THE ONSET OF TUBERCULOSIS GENERAL ADVICE TO PATIENTS ON EARLY DIAGNOSIS AND CAREFUL TREATMENT. IMPORTANCE OF A PHYSICIAN. BY JOSEPH WALSH, M. D. PHILADELPHIA, PA. Reprinted from JOURNAL OF THE OUTDOOR LIFE, August, 1908 THE ONSET OF TUBERCULOSIS. GENERAL ADVICE TO PATIENTS ON EARLY DIAGNOSIS AND CAREFUL TREATMENT. IMPORTANCE OF A PHYSICIAN. JOSEPH WALSH, M. D., PHILADELPHIA, PA. Of most importance to a patient suffering with tuberculosis is a physician in whom he has perfect confidence. The following out of the discipline of a physician whom he trusts, even though that discipline is not perfect in all its details, will accomplish more than in- different visits to a physician who might be more learned in that particular subject. Tuberculosis is a serious disease. It is at least as serious as typhoid fever. No one would attempt to go through a siege of ty- phoid fever without recourse to a physician; it is just as unwise for a layman to endeavor to cure himself of tuberculosis. In our day it is the exception to find a physician who does not know how to treat tuberculosis properly, and in difficult cases, when he is not succeeding, though cure ap- pears possible, he practically always insists on other advice. Moreover, it is very evident that no matter how inexperienced a physi- cian may be in a particular disease he knows considerably more about it than the most experienced laymen. Laymen with experience are usually those who have had the disease themselves or have seen it in their families. Their experience is limited at the most to five or six cases, and not infrequently to one or two. No matter whether a general practitioner or following a specialty, a physician must have made an ex- tended theoretical study of tuberculosis as well as other diseases before he could grad- uate ; he must have seen numerous, at least twenty or thirty, cases of tuberculosis under his teachers, and it is impossible for him to avoid seeing at least dozens of cases a year. It is safe to say, therefore, that no matter who the physician, he certainly knows more about the disease than the layman and is more competent to advise the invalid than the in- valid himself or his friends. In other words, here, as elsewhere, the adage remains true that in building a house we will get better services from a poor carpenter than a good lawyer. In regard to physicians, it is only neces- sary to say that it is advisable to go to a reputable one. Among members of the medi- cal profession it is not considered ethical, in other words honorable, to advertise. There- fore, any physician who advertises is acting dishonorably to the physician's code of morals, and if dishonorable to his professional breth- ren, it is scarcely conceivable that he will be honorable to patients who cannot judge him. If a man were in a strange city and knew no physician at all, and, therefore, could not differentiate between those who were honor- able and dishonorable, the safe course would be to inquire from a newspaper the address of the secretary of the County Medical Society of the place, and ask the secretary by letter to name a couple of reputable physicians in the neighborhood, or if a specialist in any particular thing were wished request him to name several specialists. From the laymen's point of view there are three stages of tuberculosis. The first is that in which he suspects he has the disease though as yet he manifests no particularly annoying symptoms. He may have a slight cough or hack in the morning, with more or less ex- pectoration ; he may have spit up blood once or twice and persuaded himself that it came from the throat; he may be losing slightly in weight; he may be suffering from a certain amount of indigestion. It is true that any of these symptoms may be due to other things than tuberculosis, and he readily persuades himself that they are. It is at this stage that tuberculosis, if the symptoms are due to tuber- culosis, is especially curable, and if he presents himself to a physician, he stands his best chance. The second stage is that in which the patient is manifesting any or all of these symptoms in a fashion so that he cannot under any pre- text deny them to himself. At this stage the curability depends entirely on the condition of the lungs and the amount of constitutional running down the patient has suffered. If the patient is coughing, expectorating, losing in weight, suffering from night sweats and has a hectic fever, it is likely that there is con- siderable involvement or that the condition is acute (that is, advancing rapidly). At this stage, absolute cure is frequently out of the question, though practical cure so that the patient can lead an active life for a number of years may be possible. It is at this stage that patients most commonly go to physicians. In the third stage the patient has already become markedly emaciated, or hectic in appearance, that is, shows flushed cheeks, especially in the afternoon, the cough and expectoration have become serious symptoms, and are annoying him night and day, indiges- tion is marked and he is gradually becoming unfit for labor. These patients have usually recognized their condition for weeks, and fre- quently for months, before they seek the physician, but have been trying to persuade themselves that it will wear away or that they will work it off, fearing to find out that they have tuberculosis. In this stage of the dis- ease, especially in the timid individuals who have feared to seek a physician, the disease is usually incurable. The proper treatment usually builds them up for a few weeks or for a few months, but their fate has been settled by themselves. Tuberculosis cannot be worked off, it does not wear away. Even in the very earliest stages, whatever oppor- tunity there is of getting well is very much enhanced by seeking proper advice and fol- lowing it out. In the cure of tuberculosis there are three things especially insisted on, namely, sufficient rest, sufficient fresh air, and sufficient good nourishment, and depending on the advance of the case depends the amount of each re- quired. A patient who is very ill, whether ill from an acute complication of tuberculosis or on account of the advance of the tuber- culosis itself, may require such absolute rest as to confine him in bed for several weeks or even several months. Patients who are in a very early stage, with the disease just begin- ning, may require only the giving up of some bad habits in the way of dissipation or staying up late at night, or the changing of a heavy occupation to a lighter one. The patient himself is not competent to judge in what class he stands as far as rest is concerned, and should, therefore, consult a physician. The falsest kind of ideas are in vogue among lay people in regard to rest and exercise. It is not uncommon to find lay people who believe that to rest in bed weakens one. This idea is absolutely false. Rest in bed always strengthens, never weakens. No- body ever succeeded in getting rid of a dis- ease by what he termed " working it off," half as easily as he would have gotten rid of the disease if he had gone to bed. Many of the milder diseases like, for instance, colds, chicken-pox, etc., are of such a mild character that they get well in spite of adverse circum- stances. There are none, even of these mild diseases, however, that would not recover more rapidly if rest were taken. Particularly, in tuberculosis, have many lay people the idea that the more they exercise, especially walk, the quicker they will get well. This idea is absolutely false and cannot be changed too soon. No general rules can be given which will apply to all patients. Each particular patient is a special study in himself. The following statements, however, in regard to rest are reasonably conservative. No patient should be at work if he has lost more than one-quarter of his body weight. No patient should be at work with a temperature over 100 any time during the day. No patient should exercise or work while he is spitting blood. Exercise or work, no matter however light, which sends the pulse to no a minute must be stopped. No one, sick or well, can get too much fresh air. Man was originally created to live in the open air, and it is only by hundreds of generations of civilization that he has accus- tomed himself at all to living indoors. The more time, therefore, he can spend out-of- doors, the healthier he will be. By fresh air is meant unbreathed air and air uncontami- nated with noxious gases like, for instance, the products of combustion due to the burning of a gas jet. The absolutely proper way of living, accord- ing to nature, would be to sleep outside at night and work in the fields all day. Our civilization has brought about almost the opposite condition of affairs so that we work inside all day and sleep inside all night. Not only do we work inside in a room in which our own breath comparatively soon con- taminates the air, but usually in a room with others, and not infrequently many others. Moreover, the majority of people in the world also sleep in a room with others. It is almost impossible to retain health and live under these conditions. It requires an espe- cially robust constitution and freedom from contact with contagious diseases to succeed, and the majority do not succeed, but break up more or less early in life and eventually succumb. The majority of patients with tuberculosis, come from factories, mills, bar-rooms, basements of stores, counting houses, etc. People, even in health, who are obliged to work indoors all day, should insist that dur- ing the remainder of the twenty-four hours they get sufficient fresh air. People who are in contact with tuberculosis in their families or at work must see, at least, that they sleep with open windows at night, and are out most of the day on which they are not working. With the slightest development of tuberculosis it is usually necessary to stop work for at least a time. The length of this time can only be determined by a physician studying the progress of the case towards health.