Many cases of tuberculosis that eventually run a slow course are ushered in by hemorrhage, or have it as a very early manifestation. It is surprising how many people have had hemorrhage as a symptom and live to tell of it thirty or forty years later. This was not due to any mistake of diagnosis, for a generation ago tuberculosis was more likely to be missed when actually present than to be diagnosed when absent. Indeed, this tendency for the cases in which hemorrhage occurred to run not so fatal a course as others was a fact that seemed to an older generation of physicians to require explanation. They suggested that possibly the hemorrhage swept out with it some of the virulent elements from the lungs and so lessoned the infection. From what we now know this is a doubtful explanation, but it seems not unlikely that a frank hemorrhage might reduce the amount of toxins in the circulation and so in an early stage of the disease give nature a fresh start in resistive vitality.
What is much more likely, however, is that the occurrence of early hemorrhage made it easier for the patients to appreciate the seriousness of the affection and brought them to accept advice as to proper precautions. Under ordinary circumstances it is difficult and used to be even more so in the past to make the patient understand at the beginning of the affection the necessity for giving up indoor occupations and living the outdoor life with the care for nutrition that is so important if the case is to be improved. Hemorrhage scared them into submission. In the old days it was the first positive symptom of consumption. Now we have many others, and instead of following the advice of over-solicitous relatives that we should not tell patients what is the matter with them, we tell them frankly and secure such care of the health as will bring about improvement. Probably nothing illustrates so well the necessity for thus influencing the patients' minds into caring for themselves as the fact that the hemorrhagic cases, as a rule, do better than the others. All of this can be used to make the minds of patients much less disturbed than they would otherwise be by this alarming symptom.
Cough.—In the chapter on [Coughs and Colds] we have outlined how much coughing may depend on suggestion, or habit, or on the tendency to yield to slight bronchial irritation when there is no real necessity for it. Most tuberculous patients cough much more than is necessary. This is always somewhat dangerous for them since it disturbs their lungs, has a tendency to distribute tubercle bacilli in their lungs, or in the air around them, and may by efforts at expulsion lacerate affected blood vessels and produce hemorrhage. Whenever cough is productive it should be indulged in, for it removes material that should not be allowed to accumulate. Unproductive coughing, however, can usually be controlled by training.
It is particularly at the beginning of phthisis that the control of coughing by suggestion is important. There are many little coughs, "hacks" as they are sometimes called, frequently repeated by those in a very early stage of pulmonary tuberculosis and which are consequent upon irritation either of pulmonary nerves or of pulmonary tissues, but that are quite unnecessary, as a rule, if a little attention is paid to suppressing them. As a warning sign they are excellent, but the patient should be taught not to indulge in them. Coughing tends to prevent nature's curative reaction and the contraction of pulmonary tissues which may take place around a lesion. In beginning consumption, even where there is but slight infiltration, we know from the observation of the movements of the diaphragm either by the X-ray or directly by Litton's method that its excursions on the affected side are shortened. Coughing is in direct opposition to this setting of the lung at rest and therefore should be controlled; however, as our drug remedies are likely to disturb the stomach, whose healthy function is so important in these cases, the use of the mind in the control of the cough is of the greatest value.
Thoracic Discomfort.—Complaints are often made by the tuberculous of pains in the thorax. Ordinarily the discomfort is supposed to be due to the lung condition, and it is assumed that it is either actually in the lung itself or in the pleura, or communicated from them by reflex to the muscles. In most cases, however, patients complain of pain on the side that is either not affected at all or least affected. If they have been told that the other side is suffering most from tuberculosis, they are prone either to think that now the [{362}] well side is being invaded or else that their physician is making a mistake, and both thoughts are seriously discouraging. The reason for the pains on the well or the better side, however, are easy to understand. As far as possible, as can be readily demonstrated by the X-rays or seen in the observation of the so-called Litten's phenomenon—the excursions of the diaphragm—nature puts the ailing lung at rest and the diaphragm moves much less on that side than on any other. In order to make up for the lack of breathing in this side the other lung does compensatory work. This over-stretches the muscles of the thorax on the well side and causes some over-work in them. The consequence is a tiredness which may become fatigue; in damp weather this may be even painful. Just why damp weather has this particular effect on muscles is not surely known. Muscular action is probably accomplished with more difficulty in damp weather because of the relaxing effect of moisture on tissues and circulation. Reassurances may be given them, then, that will keep them from thinking seriously of the significance of these pains except as an index of nature's compensatory efforts. The painful conditions instead of causing discouragement will, then, be a source of encouragement. It must not be forgotten that rubbing with some gentle stimulant, soap, liniment, or the like, will greatly improve the thoracic muscles in these cases, but the rubbing must be done gently and by someone else beside the patient, for it is only beneficial if done from before, backwards, in order to help the return venous circulation which runs in that direction in the external respiratory muscles.
Altitude.—There is a marked difference between the amount of water which finds its way out through the lungs at varying altitudes. At sea level an ordinary patient will lose during the night about 300 cc, that is, something more than half a pint of water, through his respiratory tract. At an altitude of 5,000 feet, however, this amount is almost doubled, and at 10,000 feet is almost trebled. At 2,000 feet it is half as much again as it is at sea level. This copious giving off of water has a marked effect on the lungs. It constitutes one of the reasons why altitude is a favorable element in the treatment of tuberculosis. Only beginning cases of tuberculosis, however, are able to stand the additional work thus put on them, though a slight elevation, up to 2,000 or even 3,000 feet, rather seems to be of benefit to all cases. How far-reaching the effect of this extra loss of fluid is, is appreciated from the concentration of blood which takes place and which produces a blood count of 8,000,000 red cells at a mile of altitude in patients who, at the sea level, have no more than 4,500,000. Such patients, of course, need much more water and fluids generally to be comfortable than when living lower down.
Suggestion and Treatment.—There are many accessory suggestions with regard to food that serve to confirm the patient in the idea that abundance and variety of food must be taken if the battle with the disease is to be won. To patients who find milk difficult to take, it must be explained that a copious amount of fluid in the system is needed in order to make coughing easier. So milk serves a therapeutic as well as a nutritional purpose. In the same way it may be explained that fats, such as bacon and cream, help to keep the bowels from becoming constipated and constipation inevitably disturbs the appetite.
Explanations as to the advisability of being out of the city and in a portion of country not very thickly populated, in order to avoid the possibilities of secondary infection with other respiratory diseases and bacteria of various [{363}] kinds, will make a patient understand the necessity for leaving town. It may be helpful, also, to insist on the value of living at some elevation above sea level as an aid to expectoration.
Cough is the symptom that many of these patients fear most, and a promise of any amelioration of it by a simple change of location helps them to make the sacrifice of city life for a while. Some patients who have been benefited by a stay in a sanatorium come back with a relapse of their symptoms. They dread to return to the sanatorium and think they can care for themselves as well at home, since they know what the regulations are, though it may be evident to the physician that they are losing ground in their city environment. It is well worth while to give them a careful explanation of what we know of the effect of altitude upon consumptives who have sufficient reactionary power to stand it.