Mortality from Tuberculosis of the Lungs

New York-Philadelphia-Boston * 1820-1920

Statisticah's Department, The Prudential Insurance Company of America

The Prudential

Insurance Company of America

Incorporated under the laws of the State of New Jersey
FORREST F. DRYDEN, President

Home Office, Newark, New Jersey

the breaking point in resistance to the old infections gathered from time to time.

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There is extant a universal belief that adults who come into contact with the tuberculous are in danger of contracting the disease. Such a belief is fortunately being proven fallacious as we learn more about the bacillus and its action under all conditions. If it is true that numerous repeated infections are received in childhood, then it seems poor reasoning to maintain that one could withstand the millions of bacilli carried in his own tissues, and yet succumb to a few hundred received occasionally by contact. Statistics show that physicians and nurses during years of daily and intimate contact with all types of tuberculous patients do not contract the disease. death rate from tuberculosis in these is not greater than that of the average community. A very remarkable illustration is that furnished by a physician known to us. der to demonstrate that there is no danger to adults he deliberately drank a glass of water in which had been placed millions of live fresh tubercle bacilli. This was some three years ago and at present he is in perfect health. Many convincing proofs could be offered to show that the danger to adults from outside sources is entirely negligible. Not so with infants and children, however. In these there is always danger of large infections or of infections with fresh bacilli proving fatal, and quickly so. They should therefore be protected by the most extreme care, by the scrupulous disposal of all sputum and by preventing contact with the tuberculous. It is dangerous, in fact, to permit them to remain in the same house, or to come into contact with persons who nurse or handle tuberculous patients. Under such conditions it is almost impossible to prevent repeated infections. True enough they will eventually become infected, but usually by partially dried or attenuated germs which will not overwhelm them: a sort of vaccination process, as it were.

The usual mode of infection is believed to be through the intestinal tract, by mouth. Without entering into controversy with the different theories of infection a classical experiment with guinea pigs will throw some light on the mode of infection. A certain number of pigs were allowed to breathe air, laden with soot, while another set were fed the same article in their food, and allowed to breathe only pure air free from dust or soot. Both series of animals were examined. Those that ate the carbon had lungs that were black with carbon deposit, while the others had a slight deposit only. This slight deposit was no more than that amount which actually lodged in the mouth and throat and later was swallowed at the feedings. This experiment seems to indicate that the most certain route to the lung is through the stomach and blood stream. Add to this the fact that it is impossible to breathe air beyond the bronchial

There are other infections which give the tuberculous patient great concern. These are the so-called "acute colds" which so frequently make the rounds in spring and fall. They are undoubtedly easily transmitted by close contact, and since they are very troublesome and injurious, every effort should be made to avoid them. They do not arise, as is usually believed, by being out of doors, but by being in close rooms and in contact with those who are infected. Not everyone so infected will show signs of being sick either, for many persons may have an immunity to certain bacteria, which is not enjoyed by all. It is therefore good practise to avoid all close contact with others, particularly in closed rooms. When a neighbor comes around with an "acute cold" it is well to avoid him strictly and not to use his belongings. For this same reason the tuberculous patient should have his own toilet articles and use no other. Persons with acute nasal and throat infections are a greater menace to the tuberculous individual than he is to them. The destruction of all sputum and disinfection of all soiled handkerchiefs, towels, etc., are sanitary measures demanded of all persons whether they are tuberculous or not.

Course and Progress

The course of tuberculosis is fortunately quite chronic in most cases, and the tendency is toward healing, so that given a fair chance every patient has an opportunity for recovery. It is, however, one of the most serious and insidious diseases, in that, while its chronicity offers a favorable chance for cure, yet it may deceive the unwary. After months of treatment and improvement sufficient to permit one to feel well, he is likely to grow impatient and to become indifferent to the dangers. It is not infrequent for one to have large active lesions and yet feel fairly well, and even to keep on working for months or years with considerable disease. This feeling of wellbeing is therefore treacherous and is responsible for more failures than most any other factor.

Usually the first manifestation of the disease are: loss of "pep"; languid tired feeling on slight exertion; fever; loss of weight; loss of appetite; cough and expectoration. There are many variations from this however and frequetnly cases are discovered at routine examinations for life insurance or enlistment. Such patients may have extensive active disease with not a single symptom of ill health.

If the patient is placed in bed at the beginning and properly supervised, it is usually not long until improvement in all

particulars takes place. At this time, if treatment is continued long enough and with a full knowledge of the goal to be attained, a good chance for recovery exists. Many, however, as soon as they begin to feel well, grow tired of the restraint. They insist on getting up and about, and will often devise every conceivable excuse to get the doctor's permission. Emergencies will arise that demand their immediate and personal attention, conditions which would hardly interest them, once they have gained their liberties. If this "breaking over" is permitted before active disease has disappeared there is great danger of relapse, especially if temperature and pulse have not returned to normal. Such a relapse means the involvement of new and larger areas and is correspondingly harder to overcome in the future. Probably the most frequent occurrence is that a stationary condition will supervene with no further improvement in the lung condition. Such patient may succeed in being up most of the time with variable fluctuations in the temperature, pulse and general condition and with now and then a short sojourn in bed for especially high fever or blood-spitting. This "stale" condition may last for months or years, and patients eventually become somewhat immune to temperature reactions. They may get actual increase in the disease without elevations or general disturbance. Such a condition is very trying to both patient and physician and is likely to make one entirely rebellious to advice. However, if it is only realized that these situations are usually the result of half-hearted and ill-defined efforts to attain a cure, and if a proper course is adopted, the results are by no means so discouraging. Oftentimes patients will go along "on an even keel" for a year or more of faithful treatment until they are ready to quit, when the lesion will start clearing up rapidly and be healed within three months or less.

No two patients are exactly alike as regards their response to treatment. There are those who pursue their treatment in the most faithful manner from the beginning and yet make very slow progress. In these the resistance is undoubtedly low and they should remember that a greater degree of patience is demanded, with an absolute denial of all forms of indulgence which make demands on the strength. On the other hand, cases are seen with moderate frank disease, who get well under the most adverse circumstances. They may stop work and are in fact often unaware of the existence of disease. One cannot, therefore, judge himself by his neighbor. It is unreasonable to assume that both have the same resistance. While it is known that each case is largely an individual problem, yet they all conform to certain general laws, and, for the vast majority who develop frank evidence of the disease, it is

never

necessary to cease all work and devote their entire time to getting well.

The time necessary for a cure varies greatly with the individual, but for the average moderately advanced case three to five years is not too long. Even after all signs of the disease have disappeared one must carefully avoid activities for a long time to prevent a return. Nature heals the lesion by depositing fibrous tissues around the diseased parts and at first this is very delicate and easily broken down. Time must be given for strengthening this wall of protection. When all signs and symptoms are absent for six months the disease is spoken of as "arrested." This is not a cure, and is no license to consider danger past. It is a very wonderful state to reach and the vantage should be guarded almost as if it were sacred. There are many who never quite reach this stage, but eventually reach a perfect state of health provided they are careful to attempt no severe strain. We have one case in mind who has had a small area of moist rales for seventeen years, yet he enjoys perfect health and works constantly. Another class is represented by those who constantly show moderate activity which varies very little, but who enjoy fair health for many years. judicious living these people may become active and useful citizens in certain lines. There is hardly a city in the West that does not have such who are leaders in the various professions or in business.

Cavitation

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There is a fairly general belief among tuberculous patients that cavitation in the course of the disease goes hand in hand with a fatal outcome. This is far from true. A cavity certainly means that a part of the lung, which was beyond repair, has broken down, and at the same time indicates a fairly active and somewhat advanced condition. But, it means more than this. It means that nature has thrown a protecting wall of fibrous tissue around the severely infected part and permitted its discharge with the least danger. It is her method of amputating and discharging the dangerously diseased part, and is evidence of a high degree of local immunity. That this is so, is shown by the fact that frequently after a cavity has broken down and the decomposing contents have been thrown out, the patient will improve rapidly and constantly. Many such will go along to a good recovery and carry evidence of a dry cavity all their lives. Some of these cavities are of remarkable size, occupying a large portion of one upper lobe. Multiple cavities are relatively more serious since they indicate more widespread infection with poorer resistance. The existence of one or two medium-sized cavities, does not, however, indicate that the fight is lost. It is simply a part of the fight in which the other fellow has scored a point, and the patient, in turn,

has successfully counter-attacked. It is a signal for a more concentrated and skillful effort to defeat him. It is not intended to imply, however, that cavities are not signs of serious trouble. They most certainly are, and an attitude of indifference toward them can only lead to disaster. Every effort should be directed toward improving the general health and giving the lung absolute rest as nearly as possible.

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The belief that cavitation is a complication of tuberculosis is erroneous. It is a part of practically all cases that progress far enough. Many cases have marked tendency to it than others, but the disease is not necessarily more serious by reason of such. Patients will often feel anxious about the presence or absence of cavities and seem entirely satisfied that all is well if none is reported. The presence of large areas of activity may impress them little, when in reality this should be their chief concern. As long as it exists there is real mischief to contend with, of which cavities form only a part.

Sputum

At some time in the career of most tuberculous patients the sputum will contain the bacillus, and at all times there is great danger to children from this source. For this reason the most scrupulous care should be taken regardless of the laboratory reports. Failure to find them is not absolute proof of their absence. Suitable paper cups should be used to collect the sputum, and the cup and contents burned daily.

To some extent, one can judge of the progress made by the changes in the sputum. A decrease in the amount is one of the unfailing signs of improvement. If bacilli are present, it is evidence that the disease is active regardless of the physical signs. Their absence continuously over a long period of time, after once being present, can be looked upon as favorable improvement. Numerous bacilli in all specimens indicate rather active disease. The change of the character of the sputum from a pus condition to one in which there is largely white mucoid material usually occurs along with other signs of improvement. Cavity cases may bring up large amounts of sputum in the mornings and yet have little or none during the remainder of the day. This sputum usually contains much pus. The nose and throat may sometimes be the source of more sputum than the lung itself. Blood-streaked sputum with or without actual hemorrhage occurs, and while many of these originate in the nose or throat, there is no certain way of proving this. Bloody sputum demands immediate enforced rest without any argument as to its source. Patients will often attempt to deceive themselves as well as the physician by assuming that the blood is from the throat, or that their fever is due to a "cold" or "indigestion," in order to avoid

being put to bed on a strict regime. True enough these things are not always tuberculous in origin, but they must be so assumed unless unquestioned evidence to the contrary is secured. In this connection it is well to know that in high altitudes it is not infrequent to find the nose and throat secretions slightly bloody, without any connection with disease.

Treatment

When a patient first learns that he has tuberculosis, he usually becomes stampeded and succeeds in becoming quite sick both physically and mentally. He is often rushed off to other climates at great financial sacrifice to become more or less an outcast from friends and family. In the rush of closing his business affairs and winding up pressing matters he is subjected to greater strain and anxiety than would ever be atFinally tempted while in perfect health. he is rushed to the train in a state of acute illness for a long tiresome journey in search of that mythical perfect climate. Much irreparable damage is done during this getting-ready-to-be-cured period, in the apparent belief that all one has to do is to go West. Some go to "rough it," while others are in such financial condition as to necessitate hardships which would kill the most rugged native. Undoubtedly the Southwest offers great advantages by its mild, high, dry climate, permitting the tuberculous patient to pursue his cure in comfort during more days in the year than he could elsewhere. It is further a most pleasant and beautiful country, offering great inducement to outdoor and sane living, but it cannot replace in the least the vital principles demanded in the treatment of such a disease. The wonderful results obtained by Fishbery in New York City and by the Trudeau Sanatorium at Saranac Lake, N. Y., are examples of what can be done in other climates.

One of the cardinal rules in medicine is that when a person becomes i with a febrile (fever) disease, he should be put to bed, to remain until the temperature returns to normal. Tuberculosis is no exception to this rule and in fact there is no disease which demands it more. This, therefore, is the first indication to be met. Change to a more favorable climate should be made if possible, but in such a way and at such time as will do the least possible harm. When any part of the body becomes inflamed, such as a knee, or appendix, nature's first effort is to put that part at rest by stiffening the muscles and tissues surrounding. Pain and swelling are protective measures and serve to prevent voluntary movement. In the lungs, this process is the same. The muscles of the chest become rigid, the lung tissue stiff and the pleura inflamed, so that breathing is (Continued on page 187)