative suggestion should be given at the very initial stage to every patient in whom the presence of pulmonary tuberculosis has been recognized. This should be a warning to exercise the greatest care against permitting the development of constipation. Tuberculous patients must never strain at stool. Almost necessarily a certain number of tubercle bacilli are swallowed every day whenever pulmonary tuberculosis is at all active and they are constantly present in the digestive tract. If tuberculous patients then strain at stool, little abrasions of the mucous membrane of the rectum are caused in which tubercle bacilli find a favorable nidus. Ischio-rectal abscesses are common among the tuberculous and rectal fistulas often give much bother. When a tuberculous patient develops such a condition, a period of depression and discouragement will follow, for there is a curious tendency to depression associated with all lesions of the rectum. A pulmonary patient who has been doing well will often fail to make progress for months after the development of even a small ischio-rectal abscess.

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