THE ' FOLLY OF SENDING TUBERCULOUS 
PATIENTS AWAY FROM MEDICAL 
SUPERVISION * 
JOSEPH WALSH, M.D. 
PHILADELPHIA 
Case 1.-Mrs. N., aged 44, in well-to-do circumstances, came 
to my office Oct. 14, 1907. She had been perfectly well until 
four months previously, when she developed symptoms of 
cough, expectoration, etc., and her physician told her that she 
had tuberculosis of the lungs and that she should go to the 
country. This was the complete advice he gave her, telling 
her neither where to go nor what to do. Being a woman of 
intelligence, she made inquiries among lay people and heard, 
among other places, of a town in a neighboring state in which 
the.re is a large sanatorium for tuberculous patients. She went 
to this town, which contains a number of physicians experi- 
enced in the treatment of tuberculosis, but having been given 
no advice about what to do and no directions about seeing a 
physician, she thought it was necessary only to remain in the 
town until she got well. She remained four months, and, find- 
ing that she had not improved, she consulted a physician con- 
nected with the sanatorium who told her her exact condition 
and described what she ought to have been doing, but had not 
been doing during the past four months. 
The patient had moderately advanced tuberculosis and I hate 
no doubt, especially in the light of subsequent events, that if 
she had been under the care of this physician during these four 
months she would have recovered, but after finding that- she 
had wasted four months she became so disheartened and so 
homesick that she felt obliged to come home for a while, even 
though, as she said, it might be attended by serious conse- 
quences. 
She asked now if she might not be treated at home, assur- 
ing me that if she did not do well she would be willing to go 
to a sanatorium. She was not only a woman of intelligence, 
but of perseverance, and in six months the disease was 
"arrested," the cough and expectoration practically stopped, 
and she had advanced in weight from 118 pounds to 137. She 
has remained in this apparently cured condition for the past 
three years. 
* Read before the Philadelphia County Medical Society, April 12, 
1911. 2 
Case 2.-T. M., a single man, aged 23, medical student, first 
consulted me Sept. 13, 1906. He said, that the previous 
December he had been advised by an eminent physician to go 
west and Keep in the open air, and to exercise. He was a 
strong, characterful young man and followed directions 
implicitly, riding horse-back and walking continuously, only 
to find at the end of five months that he was distinctly worse. 
On consultation with a physician in Texas, who knew some- 
thing about tuberculosis, he was told that he should have been 
on rest the whole period. Discouraged and disheartened he 
came east, but his five months' definitely improper regime and 
the trips west and east had done their work. He was in a 
critical condition when I saw him and rapidly deteriorated 
till he died. 
Case 3.-F. G., a man aged 40, married, machinist, went to 
the White Haven Sanatorium, March, 1910, with advanced 
tuberculosis of both lungs. None of his friends expected him 
to recover. He was so well four months later, namely, in 
July, that he insisted on going home for a few days. His 
friends were surprised at his splendid condition and realizing 
now his capability of recovery thought they would clinch the 
matter by sending him west. Though he was a poor man, 
these friends made up a purse of $800 and sent him west. 
Three months later he returned east in the hope of being able 
to enter the White Haven Sanatorium again, but he was so 
ill on arrival at his home that he could not be moved and 
he died several weeks later. The patient himself stated in 
regard to his retrogression, that the trip west on the train 
started it. He did not know what to do when he arrived 
there, fell into the hands of a physician who knew no more 
about tuberculosis than himself, and finally after spending his 
$800 in three months he came east and the trip eastward 
finished him. 
The result in the first case shows that there was no 
necessity for the patient leaving home; in the last case 
the patient was in the proper place and was advised 
away from it, and all three cases are typical of the folly 
of sending patients away from continuous medical super- 
vision. Every physician who sees many tuberculous 
pafients has numerous similar histories of patients who 
die, not on account of susceptibility, but on account of 
improper or insufficient direction. 
To recover from a tuberculous condition which is 
manifesting symptoms sufficient to bring the patient to a 
physician requires at the least months of a careful regime, 
which changes with the improvement or retrogression in 
the disease and with the occurrence of complications like 
a cold. Not one patient in a hundred can be directed 3 
at the beginning along a course that will not require 
modification, and modification sufficient to make the 
difference between life and death if it is not followed out. 
Two of these three patients went to country hotels. T 
know of no course worse than to send a patient to a 
country hotel or farmhouse away from direct medical 
supervision. In the farmhouse or in the bote] it is 
usually necessary for the patient to conceal his condition. 
He is, therefore, prevented from using sputum cups, 
uses instead his handkerchief and sometimes even is 
obliged to swallow his sputum, thereby putting himself 
in the danger of continual reinfection. Tn addition he 
is even afraid to carry out in their entirety the precepts 
that he himself understands, fearing, on account of the 
general knowledge of tuberculosis, that those around 
him will recognize his condition. At home or in a sana- 
torium the people about the patient are not only desirous 
of seeing him get well, but, understanding his condition, 
help him to carry out the regime. At the farmhouse or 
country hotel he is so anxious to conceal his condition 
that he is encouraged in just the opposite direction. 
Moreover, to send a patient to a farmhouse in which 
the family is willing to take a case of tuberculosis has 
no further advantages. Tn this case the people have 
usually had tuberculous patients previously, and have 
some ideas relative to the disease. These ideas are fre- 
quently wrong, yet wishing the patient well they 
endeavor to instruct him. Any sick individual is more 
or less at the mercy of the well people about him; if they 
insist on certain things he has not the will-power to 
resist. Unless the physician, therefore, is paying very 
close attention, the patient will be following these other 
directions. Some patients have so much recuperative 
power that despite the disadvantages of the farmhouse 
they improve, but the number of these is small compared 
with the number of patients who fail to improve in the 
farmhouse, and yet on being sent to a sanatorium get 
promptly well. 
My experience is that patients capable of recovery and 
possessing the proper character to make them persevere 
in treatment are capable under supervision of getting 
well anywhere. Patients whose personal will-power is 
not strong or who on account of circumstances, like 
business worries or family troubles, are not capable of 4 
taking care of themselves at home, should be sent to a 
sanatorium. 
The advantages of a sanatorium do not lie in its situa- 
tion, but in the ease with which the proper regime is 
followed in it. In the home or farmhouse or country 
hotel, the people are going to bed at the time suitable 
for well people; they are, if the weather is cool, living in 
confined rooms; they are amusing themselves by indoor 
occupations and they are eating meals suitable for active 
laborers. In order to follow out a regime in which rest, 
fresh air and special food are the important factors, the 
patient is obliged practically to separate himself entirely 
from the family, and on his own initiative retire while 
the others are amusing themselves, sit out alone while 
others are experiencing the comfort of indoors, and 
refuse dainties which he sees others enjoying; all this 
requires an amount of character that few people, espe- 
cially sick people, possess. Tn a* sanatorium . everyone 
about the patient is doing just what is proper for the 
disease; all are retiring at a proper hour, the daily 
amusements are outside, the meals are specially regulated 
to requirements so that there is no inducement to remain 
up late or to stay indoors, or to eat unsuitable articles 
of food. To do what is wrong at home is very easy; to 
do what is right requires special initiative on the part of 
the patient; while the opposite is true in the sanatorium ; 
in fact to do what is wrong in a sanatorium almost 
requires special malice against oneself. 
I believe, therefore, that there are only three things 
for a physician to do with a tuberculous patient, namely, 
treat the patient himself, send the patient to another 
physician or send the patient to a sanatorium; and that 
the sending of a patient to a farmhouse or country hotel 
away from supervision is an unjustifiable evasion of the 
physician's responsibility. 
732 Pine Street. 
Reprinted from The Journal of the American Medical Association 
June 3, 1911, Vol. LVI, pp. 1638 and 1639 
Copyright, 1911 
American Medical Association, 535 Dearborn Ave., Chicago