T H E I R I S H J O U R N A L M E D I C A L S C I E N C E

THE OFFICIAL JOURNAL OF THE ROYAIJ

ACADEMY OF MEDICINE IN IRELAND.

OF

SIXTH SERIES. No. 301. JANUARY, 1951.

THE TREATMENT OF THE TUBERCULOUS PATIENT. ~

By BRF~D~ O'BraEN.

T UBERCULOS~S is a disease that has been recognised from the earliest times of which we have any records. Hippocrates was well acquainted with it, though not distinguishing it clearly from

ether diseases of the lungs and pleura, and it would appear that the authors of the Indian Vedas even before his time recognised and pres- cribed for it. Yet from the time of Hippocrates until very recently no significant advance was made in the knowledge or treatment of this disease. Thus we find that Barry, a Cork man who practised medicine in Dublin and published in 1726 a Treatise on a Consumption of the Lungs, found it necessary to apologise for presuming to prescribe other medicines than those recommended by Hippocrates, who had lived more than 2000 years before.

Stark, who died in 1771, was probably the first to recognise that scrofula, which we know as tuberculous advnitis, fistula in ano, caries of bone and consumption of the lungs were all manifestations of the same disease, but it was Ren6 La~nnec, who died of phthisis in 1826, who made this truth generally known and described its pathology with great accuracy. The cause of the disease, however, remained unknown until Robert Koch in 1882 demonstrated the tubercle bacillus, proved that it could cause tuberculosis and again be recovered from the lesion.

Since so little was known about tuberculosis before the time of La6nnee it follows that the remedies used in its treatment were many and various. Drugs of all sorts were advised of both vegetable and animal origin, the aromatic gums, sulphur, arsenic and many others of which one only, used from the earliest times, is still recognised as being useful, that is opium~ Among remedies for hmmoptysis we find barley meal mixed with the urine of a youth who had not reached puberty, bull glue, and vulture 's lungs burnt above vine logs and mixed with qlfince or lily blossoms in wine. For scrofula, Asclepfon, a mixture of drugs containing opium, which was regarded as a panacea, mixed with honey was to be applied to the swollen glands, but it was important

*Inaugural Address to the Dublin University Biological Association, delivered October 28th, 1950.

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that the application should be ~nade by a naked and fasting maiden. We find that boiled crocodile was supposed to benefit chronic cough, and a Chinese remedy for consumption was the testicles of a dog, the lungs of a hog and the flesh of a crow. To test this remedy for activity " one chews a little, runs for one hour, and if one does not then vomit the remedy is good." Barry says " bleeding and gentle purgatives are to be insisted on . . . an advantage from these previous evacua- tions is that more room is obtained for the plentiful use of diluting, attenuating and in some cases stimulating, medicines."

Among dietary measures the value of milk has been recognised throughout the ages, but it was thought to lose some of its value after leaving the donor so that it had to be drunk when fresh and warm, the best being human milk; and John Wesley records that his father (who had consumption) benefited greatly by suckling from a woman; when this could not be managed asses' milk was regarded as the next best.

Physical measures also found their place, and cupping and blistering as well as bleeding were used from very early times. Dry cupping is still practised in Switzerland, and blistering with iodine is still a common practice in many countries. In this category, too, we should include touching by the King for scrofula, which was practised by Queen Anne, and possibly later still. Horseback riding has also had many advocates, among them Sydenham and again our friend Barry.

Change of climate was thought to be beneficial by Galen, who sent consumptives to Palestine because it had been noticed that tuberculosis was almost unknown among the Jews; and in the time of Pliny patients were sent also to Egypt, though he felt that it was the sea voyage and its consequent sea-sickness that did good rather than the climate of Alexandria; and in the last century the eight or more months' sea voyage to Australia and back was often recommended. Then in the middle of the last century began the establishment of sanatoria in the Black Forest, Switzerland and the Adirondack Mountains in the U.S.A.

Pierre Louis David first showed in 1779 the value of rest treatment in tuberculosis, though he was more concerned with the disease in bones and joints than in the lungs, but the importance of this form of treatment was not generally recognised until nearly a century later.

Following the discoveries of La~nnee and Koch treatment has become at last rational, though it remained for l~n tgen with his discovery of x-rays to make it possible to diagnose ~he disease early, to recognise its extent and to follow the effect of remedies applied. Let us now consider some of the present-day means of treatment. Rest is probably the most important means of all, and as the basis for all our manage- ment of tuberculous disease its value is universally recognised-

As I have mentioned, nearly every drug that human ingenuity could provide has been used, generally without any rational basis, but the injection of gold salts, which had a great vogue some ten to fifteen years ago, had the merit of being reasonable in that they were found to inhibit Che growth of tubercle bacilli in vitro. They may have done

THE TREATMENT OF THE TUBERCULOUS PATIENT 3

some slight amount of good, but they also produced a fearful crop of dermatitis and other toxic manifestations, and have now no place in the treatment of this condition, but we have at last got really potent drugs in streptomycin and P.A.S., and no doubt others even more effec- tive will be discovered in the near future. One of the most striking cases I have observed was that of a man who had extensive tuber- culous pneumonia and had been living almost exclusively on whiskey for the previous three years. IIe was admitted to the Meath Hospital rather less than a year ago, and is now out and doing a limited amount of work. I am convinced that without the use of streptomycin and P.A.S. he would by now have been dead.

Surgery has become almost a routine in the treatment of tuber- culosis, if one includes such procedures as artificial pneumothorax and pneumoperitoneum; in fact, one sanatorium physician said to me not long ago: " The treatment of tuberculosis has become terribly surgical." Lack of time forbids the tracing of the full development of surgery in the treatment of pulmonary tuberculosis, but one cannot leave this subject without mentioning some names. Forlanini, who first performed rational artificial pneumothorax in 1882, though Hippocrates advised the introduction of air into the pleural cavity by means of a reed and an ox bladder, worked somewhat in the dark as he had no x-ray control of his treatment. Saugman (1907) advanced this form of treatment. Jacobaeus (1916) first divided pleural adhesions by means of the thoracoscope and cautery, and Maurer made great advances in this operation and was the first to demonstrate it in Ireland as late as 1934.

Thoracoplasty was first described by Quincke (1888); the name Thoracoplastik was coined by Spengler (1890). I t remained for Brauer and Friedrich to perform extensive rib resection, which procedure they described in 1908. Sauerbrueh (1913) made important modifications, and since then a host of surgeons have made valuable contributions to this form of treatment, amongst whom I shall mention only the names of Moriston Davies and of Semb. Everi up to the 1930's the operation was still attended with a fairly high mortali¢y, but with increasing knowledge and experience it has beeome one of the safest surgical measures in the treatment of tuberculosis.

Paralysis of the diaphragm by interruption of the phrenie nerve was first used by Sauerbruch (1904) and was applied to tuberculous lung disease by Stuertz (1911). At first the nerve was cut, then it was found that in some cases the diaphragm continued to work, so evulsion of the nerve was introduced, but now this is very rarely used and a temporary paralysis is produced by crushing the nerve.

Extrapleural pneumonolysis, the space being maintained by wax or other solid materials, enjoyed some popularity about 1930-40, and is once again creeping back into favour, with polythene as the filling substance, and the same operation with the space maintained by air as an extrapleural pneumothorax sprang in¢o popularity with the work of Graf (1930) and became altogether the fashion in England about five years later. This fashion did not last long, and the operation fell

4 IRISH JOURNAL OF MEDICAL SCIENCE

into an unmerited disfavour, but in some form can still play a useful role.

Resection of the lung for tuberculosis was performed successfully by Tufter about 1897, and in 1899 Macewen removed a tuberculous lung from a patient who survived his operation many years, but it is only since 1945 that it has reached such a degree of safety as to make its use justifiable at all frequently. Like extrapleural pneumothorax in its day, lung resection is enjoying a wave of popularity which in my opinion is quite unjustified and which is now just beginning to recede.

Drainage of lung cavities was first done extensively by Monaldi ~ in the late 30's and Maurer 2, 8 has introduced his method of cavity ~rainage and packing only in 1948.

Pneumoperitoneum is another form of collapse therapy popularized within Che last ten years, and at present enjoys a generally deserved, though perhaps excessive, popularity.

All these means of treatment, including simple bed rest, can be effec- tively carried out only in a chest hospital or sanatorium, and to quote from a recent l e t t e r in the L a n c e t ~ : " We cannot be satisfied until a patient with recoverable pulmonary tuberculosis can be admitted into hospital within a week of diagnosis and does not return home until his disease is controlled and non-infectious." I should like to pay a tribute to Dr. Noel Browne, our present Minister for Health, for the energy and success with which he has pursued this ideal. Tuberculosis mortality has been decreasing in civilized countries ever since reliable statistics have been kept, though more slowly in some countries than in ethers, and it is to be hoped that Dr. Browne's fine new sanatoria will, within his lifetime, be converted into schools or hostels, as proof of the success of the attack on this disease.

So far I have considered the means used to treat the disease. I want now to turn to the patient as an individual, not just as a unit in a tuber- culosis national health problem. Treatment of the individual starts at the time of diagnosis, and it rests with the family physician or the con- sultant who has to break the news of his condition to the patient to start treatment from that moment.

I feel that it is best to tell the patient straight out that the trouble is tuberculosis, that it is curable, but that cure will take a long time and treatment will have to be carried out in a hospital. Very many people have a horror of the word sanatorium, and are difficult to persuade that the sanatorium is merely a hospital devoted to and specially equipped for the treatment of tuberculosis, and that treatment in the home is virtually impossible. I have known many instances in which patients have been told that they had " just a little spot " on the lung which would,disappear with a few months in bed, or in Switzerland, and tl~en were disappointed and resentful when they found that they had to spend years in sanatoria.

One can imagine the blow it is to a married artisah with a family, to a married woman with children, to the youth starting on his career, or to the girl who is looking forward to marriage or has recently ~tarted to earn her living, to be told that there is to be a complete

THE TREATMENT OF THE TUBERCULOUS PATIENT 5

break in their lives and that they will have to be separated from their families for a long time. Then there is the fear which must be aroused in the hearts of most when told that they have contracted a disease from which so many thousands die every year.

There can be few diseases in which the mental attitude of the patient has such a profound influence on the course of the illness. I can remember several instances in which patients just gave up hope and died, though the disease when diagnosed was of such a nature as to suggest a strong probability of cure and on whom no form of treatment seemed to have any effect. I can also remember very many more patients whose courage and strength of mind have enabled them to overcome the most severe infections. I t is therefore essential to start treatment from the very beginning by trying to inculcate this con- fidence in the possibility of eventual recovery. This can best be done by the physician who first tells ~he patient the nature of his complaint, and it cannot be done in a hurry. Time must be taken to talk the patient through the shock of the initial blow, to win his confidence and co-operation. The provisions of modern social Services have helped to a great extent in allaying the anxiety as far as the well-being of family and dependents is concerned, and thereby in securing their co- operation in treatment.

I t is a bad start to a person's period of cure to have to sit in a crowded waiting-room in a chest clinic with a number of others who may know about their condition and talk about it, then to be faced by an overworked tuberculosis officer who asks: "Name? Address? Age? Married? Employment? Rate of pay?" and so on, meanwhile busily filling up a large form, adding: " Nurse will give you a bottle, spit into it in the morning and send it back here with this card. Take this other card to Blank St. and get an x-ray. Come back this day week. Next, please." This is of course a caricature, but not a gross exaggeration of what tends to happen in our present tuberculosis dispensaries. One patient of mine, a young married woman, had a baby in Ju ly and h~emoptysis in November. After being kept in bed by her family doctor for some time she was sent to a tuberculosis dispensary for fur ther investigation, and was eventually x-rayed. On several occasions she was told to attend the dispensary, to which she had to ~ravel a considerable dis- tance, was kept waiting for a time, and was each time seen by a different doctor, who knew nothing about her and could not find his predecessor's notes or x-ray films. Fortunately, she had great recuperative powers and had almost healed herself by the time I saw her.

As things are at present, there is an inevitable time of waiting between diagnosis of tuberculosis and admission to a sanatorium, and during this period the patient is inclined to become despondent and resentful of his apparent neglect. Therefore one of the most impor- tant forms of treatment to be given by the physician who is t rying to build up his patient's morale is to explain the difficulties and emphasise the importance and value of simple bed rest. Many people find it hard to believe that anything is being done for them unless medicines are

6 IRISH JOURNAT, OF MEDICAL SCIENCE

poured down their throats or needles stuck into them, and it takes a great deal of persuasion to convince them that this waiting time can be a part of the cure.

I should like to see chest clinics attached to general hospitals which would provide a certain number of beds in suitably isolated wards for the treatment of urgent cases and provision made for the complete in- vestigation of the patient at one visit. It should be possible for the physician to see the patient and have a film taken that same day ; to have time to talk to the patient and so start his treatment; to have a clerical staff to record the necessary family details and a team of visiting nurses who can attend the patients in their homes, report on their condition to the doctor and avoid the necessity of bringing the patient back to the clinic except at long intervals. I t should also be able to supply meals for those patients who are inevitably kept late and possibly far from home.

Such clinics with their associated hospital beds may obviate the need for sanatorium treatment altogether, by admitting patients with early disease, instituting some form of collapse therapy and sending them home to continue pneumothorax refills or the like at the clinic, and give students the chance of learning about tuberculosis as part of their general medical education and not as an isolated speciality. Toussaint and others have written much of late about this aspect, and it has been the practice in the Meath and other hospitals for years. To quote one or two particular cases. A young bank official was admitted to hospital for approximately two months; during this time pneumothorax was induced and adhesions were divided, after which he was discharged to the O.P.D. for refills; when, six months after diagnosis he was offered a vacancy in a sanatorium, it was possible to decline it with thanks as he was just about to return to work. Now, three years later, he is still at work and apparently quite well. A chartered accountant of 40 with a wife and child was found to have a tuberculous cavity in the apex of the right lung. As it seemed unlikely that simpler methods of collapse therapy would succeed, an apical thoracoplasty was performed and he was able to resume his work in about 6 months. He belongs to that group of people whom tuberculosis strikes perhaps hardest, the professional men and women, doctors, lawyers, accountants and many others, whose work cannot be delegated and whose standards of living are such that the assistance which can be offered by social services seems to mean little more than destitution.

Patients such as the two whom I have mentioned are lucky, not in avoiding the sanatorium, but in being able to return to a normal life soon after the beginning of illness. Such, however, form only a small minority of those who contract tuberculosis. Most will have to go to a sanatorium and stay there for many months.

To turn to sanatorium treatment, I consider that the comparatively small hospital of about two to three hundred beds is the ideal, as the superintendent can get to know his patients as individuals and plan his treatment to suit the particular needs of each. The superintendent makes or mars a sanatorium, and it requires a man of outstanding character to make such an institution successful. Tuberculous patients

THE TREATMENT OF THE TUBERCULOUS PATIENT 7

come to depend very much on the doctor who is looking after them: if h e can gain their confidence he has already gone half way to curing them, therefore it is most important that they should be treated throughout by the same one. In the small sanatorium the superin- tendent provides this sense of'continuuity. The good superintendent will produce good results in almost any surroundings; the bad one, who cannot gain his patients ' confidence, will be much less successful however beautiful his buildings or complete his equipment. I f I send a patient to Switzerland I send him to Dr. Maurer or some other doctor whose work I know to be good, and whose ability will be helped by the magic of the name Switzerland and by the benefit of a better climate than ours, but I should much prefer to send a patient to a sanatorium in this country whose superintendent I know to be good than to some unknown centre in Switzerland. The mountain may have its magic, but it must be used by the right magician. Dr. Todd's sanatorium at Midhurst is well known to all who treat tuberculosis and has only one drawback, the extreme difficulty of getting into it.

The superintendent has to decide what particular form of treatment should be given to each patient: one must have bed rest, another streptomycin or P.A.S., or some such treatment, another should have an artificial pneumothorax and a pneumoperitoneum, yet another a thoracoplasty or a lung resection. In many cases he must restrain the enthusiasm of his visiting surgeon. I feel that these gentlemen, whose skill is undoubted and of a very high degree, at times find it irksome to perform the simpler and less dramatic operations, and when called upon for advice choose that method which most exercises their skill. In some sanatoria too much reliance appears to be placed on the advice of the visiting surgeon in selecting the appropriate treatment for parti- cular cases. I t is impossible to employ full time a highly skilled chest surgeon in a single sanatorium of reasonable size. Such surgeons of necessity must serve a number of hospitals and therefore cannot know the patients as individuals; hence they have to depend very largely on the iuspection of x-ray films, which is obviously an unsuitable state of affairs. The superintendent has to devise means to relieve the tedium of the long months of treatment. Many of you have read with amusement tinctured with horror The P / ~ and I by tha t brilliant authoress of The Egg a#d I, Betty MacDonald, and noted the inhumanly wechanical procession of the patient through the various stations of the hospital. The superintendent 's success in dealing with this problem is measured by the di~iculties he finds in his next problem, that of maintaining discipline. The sanatorium is a microcosm, a small enclosed community, whose inhabitants, of widely varying character, are all enclosed in the walls of the same disease. Many patients in a sanatorium do not feel ill at all and tend to seek relief from their tedium in the arms of Bacchus or of Venus, neither of which deities is a welcome inmate of their little world; the good superintendent will be able to say, as it was said of Sir John Reith when he was head of the B.B.C., " I managed their morals so carefully that we've never had a baby in the B.B.~C."

His next duty, and perhaps almost his most important, is to prepare

IRISH JOURNAL OF MEDICAI~ SCIENCE

Iris patients for their re-entry into normal life after their discharge from his care. Patients whose normal work is sedentary present very little diffeulty. Many of mine have been civil servants, who in pleading Lo be allowed to return to work have assured me that the life is very easy, that they need not do very much work and that what they do does not strain them at all. Clerks, accountants, bank officials all have a suitable employment ready for them, provided that employers do not shy away from them on the grounds that they may become a liability on the firm by breaking down after starting work again. But manual labourers present a problem which I find most baffling. Take the farm labourer, small farmer, miner, navvy, builder's labourer, for example who often develop the disease in their middle thirties o r

later when it is almost impossible for them to learn new tricks. How is one to return such to a normal useful life~. Village settlements such as Papworth may provide for a certain number, but it would be necessary to provide an impossible number of Papworths to accom- modate all of them. Many could be trained to do light bench work in industry provided that there were places in industry to be found for them. This has been done in England to a great extent where firms such as the Austin Motor Co. provide work for the partially disabled. In this country, whose chief industry is agriculture and where there is but little of such light bench work available, the problem is very much more diffeult. A small but valuable start has been made by the voluntary efforts of the Post-Sanatoria League in providing suitable work for patients after their discharge from hospital.

Before concluding, I must consider the r~le of Government and National Health Service in relation to the tuberculous patient. We have already noted that tuberculosis dispensaries are crowded, under- staffed and suffer from their separation from a hospital. Excellent provision is made for allowances to the tuberculous and for payment for such costly drugs as streptomycin and P.A.S., but the actual pay- ments are extremely difficult to collect owing to numberless irritating rules. All applications must pass through the proper and devious channels; if they do not, they are merely ignored ; and one is constantly trying to get things settled before the patient abandons all hope. There are two phrases which I regard with grave suspicion, viz., the " proper authority " and the " p r o p e r channels " : both are used to make things difficult for the ordinary person. I quote again from Betty MacDonald, this time from her latest book: " For months I worked . . . trying to make the (U.S.A.) Treasury do things in a way not quite as frenziedly hurried as glacial movement, but not quite as slow as the decomposition of ferns into coal." The treatment o£ tuberculosis is so prolonged that its cost can be borne by but few patients, and the remainder must be paid for by the community at large, which is what free treatment amounts to. Let the payments be made in such a way as to leave no resentment against those agents who make the final distribution.

I have wandered about a good deal over the field of the treatment of the tuberculous patient, and I should like to conclude by making a plea that every patient should be treated as an individual, that we should not be over-influenced by passing medical or surgical fashion~

T H E T R E A T M E N T OF T H E TUBERCU LO U S P A T I E N T 9

but s tudy every suggested remedy and apply to each pa t ien t t h a t t r ea tment which seems most suited to his par t icu la r state of body and of mind.

(1) Roche, H. (1941). Tubercle, xxii, 1. (2) Maurer, G. (1950). /)/e C'hemotherapeutische Tempo~de der L ~ g e ~

kave~en. Thieme Verlag Stuttgart. (3) O'Brien, B. (1950). Irish J. Med. Sci., 297, 409. (4) Harwood, H. F. (1950). Lancet, 6633, 477.

Other works consulted include: Barry, F. (1726). A Treatise on a Uonsumption o] the Lungs, Dublin. Webb. A History o] Tuberculosis. Kane, Pagel and O'Shaughnessy. Pulmonary Tuberculosis. Betty MacDonald. The Flague and I; Anybody can do Anything.

MEDICAL RESEARCH COUNCIL OF IRELAND.

Colloquium on the Chemotherapy of Tuberculosis (Preliminary Announcement)

It is proposed to hold a Colloquium on the above subject in Dublin from July 10th to 13th (inclusive), 1951. The lecturers will include Dr. V. C. Barry (Medical Research Council of

Ireland), Dr. Marc Daniels (Medical Research Council, London), Professor G. Domagk (Wuppertal-Elberfeld), Dr. W. H. Feldman (Mayo Foundation), Dr. P. D'Arcy Hart (Medical Research Council, London), Mr. T. J. D. Lane (Meatlt Hospital, Dublin) and Dr. Edgar Lederer (Institut de Biologie Physico-Chimique, Paris).

Further information on the detailed arrangements may be had from J. G. Belton, Honorary Secretary, Organising Committee, Laboratories, Medical Research Council of Ireland, Trinity College, Dublin.