THE PLACE OF THE WILL IN TUBERCULOSIS
"And like a neutral to his will and matter
Did nothing."
_Hamlet_.
Probably the very best illustration in the whole range of medicine of
the place of the will in the cure of disease is afforded by
tuberculosis. This used to be the most fatal of all human affections
until displaced from its "bad eminence" within the last few years by
pneumonia, which now carries off more victims. As it is, however,
about one in nine or perhaps a few more of all those who die are
victims of tuberculosis. This high mortality would seem to indicate
that the disease must be very little amenable to the influence of the
will, since surely under ordinary circumstances a good many people
might be expected to have the desire and the will to resist the
affection if that were possible. In spite of the large death rate this
is exactly what is true.
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Tuberculous infections are extremely common, much commoner even than
their high mortality reveals. After long and critical discussion with
a number of persistent denials, it is now generally conceded by
authorities in the disease that the old maxim "after all, all of us
are a little tuberculous" is substantially correct. Very few human
beings entirely escape infection from the tubercle bacillus at some
time in life. The great majority of us never become aware of the
presence of the disease and succeed in conquering it, though the
traces of it may be found subsequently in our bodies. Careful
autopsies reveal, however, that very few even of those who did not die
directly from tuberculosis fail to show tuberculous lesions, usually
healed and well shut off from the healthy tissues, in their bodies.
One in eight of those who become infected have not the resistive
vitality to throw off the disease or the courage to face it and take
such precautions as will prevent its advance. All those, however, who
give themselves any reasonable chance for the development of
resistance survive the disease though they remain always liable to
attack from it subsequently if they should run down in health and
strength.
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Heredity, which used to be supposed to play so important a role in the
affection, is now known to have almost nothing to do with the spread
of the disease. Family tendencies are probably represented by nothing
more than a proneness to underweight which makes one more liable to
infection, and this is due as a rule to family habits in the matter of
undernourishment from ill-advised consumption of food. Probably a
certain lack of courage to face the disease boldly and do what is
necessary to develop bodily resistance against it may also be an
hereditary family trait, but environment means ever so much more than
heredity.
There is a well known expression current among those who have had most
experience in the treatment of patients suffering from tuberculosis
that "tuberculosis takes only the quitters", that is to say that only
those succumb to consumption who have not the strength of will to face
the issue bravely and without discouragement to push through with the
measures necessary for the treatment of their disease. In a word it is
only those who lack the firmness of purpose to persist in the mode of
life outlined for them who eventually die from their affection of the
{170} lungs. No specific remedy has been found that gives any promise
of being helpful, much less of affording assured recovery, though a
great many have been tried and not a few are still in hopeful use.
Recent experience has only served to emphasize the fact that the one
thing absolutely indispensable for any successful treatment of
tuberculosis of the lungs is that the patient should regain weight and
strength and with them resistive vitality so as to be able to overcome
the disease and get better.
To secure this favorable result two conditions of living are necessary
but they must be above all persisted in for a considerable period.
First there must be an abundance of fresh air with rest during the
advancing stage or whenever there are acute symptoms present, and
secondly an abundance of good food which will provide a store of
nutritive energy and make the resistive vitality as high as possible.
Curiously enough this "fresh air and good food" treatment for the
disease was recognized as the sheet anchor of the therapeutics of
consumption as long ago as Galen's time, the end of the second
century, when that distinguished Greek physician was practising at
Rome. Nearly eighteen hundred {171} years ago Galen suggested that he
had tried many remedies for what he called phthisis, the Greek
equivalent of our word consumption or wasting away, and had often
thought that he had noted a remedial value in them, but after further
experience he felt that the all-important factors for cure were fresh
air and good food. He even went so far as to say that he thought the
best food of the consumptive or the phthisical, as he called them, was
milk and eggs. A great deal of water has flowed under the bridge of
medical advance since his time and at many periods since physicians
have been sure that they had valuable remedies for consumption; yet
here we are practically back at Galen's conclusion more than fifty
generations after his time, and we are even inclined to think of this
mode of treatment as comparatively new, as it is in modern history.
The influence on consumption of the will to get well when once aroused
was typically exemplified in the career of the well-known London quack
of the beginning of the nineteenth century, St. John Long. He set
himself up as having a sure cure for consumption. He was a charlatan
of the deepest dye whose one idea was to make money, and who knew
{172} nothing at all about medicine in any way. He took a large house
in Harley Street and fitted it up for the reception of people anxious
to consult him. For some seasons every morning and afternoon the
public way was blocked up with carriages pressing to his door. Nine
out of ten of his patients were ladies and many of them were of the
highest rank; fashion and wealth hastened to place themselves and
their daughters at the mercy of the pretender's ignorance. His mode of
treatment was by inhalation. He assured his patients that the
breathing in of this medicated vapor would surely cure their pulmonary
disease, and because others were intent on going they went; many of
them were greatly benefited for a time and these so-called cures
proved a bait for many other patients.
J. Cordy Jeaffreson in his volume "A Book about Doctors", written two
generations ago, has told the story of St. John Long's successful
application of the principle of community of treatment and its
effectiveness upon his patient. Like Mesmer he realized that treating
people in groups led them mutually to influence each other and to
bring about improvement. St. John Long {173} had in one of the rooms
in Harley Street "two enormous inhalers, with flexible tubes running
outward in all directions and surrounded by dozens of excited women--
ladies of advanced years and young girls giddy with the excitement of
their first London season--puffing from their lips the medicated vapor
or waiting until a mouthpiece should be at liberty for their pink
lips." In our generation of course we had various phases of similar
treatment, including nebulizers and compressed air apparatus and
medicated vapor, all working wonders for a while, and then proving to
have no physical beneficial effect.
What is surprising is to find the number of cures that were worked.
St. John Long had so many applicants for attention that he was
literally unable to give heed to all of them. The news of the
wonderful remedy flew to every part of the United Kingdom and from
every quarter sick persons, wearied of a vain search after an
alleviation of their sufferings, flocked to London with hope renewed
once more. This enabled St. John Long to select for treatment only
such cases as gave ready promise of cure. He made it a great
preliminary of his treatment that his {174} patients should eat well
as a rule and on one occasion when he was called into the country to
see a man suffering in the last stages of consumption he said quite
frankly, "Sir, you are so ill that I cannot take you under my charge
at present. You want stamina. Take hearty meals of beefsteak and
strong beer; and if you are better in ten days I will do my best for
you and cure you."
It is easy to understand that if he made it a rule for his consumptive
patients that they should eat well or not expect relief from his
medicine he would secure a great many good results. Especially would
this be true in many cases that came up to him from the country, had
the advantage of a change of climate, and of environment and very soon
found that they had much more strength than they thought they had.
They had been dreading the worst, they were now led to hope for the
best; they took the brake off their will, they fed well and it was not
long then before they proceeded to get well.
As even a little experience with consumptive patients shows it is
often difficult for them to follow directions--and keep it up--in the
matter of fresh air and good food and here is where the question of
the will in the {175} treatment is all important. Many a consumptive
has in early life formed bad habits with regard to eating, especially
in the direction of eating too little and refusing for some reason or
other to take what are known to be the especially nutritious foods.
Not infrequently indeed it is their neglect of nutrition in this
regard that has been the principal predisposing factor toward the
development of the disease. This bad habit must be overcome and often
proves refractory.
Then it is never easy to give up the pursuit of a chosen vocation and
pursue faithfully for a suitable period the humdrum monotonous
existence of prolonged rest every day in the open air with eating and
sleeping as almost the only serious interests, if indeed they can be
called such, permitted in life. It is only those who have the will
power to follow directions faithfully, whole-heartedly and
persistently who have a reasonable prospect of getting ahead of their
disease and eventually securing such a conquest of it as will enable
them to return to their ordinary life as it was before the development
of tuberculosis.
Unless patients are ready to follow directions as regards outdoor air
and good food the {176} cure, or as specialists in tuberculosis prefer
to call it the arrest of symptoms in the disease, is almost out of the
question. Above all it is extremely important that those who suffer
from pulmonary tuberculosis should be ready to follow directions at an
early stage of their disease, before any serious symptoms develop, for
it is then that most can be done for them. Many a sufferer from
tuberculosis makes his or her cure extremely difficult, certainly ever
so much more difficult than it would otherwise have been, because the
dread of going to see a physician--lest they should be told that their
affection is really consumption and demands immediate strenuous
treatment--causes them to put off consultation with some one whose
opinion in the matter is reliable.
This is indeed one of the principal reasons why tuberculosis of the
lungs still continues to carry off so many victims every year,--
because people are afraid to learn the truth. They dare not put the
question to a definite issue and refuse to believe the possibility
that certain disturbing symptoms represent developing tuberculosis.
They defer seeing an expert; they take this and that suggestion from
friends; they buy cough remedies which {177} they see advertised,
sometimes they tinker with so-called "consumption cures." After a
while an advance of their symptoms makes it absolutely necessary to
see a physician but often by this time their disease has progressed
from an incipient case rather easy to be treated and with an excellent
prognosis to a more advanced stage at which cure is ever so much more
difficult; or by this time it may even prove that their strength has
been seriously sapped and they have not enough resistive vitality left
to bring about reaction toward the cure.
The all-important thing for all those who have at any time lived near
consumptives, whether relatives or others--for the disease is almost
invariably acquired and not hereditary--or who have worked for any
prolonged period in more or less intimate contact with those who had a
chronic cough or who subsequently developed tuberculosis, is that on
the first symptom that is at all suspicious they should make up their
minds to have the question as to whether they have tuberculosis or not
definitely settled and that they should be ready to do what they are
told in the matter. The first symptom is not a persistent cough as so
many think, nor continued loss of {178} weight, which is an advanced
sign as a rule, but a continued rapidity of pulse for which no
non-pulmonary reason can be found.
The old idea that consumptives should not be told what their affection
was, lest it should disturb their minds and discourage them so much as
to do them harm, has now been abandoned by practically all those of
large experience in the care of the tuberculous. The opposite policy
of being perfectly candid and making the patients understand their
serious condition and the importance of taking all the measures
necessary for cure, yet without permitting them to be unnecessarily
scared, has been adopted. Their will to get well must be thoroughly
aroused. After all, it must be recalled that tuberculosis is an
extremely curable disease. It is now definitely known that more than
ninety per cent. of humanity have at some time had a tuberculosis
process, that is to say a focus of tuberculosis active within their
tissues. Only about one in nine of the deaths in civilized countries
is from tuberculosis. That means that at least eight other people who
have not died from the disease but from something else have had the
affection, yet have recovered from it. Instead of the old shadow of
{179} heredity with its supposedly almost inevitable fatality, so that
young people who saw their brothers and sisters or other relatives
around them die from the disease felt that they were doomed, we now
know that the hereditary factor plays an extremely minor role if
indeed it plays any serious role at all in the development of the
disease.
No affection is so amenable to the state of mind and the will to be
well as tuberculosis. That is exactly the reason why so many remedies
have come into vogue and apparently been very successful in its
treatment and then after a while have proved to be of no particular
service or even perhaps actually harmful so far as their physical
effect is concerned. It cannot be too often repeated that anything
whatever that a patient takes that will arouse new hope and give new
courage and reawaken the will will actually benefit these patients. No
wonder then that scarcely a year passes without some new remedy for
tuberculosis being proposed. All that is needed to affect favorably
patients suffering from the disease is to have some good reason
presented which makes them feel that they ought to get better and then
at once they eat better and proceed to increase {180} their resistive
vitality. The despondency that comes with the lack of the will to be
well hurts their appetite particularly and no tuberculosis patient can
ever hope to recover health unless he is eating heartily. With better
eating there is always a temptation to be more outdoors and the
ability to stand cooler air which always means that the lungs are
given their opportunity to breathe fresh cool air which constitutes
absolutely the best tonic that we have for the affection.
It has been recognized in recent years that the only climates which
give reasonable hope of being helpful for the tuberculous are those
which present a variation of some thirty degrees in their temperature
every day. Whenever this is the case chilly feelings are always
produced in those who are exposed to the change, even though the lower
temperature curve may not go down to anywhere near freezing. If for
instance the temperature at the hottest hour of the day, say three
o'clock in the afternoon, is 90 deg. F. and that of the later evening or
middle of the night is 60 deg. F., chilly feelings will be produced. Just
the same thing is true if the temperature is between 30 deg. F. and 40 deg. F.
shortly after the middle of the day and then goes down to {181} near
zero at night. These chilly feelings are uncomfortable, but they
produce an excellent reaction in the circulation and set the blood
coursing from the heart to the tissues better than any medicine that
we have. In the midst of this the lungs have their resistive vitality
raised so as to throw off the disease.
This is probably one of the principal reasons why mountain climates
have been found so much more helpful for the treatment of tuberculosis
than regions of lower elevations. Whenever the elevation is more than
fifteen hundred feet there will almost invariably be a variation of
thirty degrees between the day and the night temperature. There are of
course still greater variations, even sixty or seventy degrees
sometimes where the altitudes are very high, but this is often too
great for the tuberculous patients to react properly to, in their
rundown conditions. Besides, the air is much rarer at the higher
elevations, breathing is more difficult, because the lungs have to
breathe more rapidly and more deeply in order to secure the amount of
oxygen that is needed for bodily necessities from the rarified air.
The middle elevations then, between fifteen hundred and twenty-five
{182} hundred feet, have been found the best for tuberculosis
patients, and they are very pleasant during the summer time, though
never without the chilly discomfort of the drop in temperature. During
the fall and winter, however, many patients become tired out trying to
react to these variations of temperature and want to seek other
climates where they will not have to submit to the discomfort and the
chilly feelings. If they come down to more comfortable quarters before
their tuberculosis has been brought to a standstill by the increase of
their resistive vitality, it is very probable that they will lose most
of the benefit that they derived from their mountain experience. Here
is where the will comes in. Those who have the will to do it and the
persistence to stick at it and the character that keeps them in good
humor in spite of the discouraging circumstances which almost
inevitably develop from time to time, will almost without exception
recover from their tuberculosis with comparatively little difficulty,
if they have only taken up the treatment before the disease is so far
advanced as to be beyond cure.
In the older days consumptives used to be sent to the Riviera and to
Algiers and to {183} other places where the climate was comparatively
equable, with the idea that if they could only avoid the chilly
feelings consequent upon variations of temperature it would be better
for them. Many of the disturbing symptoms of tuberculosis are rendered
less troublesome in such a climate, but the disease itself is likely
to remain quiescent at best or perhaps even to get insidiously worse,
as tuberculosis is so prone to do. These milder climates require much
less exercise of the will, but that very fact leaves them without the
all-important therapeutic quality which the lower altitudes possess.
For many people the outdoor life and the sight of nature in the
variations produced in scenery during the course of the days and the
seasons are satisfying enough to be helpful in making their cure of
tuberculosis easy. They are extremely fortunate if they have this
strong factor in their favor. It is very probable that we owe the
discovery of the value of the Adirondacks and other such medium
altitudes in the treatment of tuberculosis to the fact that Doctor
Trudeau liked the outdoors so much and was indeed so charmed with the
Adirondack region that when death from tuberculosis seemed {184}
inevitable, he preferred the Saranac region as a place to die in, in
spite of the hardships and the bitter cold from which at that time
there was so little adequate protection, to the comforts of the city.
He scarcely hoped for the miracle of cure from a disease which he as a
doctor knew had carried off so many people, but if he were to die he
felt that he would rather die in the face of nature with his beloved
mountains all around him than in the shut-in spaces of the city.
His resolution to go to the Adirondacks seemed to many of those who
heard of it scarcely more than the caprice of a man whom death had
marked for itself. His physicians surely had no hope of his journey
benefiting him but they felt very probably that in the conditions he
might be allowed to have this last desire since there were so few
other desires of life that he was likely to have fulfilled. His will
to live outdoors in spite of the bitter cold of that first winter
undoubtedly saved his life and then he evolved the system of outdoor
treatment which has in the past fifty years saved so many lives and is
now the recognized treatment for the disease. It is easy to
understand, however, how much of firm determination was required {185}
on his part forty years ago, when there were no comfortable ways of
getting into the Adirondacks, when the last stage of the journey had
to be made for forty miles on a mattress in a rough wagon, when water
for washing had to be secured by breaking the ice in the pitcher or on
the lake and when the bitter climate must have been the source of
almost poignant torture to a man constantly running a slight
temperature. He had the courage and the will power to do it and the
result was not only his own survival but a great benefit secured for
others.
Unfortunately many a consumptive patient who during his first period
of treatment keeps to the letter the regulations for outdoor air and
abundant food fails to do so if it is necessary to come back a second
time. Persistency is here a jewel indeed and only the persistent win
out. Many an arrested case fails to keep the rules of living that may
be necessary for years afterwards and runs upon relapse. The will to
do what is necessary is all-important. Trudeau himself, after securing
the arrest of his disease in the Adirondacks, though he lived and
worked successfully to almost seventy years of age, found it quite
impossible to live out of them {186} and often had to hurry back from
even comparatively brief visits to the lowlands. Besides, every now
and then during some forty years he had the will power to take his own
prescription of outdoor air and absolute rest. It was the faculty to
do this that gave him length of life far beyond the average of
humanity and the power to accomplish so much in spite of the invasion
of the disease which had rendered large parts of both lungs
inoperative. Not only did he live on, however, but he succeeded in
doing so much valuable work that few men in the medical profession of
America have stamped their name deeper on modern medical science than
this consumptive who had constantly to use his will to keep himself
from letting go.
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