PULMONARY TUBERCULOSIS, DIFFICULTIES AND DISADVANTAGES IN TREATMENT.*

J. W. Cannon, M. D., Canon City, Colo.

Y remarks on the subject of tuberculosis will not be scientific nor learned. They are intended to be practical and plain, dealing with the invalid and his disease as we come in contact with them in our every day life. This will necessarily exclude reference to the treatment of the disease by the culture products, the serum in mixed infection, and the tuberculins. It is mainly the care and treatment of tuberculosis in this climate which seems to be especially adapted to the disease that claims our attention.

Colorado has become famous as a health resort for consumptives on account of the equable climate, bright sunshine, pure air, mild winters, and medium altitude, and as these natural advantages become more widely known the number of exiles afflicted with this disease increases. There is a constant procession from all parts of the country to these mountainous regions in season and out of season, hoping to be benefited and cured by the climate.

This paper will emphasize some of the unfavorable conditions and disadvantages with which we are constantly meeting in the care and treatment of tuberculosis, and measure in our minds the great gulf between the actual requirements for the cure, and the ugly realities which are constantly present. We are told that tuberculosis which has such a strong hold on humanity is not only a preventable disease, but that it is eminently curable in the greatest number of cases. That pathological anatomy has never given more decisive proof of the curability of a disease than it has for tuberculosis, and that no disease gives stronger evidence of healing tendencies.

We hesitate to accept these apparently optimistic statements, and feel that they are almost incredible, especially when we see so many hopeless cases in the advanced stages where all treatment has proved unsuccessful, and when statistics inform us that this cruel monster claims at least oneseventh of all those who go down to death, and more than all the other infectious diseases put together. Not satisfied with this it insists that its victims be taken from among those just entering life's active duties, and when they are of the greatest benefit to society.

To be successful in the great battle which we have taken up against this disease there can be no compromise of the conditions and requirements, neither can there be an adjustment of the controversy by arbitration. The conditions outlined for their cure must be met or millions must perish. The disease must be taken in its incipiency, or before it is far advanced, and every available means must be used. The earlier the disease is recognized and the patient placed under favorable conditions the greater the chances for an early and complete recovery.

A suitable climate in which to make a permanent home for the patient should be the battle ground. Hygienic conditions which means plenty of light and ventilation, fresh air in unlimited amount, personal cleanliness

Read before the Fremont County Medical Society, Canon City, Colo., May 6, 1907.

which is next to godliness, sanitary surroundings, the diet to be of nutritious value, well cooked and well seasoned, the amount to be determined by the ability of the stomach to digest it, perfect rest when the temperature reaches 993 degrees, out-door living from morning until night-these are our weapons of warfare. Climate, hygiene, and diet, these three, but the greatest of these is diet.

It is comparatively infrequent that we see the disease in its incipiency. This is necessarily true on account of the thousands who come to this climate after the disease has advanced beyond this important stage. The cases we mostly see are advanced tuberculosis which have been under the care of other physicians. It is usually after weeks and months of the cough, the evening temperature, and perhaps a hemorrhage that they become alarmed at the danger and fully realize the necessity of a change of climate. No financial or physical efforts at this unexpected event can be too great to satisfy the anxieties of the patient and friends.

They come to this climate in all stages of the disease, incipient, advanced and moribund, and of all ages. The wealthy, those in moderate circumstances, and those without means. Among the great army may be mentioned the worn-out school teacher, and her embryo the normal school girl, the young man from the farm or factory, the boy in his teens, the mother with babe in her arms, and the man with a family to support.

The well-to-do when tuberculous are comparatively fortunate, for they can avail themselves of the most desirable climate for a temporary or permanent location, and have the advantage of being at home with their own families.

Or if not convenient to make a permanent change of location the tuberculous invalid may come alone and enter one of our well-directed sanitariums which is always open to him.

Far too frequently do we see the wealthy patient make an injudicious use of his means in the matter of selecting climate in which to settle down patiently and contentedly for the desired improvement. Having selected a locality in which it is hoped to affect a cure of the patient's disease it is advisable to remain there until the desired end is accomplished. He too often becomes restless and impatient at the seeming slow progress of the disease, and is inclined to travel about from one resort to another, hoping to find a locality where the conditions are perfect, and the accommodations are desirable. While it may be necessary occasionally to change from one climate to another, or from one locality to another in the same climate, too much traveling is detrimental to the patient and should be discouraged. A great many consumptives do not consider their condition serious enough to submit to special control and will drift about from place to place until they are sick enough to die, and it is only at this stage that they learn their lesson by actual experience. Too many times have our people been shocked by the report of a sudden death on the streets or at the depot the result of exhaustion or a hemorrhage. To send a patient away from home in the advanced stages of the disease seem cruel and useless as it nearly always hastens a fatal termination, and is the more pitiful by being among strangers.

The evil results of sudden changes from one climate to another are not only manifested in the ways just mentioned, but there are many ex

amples where a sudden return home to a lower altitude, even for a few weeks time is followed by a marked change for the worse. It is difficult for patients to realize the danger they incur by a short visit to their former homes, and will many times take the risk against the earnest protests of physician and friends. The risk is the more readily taken after there has been a gradual improvement of their condition, and when their acute anxieties have been relieved. It is surprising to see the relaxation of all personal efforts and interest in themselves after a short period of improvement and the many grievous mistakes that are made.

There are many who are imbued with the idea that climatic influences alone are all that is needed to arrest their disease and restore them to health. Experience teaches us that good results can be looked for only when climatic influences are aided by hygienic, dietetic and medicinal treatment.

Cases have been sent out here after weeks and months of failing health, emaciated, with severe cough and evening temperature, when the diagnosis of tuberculosis has become positive, with the advice to go into the country and do light farm work, let doctors alone, take no medicine and they will come out all right. Advice which is wholly unwar

ranted and unjustified.

They come for a short time only, perhaps for the winter season and then return home which for reasons already assigned should be never be encouraged. Unfortunately, the vast majority of those afflicted with tuberculosis of the lungs are handicapped by lack of means, and it is among this class that we see so many anxious, dissatisfied, cheerless faces peering into our eyes for help and consolation, aided by their friends or receiving benefits from fraternal orders to which they belong, by which they hope to live and improve until they are able to work and care for themselves.

Among my patients are many afflicted with tuberculosis of the lungs. They come in but once only. They have seen from one to a half dozen doctors, their lack of hope and confidence driving them from one to another. They have been percussed and auscultated, their sputum has been examined and pronounced positive. Their diagnosis has been made for them. Their hollow eye and longing looks betray the fear of impending death for many of them have been told that they have consumption and nothing can be done for them. It is a sad picture to see the young man suffering with the disease in its advanced stages thousands of miles from home home-sick and discouraged, disappointed when he gets a letter from home and disappointed when he does not.

When one of this class is compelled to practice economy strictly he takes to tent life. He does his own cooking. He fries meat, fries eggs, fries potatoes and makes his own coffee. Aside from the forced seclusion, this mode of living is as far from the rules laid down for dietetics as it is possible to be, and sooner or later it not only becomes monotonous, but it means defeat in the end. The salvation of the patient lies in eating good food and an abundance of it. As a rule. these patients have poor appetites, and it is only by giving them a variety of nourishing food and some persuasion that they are able to eat a sufficient quantity to sustain them. Mountain scenery, dry air, sunshine and altitude do not put on flesh.

The tuberculous invalid when he comes here is very much inclined to go into business to help defray expenses which are always heavy. Very often we see the newly arrived exile, after a few weeks sojourn, take a clerkship, or enter the employment of some one, or plunge himself into the real-estate or some other exciting business. When he is at liberty to come and go as he pleases, and when he makes the treatment of his disease a secondary matter all attempts at cure are futile. It is his power of physical endurance and the benefits of the climate that determines the length of time he can live. Going into business may be admissible and proper after a year or two if the climatic influences and other conditions have been favorable to him, and there has been a satisfactory improvement of his disease.

Judging from the many statements and reports heard, and the number of "lungers" residing in Canon City, one would conclude that at least a third of our population are here on account of their tubercular condition, or the disease in some member of their family. Living year after year apparently in about the same condition of health, relying on the climate and outdoor life, and wholly without medicinal treatment. It is evidently far better for the patient to make this a permanent abode, even after the disease has been arrested, than to return to his former home and former environments where the disease was contracted.

There are other difficulties of a personal nature which may be mentioned at this time. It is commonly understood that the consumptive is almost always hopeful of his condition, and is always planning for the future-what he will do when he gets well. This attitude is favorable in itself rather than otherwise, when it is not based on a misapprehension of his disease. It is always well to inform the patient as to his real condition in order to enlist his utmost efforts in the treatment and cure of his disease. I have seldom ever known a misrepresentation of the patient's condition that did not reflect adversely to the physician or friends guilty of the charge. Pages might be written on this one feature of our subject with benefit to the doctor and all concerned, if a full exposure of the cruel deceptions that are used, and the evil results that follow would remedy them.

There are those who take a different view of life and go to the opposite extreme, and can see nothing hopeful in the future for them. They are given up and resigned to their fate, even when their real condition does not warrant their adverse feelings, and when there is signal improvement of their symptoms, and when encouragement is justly due them. Some are nervous, restless and excitable by nature, and are easily overcome and exhausted by mental exertion, as in political and religious discussions, and even ordinary business transactions of life.

Consumptives should be relieved of all business cares and responsibilities as far as possible in order that their nerves may be at rest and undisturbed.

I meet a consumptive occasionally who is unreconciled and rebellious to his condition, and is fighting the disease with sheer force of will power, without using ordinary judgment and reason, exposing himself in various ways, as in long excursions into the mountains, staying all day at the races, dancing all night, and the too free use of liquors.

Ascher says that "one of the practical results of the age law of resisting forces, is that the outlook for sanitarium treatment of tuberculosis is most promising between the age of sixteen and twenty." While this may be true in the sense which he means it, I believe the results are sadly overcome by the disposition and temperament of the patient at this age. In no other disease dces the prognosis depend so much on the character of the patient and his co-operation as in tuberculosis. Boys at this age are apt to be restless, uneasy and difficult to control. With many there is irritability of temper, want of mental repose, and unnatural craving for excitement. The disease tends to intensify these traits of character.

A word on the importance of the early recognition of this disease will not be out of place in an article devoted to the difficulties and disadvantages in the treatment. The diagnosis of tuberculosis of the lungs in the incipient stage is very often overlooked and neglected. This is to put the question mildly. In fact it is no easy matter to diagnose the disease in the first days of its existence. It is impossible to determine the exact date of this stage of the disease. It is not unreasonable to claim that there is a latent unrecognizable period which precedes any physical or outward manifestations. While we claim that the early diagnosis of the incipient stage of the disease is eminently important from the standpoint of treatment we do not mean to say that the cure of the patient necessarily depends upon it. To hold this view would make our statement that the disease can be arrested and cured in the more advanced stages, and our efforts to do so, appear incredible. The exact date of the beginning of the incipient stage of tuberculosis is just as obscure and difficult to describe, as is the passing of the disease from the first to the second, or the second to the third stage. It is only a mere matter of convenience of description. Failure to diagnose the disease until it is well advanced greatly augments the danger to the patient and diminishes the chances for recovery. It is enough for all practical purposes to affirm that the disease is infectious, that the bacillus is the cause of the disease-no bacillus no tuberculosisthat the bacillus may and most usually does implant itself upon a morbid process already established in the lung, that the morbid process may be the result of some previous disease as bronchitis, pneumonia, la grippe, or pleurisy, that the victim of any one of these diseases may be a healthy rugged person, yet the bacilli may grow and flourish and tuberculosis develop and prove fatal. Being a young man, however, in the prim of life, with the best care in a sanitarium, or in a suitable climate under the most favorable conditions he may recover, the bacilli being overcome by the phagocytic action of the white corpuscles of the blood, and a cure of tuberculosis is established in the incipient stage or before it is far advanced. The relatives and friends of the patient who were so grieved at the sudden development of the disease, were as happily surprised at the recovery, and the physician congratulating himself on his success uses the cure for statistic purposes.

If the morbid process be located in a delicate constitution which is far more frequently the case, weakened and enfeebled by any cause whatever, either hereditary or acquired, or predisposed to the disease, or has the so-called pretubercular condition, or from unhygienic living or unsanitary surroundings, the bacilli may grow and tuberculosis be estabilshed and run a rapid course to a fatal termination.