"ODDS AND ENDS" IN TUBERCULOSIS. BY,C. 0. P'ROBST, M.D., COLUMBUS, OHIO. When asked by the President to read a paper at this meeting I tried to find some part of the tuberculosis field where "keep off the grass" might have protected it against well worn paths. There is, of course, plenty of unexplored territory, but the busy practitioner, trying to keep in sight of Mr. "H. C. L." can except to do little more than present a few odds and ends gleaned in daily experience. TUBERCULIN. I suppose one will be considered passe to advocate the use of tuberculin in the treatment of tuberculosis. I am not coming to its defense except when I shall refer to the psychology of tuberculosis. I should like to briefly relate, however, my experience in two cases with exceptional minimum and maximum doses. I have under by care now a woman with tuberculosis of the left eye. The patient was exhibited at a meeting of the American Ophthamological Society, held in Cleveland some months ago. She was examined by some twenty-five or thirty physicians present, and the diagnosis of tuberculosis was agreed upon. Also tuberculin in small doses was recommended, and was especially urged by Dr. Jackson of Denver, whom some of you doubtless know. Last October, when I first saw the patient, a woman of 37 years, she was suffering from intense pain and photophobia from a highly inflammed eye, in which vision had been almost entirely destroyed by corneal ulcers. She had begged for removal of the eye, but her physician refused. Her trouble was of seven years standing with periods of improvement. She had had hamoptysis on several occasions years before, but there were no symptoms or signs of present lung trouble. 72
" ODDS AND ENDS"Y IN TUBERCULOSIS 73 Under tuberculin, or it may have been withdrawal of local treatment, (I have no reason to think the eye had been mistreated in this respect) the inflammation, pain and photophobia, disappeared. Except for vision her present condition is excellent. Her general health is better than for years. It is because of quite intense reactions to tuberculin that I present this case. The first injection was one-one millionth of a mgm. This gave a marked local reaction. A week later 1/10 of this amount caused no reaction. This dose was adhered to, or very slightly increased, with moderate reaction but twice, until the eleventh week, when three-tenths-millionths of a mgm. (.0000003) caused not only severe arm trouble but a temperature the day after of 101.6. This lasted ten or twelve hours, and the arm cleared up in four or five days. The tuberculin for this injection was Mulford's O.T. Some of the other reactions were produced by Gilliland's O.T. At no time was there any focal reaction in the eye. I feel sure infection of the tuberculin solution or of the syringe may be ruled out. I have had two or three other cases of extreme susceptibility to tuberculin, but not so marked as this one. In contrast with the eye case is one in which massive doses of tuberculin were given to a patient with a tuberculide of the buttock as large as the hand, with involvement of the larynx. Three other physicians saw the case with me and agreed on the diagnosis. Two Wassermanns were negative. The ulcer had resisted local treatment for nearly two years, though at times it had improved. In ten months' time, with tuberculin and local treatment, it entirely healed and has remained healed to this time-six or seven years. In this case I gave the man on five different occasions 1 c.c. of pure tuberculin (O.T.) There were never local reactions but occasionally a slight focal reaction. TEMPERATURE. We all recognize the great importance of accurate records of temperature in tuberculosis. It aids in diagnosis, it largely decides the degree of activity permissible, and it mainly determines the
74 C. 0. PROBST liberty of action we allow the patient. However, if we allow ourselves to be guided by invariable rules, we may fall into serious error. Are we sure that the normal temperature of every individual is at the arrow mark where the makers of thermometers have placed it! I have often doubted it. I had one individual under observation for four years, often for weeks and sometimes for months at a time, with temperature records at frequent intervals. Most of this time he was apparently in perfect health. In the beginning a doubtful diagnosis of tuberculosis was made. At no time in these years was his temperature above 98. In another case, in which tuberculosis was highly probable, records at frequent intervals during five years showed a daily rise to 99. The effect of psychical influences in raising temperature is well known. It is a common experience at first examinations, where dread of the diagnosis is well marked, as it usually is, to find a temperature above 99. I no longer pay any attention to this except to point out the great necessity for records taken every two hours for fouir days or more. I had one woman whose husband I had sent away on account of tuberculosis who on four different occasions at my office (she was determined to have tuberculosis) had a temperature above 99. In the intervals at home it was never above normal. A patient who was keeping records of temperature, which had been normal for some time, brought a record of one observation of 102.4. On questioning I learned that her little girl had gotten the pepper box from the table and filled her eyes with pepper. The mother carried her screaming to the bath room and soon after found the 102.4. Is it possible that some nervous patients who, through their physician or otherwise have been highly impressed with the importance, perhaps danger, of slight variations in temperature, may give themselves a physical rise whenever they use the thermometer? Some years ago I suggested to the professor of physiology at our state university that he should conduct an experiment by taking the temperature of healthy students of both sexes before and after examination. This was done on two occasions. As I have seen no reference to such a test, though it may have been previously made, I venture to briefly report the results.
"ODDS AND ENDS"1 IN TUBERCULOSIS 75 The thermometers used were the "Sunshine" made by Randall and Faichny of Boston, and were new. The examinations were from 8 to 11 A.M. The time used in the examination varied from one hour to two hours and a quarter, the average being one hour and three-quarters. The room temperature was 70 on one occasion and 74 on the other. The number of students examined was thirtyone, twelve males and nineteen females. Mouth temperatures for five minutes were taken. Three males and two females had temperature above normal before the examination began. One boy had a temperature of 100.2 and one girl had a temperature of 100.1. They still had these temperatures after the examination. In the other three the temperature returned to normal after the examination. Of the twelve males, six showed an increase of temperature after examination, the greatest increase being 7/10 of a degree. In five males there was a decrease of temperature after examination. The greatest decrease was 1.3 degrees. Of the nineteen females ten had increase in temperature after examination, the greatest variation being 1.7 degrees. Seven showed a decrease the greatest being 8/10 of a degree. In but three students, one male and two females, was there no change in temperature. I make no attempt to draw conclusions from this test. Fear and anxiety may have caused elevation of temperature before the examination, and active cerebration after the examination. The experiment was not carried out as I had planned it. I had suggested that the examination be suddenly announced and conducted at a time entirely unexpected. We know, of course, that the patient's feelings as regards temperature are very deceptive. I encountered a marked example of this recently. The wife of an intelligent man, a university professor, consulted me about her husband. A diagnosis of tuberculosis had just been made though the disease proved to be of long standing. I asked for temperature records before I saw him. He mildly protested thinking it of no use, as he was sure he was not having fever. The record showed daily rises to almost 103. Premenstrual rise in temperature is not uncommon, but I have had three cases where two weeks before the temperature was above
76 C. 0. PROBST 99 and normal after and during menstruation. I do not konw whether this may occur in the non-tuberculous, but if it does it might easily lead us astray. I kept one woman at complete rest for three months on account of this premenstrual rise in temperature. I have not done so since. Indeed, I must say that I do not consider it necessary to keep patients at complete rest for slight elevations of temperature if there is no other reason for so doing. I have one man for a patient, or had, whose life has ibeen absolutely spoiled by overtraining, who will go to bed for days whenever his temperature is above 99 or his pulse above 90. He is a big husky fellow, a nuisance to his family and a burden to himself. WORK OR REST. I have carried a good many cases of tuberculosis with slight temperature to a successful conclusion who never quit work. I shall no doubt be in serious disagreement with many here when I say I think rest in tuberculosis is often much overdone. I certainly do not underestimate the great importance of rest in most cases in beginning treatment. But take a man at work with a dependent family and no resources. With an early, slightly active case of tuberculosis, it may be possible to carry him to complete arrest with twelve to fifteen hours out of the twenty-four and all of Sunday for rest periods. In some cases three or four months in bed with the resulting financial loss might actually destroy chances for recovery. In certain characters the mental unrest from such enforced rest may more than offset its benefits. We should have some agreement as to the best methods for the treatment of tuberculosis but rigid rules for the treatment of the individual who has tuberculosis would not seem advisable. I venture to enter a protest against the too common practice of putting every case of tuberculosis to bed regardless of his physical or financial condition. It works a very serious hardship in many cases where, in my judgment, it is not necessary. It is true that this opinion rests upon individual experience and I am not unaware of its limited value. In accepting the responsibility for keeping such a patient at work I always fully explain the possible danger of doing so, and
"{ODDS AND ENDS"y IN TUBERCULOSIS 77 require accurate records of temperature and pulse to be kept. I see him frequently and have the understanding that if he has not shown improvement in three or four months a change will be made. I also give him positive assurance that I will notify him at once if conditions become worse. In only one or two instances hav'e I had reason to regret this, while in quite a good many cases complete arrest has been accomplished without loss of work. MENTAL INFLUENCES. The first paper I ever read before a medical society, now thirtyfour years ago, was on "The Influence of the Mind on the Body." I had heard little or nothing at that time of "psycho-therapy." I am still profoundly impressed with the possibilities of such an influence. All eminently successful physicians, I believe, consciously or unconsciously make use of psycho-therapy, but few, perhaps, deliberately and intelligently apply it. I sometime ask myself whether Christian Science and various fakes and fads in medicine, have not grown up and been maintained because we have so largely neglected to employ the mind (our own and the patient's) in combatting disease. All those who see many patients with tuberculosis recognize their easy impressibility. Few, I take it, deliberately make use of this in handling the patient. I am sure I do not. Many of us rarely use drugs except to meet urgent symptoms. But a drug of any kind, where a high degree of expectancy has been created, may prove of high potency. The elder Flint cured, if we may use the term, acute rheumatism with quassia water. H. C. Wood, by pretending to increase the dose, got all the effects of morphia with distilled water. Charcot amputated legs without pain under hypnotic, that is, mental influence. How little we know of the mind's working anyway? And how limited is our knowledge of physiology? Is it not at least possible that the defensive forces of the body, which alone can protect or heal it, may be activated by mental impressions? Old John Hunter said he could fix his mind on his toe until he got a pain in it, and that he was at the mercy of his enemy who could kill him at any time by anger-and this happened. To come back and end with tuberculin.
78 C. 0. PROBST I once heard our president say that he used it but would probably have better results from it if he had more faith in it. In other words, if he inspired his patients with more faith in it. I use it daily and am trying to keep my faith in it. I still believe it has some therapeutical value and am certain of its psychological effect. But of even more importance, probably, is the close surveillance it enables one to keep over office patients. I pay full tribute to the true scientist in medicine. But after all medicine is still largely an art, and to most of us the relief or cure of our patients, by whatever means this may be brought about, is the life work we have undertaken.