A Plea For a More Rational Therapy in Tuberculosis

As long as tuberculosis was looked upon as hereditary, little or no headway could be made in its prevention. It was considered to be a matter of fate, and consequently surrounded by an air of hopelessness. The discovery of the specific cause not only paved the way for the overthrow of the heredity theory, but also made it possible for the disease to be discovered earlier than before, thus bringing it before the medical practitioner at a time when many cases are curable.

Pathologists had seen evidence of healed tuberculosis postmortem; but now the profession is able to find the bacilli in the sputum and then see the patient get well. The evidence of the curability of tuberculosis has been accumulating so rapidly that we know the disease which was considered to be one of the most hopeless a quarter of a century ago is now recognized, not only as the most curable of all chronic diseases, but the proof is overwhelming that, if diagnosed early and treated intelligently, it will afford a mortality even lower than pneumonia and typhoid fever. In spite of all this evidence, we not infrequently hear physicians say that they never saw a genuine case of consumption get well. Such statements reveal not only a limited experience with tuberculosis, “for genuine cases of consumption do get well,” but they also show a lamentable lack of appreciation of the most valuable lessons connected with this disease, viz., that tuberculosis can be diagnosed early before breaking down occurs, and before the advent of that complex condition known as consumption, and that the earlier the diagnosis the more favorable the case for treatment. That most cases of far advanced consumption die is not evidence against the curability of tuberculosis, simply a rebuke to the carelessness of the patient in not seeking medical aid soon enough or to the medical attendant for not exercising sufficient skill to detect it when the disease presented.

To-day the curability of tuberculosis is established. No one conversant with facts will deny it. But the question which will bear discussion is, are we curing as many of the cases as we should? Are we curing as many as we can? Are we doing as much in the way of treatment of this disease as is possible, or are we falling into a dangerous rut? Are we worshiping at the shrine of fresh air, good food, and hygiene, and closing our eyes to many other important and helpful measures? Have we advanced only a degree beyond the fetiches of cod-liver oil and creosote to fall worshipers at the altar of fresh air? True the advance is welcome. It is a wonderful improvement, but whoever would treat a disease so serious as tuberculosis should worship at no shrine except results. He should endeavor to use all remedies and measures which will aid in producing a cure.

As a basis for such a discussion as this, it is well to inquire into the causes which lead up to a cure in tuberculosis. What is it that makes it possible for the organism to overcome the tubercle bacillus and the results of its activity?

Osler is quoted as saying, “Make the patient fat and the local disease will take care of itself,” thus making the cure a matter of nutrition. Great stress is laid upon nutrition by all physiotherapists, yet all who have had a wide experience know that it is not all. There are many exceptions to Osler’s statement. Often we see patients who are thoroughly nourished, and who are progressing favorably toward recovery, begin, through no indiscretion of their own, to go down. The disease does not “take care of itself.” Nature cures most of her cases of infectious disease, in spite of a low grade of nutrition. The cure of tuberculosis is more than nutrition. If it were not, we would not see men in robust health become tuberculous; yet every one of us has seen this occur. True, a well-nourished man does not stand in much danger, comparatively speaking, of becoming infected. The inoculation, if of a few germs only, will not produce the disease; however, if there be a great number of germs of a low virility, or fewer of a very virile strain, even well-nourished individuals will not be able to overcome the germs.

Where tuberculosis has made any considerable advance in the system, we have a tendency for it to spread. So many bacilli may invade new tissue at one time that no matter what the nutrition of the patient, the bacilli will gain the day. We, who follow these cases carefully, see this thing happen very often. So, if we can administer any remedies which will increase the natural resisting power of the body and keep the healthy parts bathed in serum rich in antibodies, we are doing more than we can by nutrition alone.

Modern studies in immunity show that bacterial diseases produce toxic elements, which stimulate the cells of the organism to the formation of defensive bodies, which thus tend to cure the disease. To this tuberculosis is no exception; however, for certain reasons, the discussion of which we cannot enter into here, the toxins in this disease do not seem to be set free in the proper manner to be effective, so the disease does not limit itself when it has become well started. If this failure on the part of nature to furnish the natural stimuli for the cells can be supplied artificially, or if the defensive bodies themselves can be supplied, then another aid to cure has been found.

That the use of certain culture products will supply this want has been thoroughly established. The original tuberculin of Koch, his later preparations, as well as numerous preparations made by other men, when used properly, will stimulate the cells of the individual suffering from tuberculosis to the formation of defensive bodies, as is shown by the increase of the agglutinating and opsonic power of the blood. Further proof of their value is shown in certain cases of tuberculosis which fail to respond to ordinary open air, dietetic, and hygienic treatment, but improve at once when tuberculin is added to the treatment. There are also certain sera which seem to furnish the antibodies already formed which are of some value, the best known of which are the Fisch, Maragliano, and Marmorek.

Aside from the matter of nutrition and culture products, we can do much for those suffering from tuberculosis by alleviating certain symptoms, relieving certain complications that may be present, and putting the diseased organs in that condition which is most favorable for a cure. These, then, are the lines upon which we should base a rational therapy for tuberculosis. Not any one of them should be employed to the exclusion of the others but all should be worked out into one harmonious whole. Of those remedies and measures which have been put forth as “cures” for tuberculosis in the past, nearly all have some merit, although the merit is not always where it is supposed to be. Cod-liver oil certainly increases nutrition when well borne, although there are more palatable ways of accomplishing this end. Creosote will often improve nutrition by its action upon the digestive system. When given in too large doses, however, even in suitable cases it does harm. It also has a beneficial effect upon the mucous membranes of the air passages, but to think that it will kill the bacilli by its antiseptic action is positively absurd. The pneumatic cabinet is based upon the idea of exercise for the lung; nitrogen gas, upon rest for the lung. The various culture products find their basis in the natural defenses of the organism. Perhaps none of these measures is wholly bad, but none of them should be put forth as a cure; they are aids to a cure. They, and many more remedies and measures, find a rational basis for employment in the treatment of certain cases of tuberculosis. but they are not to be used in a routine manner. The treatment of tuberculosis is a matter of careful individualization.

Recognizing the importance of nutrition, it should be one of our chief aims to maintain this at the highest point. Everything which interferes with it must be eliminated. The hygienic-dietetic-open-air treatment, which is deservedly so popular throughout the world to-day, has for its basis the betterment of nutrition. One of the most noticeable, and perhaps the most important effect of the open-air treatment of tuberculous patients, is its effect upon digestion and assimilation. Coincident with the beginning of this treatment we note a marked improvement in the appetite. When digestion has been previously slow, and attended with more or less unpleasant symptoms, we not infrequently observe a disappearance of all embarrassment. Assimilation improves, and the patient takes on flesh. The effect of the open air is to enable the patient to digest and assimilate more food and to furnish the appetite which demands it.

The best effect of open air can be obtained only by using it discreetly. While in itself harmless, doubtless more lives have been wrecked while trying to follow this mode of treatment than by any other measure. Open air is not a cure for tuberculosis; it is only a measure for the production of a certain end. If used properly, it is one of the greatest aids to nutrition that can be employed; if used improperly, it will defeat its own purpose.

An individual suffering from tuberculosis should not be told that open air will cure him, but that proper living in the open air will be one of his greatest aids. Many an individual has eaten good food and remained in the open air all the time, and yet killed himself. The oft-repeated advice of well­-meaning eastern physicians to their patients to “go West, live in the open air or rough it, and keep away from physicians,” is responsible for the deaths of hundreds of patients annually. Not open air, but the proper use of open air, is one of the chief aids in the cure of tuberculosis.

Open air should be supplemented by proper food and carefully regulated rest and exercise to make it most effective. While we recognize that rest is a wonderful aid to nutrition, and that overexertion decreases the resisting power of the patient, yet there comes a time in the treatment of nearly all cases of tuberculosis when exercise short of tiring will increase nutrition and hasten recovery. The physician must be the judge when this time comes.

Beside prescribing open air, a carefully selected diet, and the proper amount of rest and exercise, the physician must control and regulate the entire life of the tuberculous patient. He must guide him even to the minutest detail of his life. Nothing of importance should be left to the patient’s judgment until he has proven himself competent.

Another measure of great value in improving nutrition is hydrotherapy. The careful and intelligent application of water offers us one of our most valuable and most flexible aids to nutrition, and should never be omitted.

Climatic conditions affect the state of nutrition very decidedly, While sunshine is not indispensable to the treatment, as is shown by the results obtained in many places where there is a large percentage of cloudy days, yet those of us who are fortunate enough to be able to give our patients the benefit of almost constant sunshine realize its value. Its cheering and tonic effect is a very potent factor in aiding nutrition. A climate which not only affords an opportunity, but which invites the patient to be out of doors a great portion of the time, and which also affords a large amount of sunshine, is a great aid in the treatment of tuberculosis.

Modern research points to the possibility of the laboratory giving us cures for all bacterial diseases. Vaccination of bacterial toxins is assuming an important and rational place in treatment. It is now about fifteen years since the first efforts at specific treatment in tuberculosis began. This first trial of tuberculin marks one of the saddest pages in the history of the treatment of this or any other disease. Never were hopes raised higher, and never were they dashed lower. The misuse of tuberculin in the early nineties not only resulted in the death of many patients, but it so embittered the medical profession against it that it will still take time before the remedy can be assigned its proper place. During all these years those suffering from this disease have been denied the help which could have been rendered by this immunizing treatment. The per­sistence of a few men, however, such as Spengler, Petreschky, Turban, Goetch, Trudeau, and von Ruck, who were convinced of the value of tuberculin, has finally made the profession reconsider and give a more favorable opinion.

Laboratory experiment, as well as clinical evidence, shows that tuberculin will aid in the cure of tuberculosis. Its effect on local lesions, such as can be seen by the eye, in the larynx, for example, proves its value beyond question. The increase in the agglutinating and the opsonic power of the blood of those patients who are treated by it, shows that its action is that of a specific immunizer.

Tuberculin stimulates the cells of the body so that they throw out more specific antibodies into the bloodstream, and should be employed in the treatment of this disease. So we can do more than nourish our patient; we can artificially increase his resisting power. We can make him more able to destroy the tubercle bacilli and the toxins which they form.

Since the important researches of Wright and Douglas upon the opsonic power of the blood have shown us that Buchner and Nuttall were right in ascribing an antibacterial action to the serum of the blood, we can see the wisdom of keeping areas which are infected with tubercle bacilli well bathed in serum. The action of the Finsen light is to cause an irritation, with an increased flow of blood to the part. Poultices to certain lupus patches have hastened their cure. Bier’s method of treating tuberculous joints, as well as acute inflammations, by passive congestion, can be explained in this same way. In this way we can also explain the action of violet light upon pulmonary tuberculosis. By causing an active hyperemia it is aiding in bathing the parts with serum. Thus, all these measures which tend to divert more blood to the part involved are of value, and should be used in connection with tuberculin, for by so doing we are bathing the diseased areas with a blood which is rich in antibodies.

Another measure which is of value is the giving of raw meat or muscle juice. Experiments of Richet and Hericourt, also of Philip and Galbraith, show definitely that the employment of raw meat and raw meat juice causes a much greater retention of nitrogen than when the meat has been cooked. It is also the belief of these writers that there is something specific against the muscle waste, in the ingestion of the raw muscle.

In order to be most successful in the general therapy of tuberculosis, all distressing symptoms and complications should be carefully managed. It is rarely necessary to give medicines for cough, night sweats, shortness of breath, loss of appetite, indigestion, or fever of the early or moderately early cases. The careful management of the patient, putting him to rest in the open air, together with the proper hydrotherapeutic measures, will usually relieve all these symptoms very quickly. Organic diseases of the stomach should receive most careful attention, for a good stomach is indispensable. The bowels should also be kept active. In more advanced cases, sometimes these distressing symptoms will have to be relieved by appropriate drugs.

Among the most distressing complications are dry pleurisy, which can be best relieved by strapping, and pleurisy with effusion, which should be removed if it causes embarrassment of the heart or respiration; tuberculous laryngitis, which will yield most readily to tuberculin, local cleanliness, rest, and wet packs; and tuberculosis of the bowel, which will require careful regulation of the diet and such harmless astringents as bismuth in large quantities, or lead and opium in intractable cases. The tuberculous patient is also subject to all other “ills that flesh is heir to,” and when present they must be treated carefully.

Mixed infection is a very serious complication. Tuberculosis does not long remain a simple process. Germs, other than the tubercle bacilli, soon gain entrance to the diseased areas, thus complicating the condition. Just what part mixed infection plays in the pathology of tuberculosis is as yet uncertain, but the advent of other germs is generally looked upon as being a serious complication. Mixed infection unquestionably hastens destruction of tissue in the local areas and causes the liberation of toxins which are responsible for many grave constitutional disturbances.

Mixed infection is doubtless present early in the infection, long before we are wont to recognize it by the symptoms which are usually ascribed to it, and it is undoubtedly the part of wisdom always to bear this in mind in treatment. When the symptoms have once become marked the patient should be put to bed in the open air. The temperature should be relieved by sponging, the patient should be encouraged to eat plenty of good food, taking solid food at that time of the day when the temperature is low, and relying on milk, eggs, and muscle juice mostly at other times. All distressing symptoms should be relieved, and the patient kept in as cheerful a condition as possible. Every effort should be made to keep up the patient’s nutrition. It is not at all uncommon to find patients who are thus carefully treated run a course of fever for weeks, and yet gain in weight.

The most dangerous germ found in these cases of mixed infection, and the one which is nearly always present, is the streptococcus. If we can overcome it, the other germs will usually cause little trouble. A very efficient remedy against these germs is streptolytic serum. The difficulties in its use are that it is expensive, it requires to be used in large quantities for a long period, and its action is not always certain. But it is undoubtedly a remedy worthy of use and a great aid in this usually-considered helpless condition.

Aside from mixed infection, fibroid changes, necrosis, and in some instances calcification, occur in the diseased areas. From the blocking up of the blood-vessels in the lung there is a damming back of the blood, with more or less passive congestion of the internal viscera; the heart has an extra burden thrust upon it, and its muscle, weakened by the strain, often becomes damaged. Cavities form in the lung; contraction occurs. That part of the lung which is not affected hypertrophies, and becomes emphysematous, thus adding more burden to the heart; the general system is poisoned by the toxin; wasting occurs, and all organs suffer more or less. This gives us the picture of consumption. This is what we are trying to relieve when we attempt the treatment of advanced cases of tuberculosis. Tuberculosis is a disease, consumption a condition resulting from the disease. When we have done all we can for such cases we have done little enough. Fresh air will do much for them, but it comes far from being the only thing that can be done. Every such case must be made a study of itself, and then, by careful attention to details of treatment, much can be done, even for many of these advanced cases.

Until the medical profession becomes more alert at early diagnosis, we cannot hope to treat our cases in that early stage when at least three-fourths of them should be cured, but must direct our efforts toward the relief of the cases as we find them. There is one thing gratifying, however, in the treatment of advanced cases of tuberculosis, and that is that much more can be done for them than is usually supposed. Some of those who are even far advanced can be cured, many of them can secure an arrest of their disease, and most of them can be improved.

In order to obtain such results, however, we should worship no idols, neither cod-liver oil, creosote, climate, open air, or tuberculin. We should grasp the full meaning of the pathological process with which we are struggling, and then endeavor to apply our therapeutic measures accordingly, remembering that it is far better to attack an enemy at every vulnerable point than at one alone. While I am a firm believer in the open-air, dietetic, and hygienic treatment of tuberculosis, and recognize it to be one of the greatest advances of modern therapy, yet I should dislike very much to see our therapeutic efforts stop here. My plea is for a broader view and a more rational therapy, not only one based on nutrition, but one which considers the disease in all its varied aspects.