The Treatment of Pulmonary Tuberculosis Outside

the Sanatorium.

DUDLEY B. DEMING, M.D., WATERBURY, CONN.

The first and most important factor in the treatment of tuberculosis is to prevent its communication to others, and the second is to benefit the patient. I firmly believe that with the vast majority of patients both these factors are more advantageously carried out in a sanatorium than at home. The sanatorium is undoubtedly the model of life for a consumptive-there he learns what to do and what to avoid; he is shielded from the turmoil of business life; he is obliged to rest; his food, drink, and clothing are all arranged for him; he is under constant supervision and is trained to live so as to minimize the risk of communicating his disease to others. It is impossible to overestimate the educational value of sanatorium life and influence.

But, unfortunately, only a very small proportion of the vast number of victims of this disease can avail themselves of the advantages of residence in sanatoria. The three chief reasons for this are: First, the nature of the disease itself; second, the sociology of the situation, and third, the rules which are in force in most sanatoria.

The nature of the disease is essentially chronic, and it takes the patient a long time to die if he is going to a not much shorter time to recover should he be so fortunate; therefore, the time spent in a sanatorium by the individual case is very protracted. All this time he is deprived of his earning capacity and is put to extra expense to follow out the treatment. But it is a disease of the poor (it is they from whom infection comes to other classes of society), and for one person in comfortable circumstances who has tuberculosis, there are ten shopgirls and day laborers who, with their families, must live

on from six to fifteen dollars a week. For these a long sojourn in a sanatorium at the so-called nominal price of seven dollars a week is impossible. The rules of most of the sanatoria exclude advanced cases, and even if the poor should be fortunate enough to secure the means to keep them at a sanatorium, too often the disease has progressed beyond the stage at which they can be admitted; or, if after admission the disease continues to progress, they are sent home to die. Other cases stay their allotted time and are discharged as improved, arrested, or cured.

Thus we see that in spite of the manifest advantages of sanatorium treatment, a very large proportion of patients must of necessity be treated outside of sanatoria. With a view to reaching this class of cases in Waterbury a concerted effort was made by the Anti-tuberculosis League in the spring of 1907. Rooms were secured and a small dispensary started for tuberculosis patients. I consented to devote one morning a week to the dispensary work, examining and prescribing for the patients. We secured the services of two graduate nurses, whose duty it is to make frequent visits at the homes of the patients and to train them, if possible, to follow the régime prescribed.

Perhaps the most effective work of the nursing staff has been in discovering suspicious cases in the households where there are more advanced cases, and persuading these to go to the dispensary for examination; then where the disease proved to be present, inducing them to lead the life requisite for a cure, or else placing them in some sanatorium.

Although the dispensary has had the advantage of considerable sums of money which could be devoted to aiding the patients to secure better rents, with suitable sleeping porches, and to help to furnish them with nourishing food, the circumstances under which the patients live frequently make it impossible for them to carry out the proper technique. Even where their intentions are the best and they are acting with the utmost confidence that they are doing the right thing, they will unconsciously do or leave undone something which nullifies all the

care they have taken. For instance, when the mother of a family is also the caretaker of a consumptive, we see her leave her cooking to run out and arrange the patient's pillows, or perhaps to place the sputum cup where it will be more accessible to the patient; then she goes back to complete her preparations for the meal without stopping to wash her hands—a trifle in technique which she is not sufficiently trained to appreciate. Then again, patients are often fairly careful about the sputum cup, and it may be the object of close attention on the part of the family, yet they will allow it to stand on the kitchen. table or will entrust it to a child to empty, so that it becomes a serious source of danger. When the household worker, whose hands are already more than full, is pressed into service as a nurse, mistakes and lapses like these just cited are certain to

occur.

The casual observer, seeing the patient spending his time out on the porch and using his sputum cup, might conclude that the case was a demonstration of the triumph of home treatment; close inquiry, however, too often reveals to how great a risk the other members of the family are exposed.

Many times the patient and his family start out with the firm intention of doing exactly as they have been instructed; but gradually they grow careless, and seeing no bad results, they become indifferent to the teachings of the physician and nurse. If tuberculosis were more sensational in its development we should get better results. As it is, the period which elapses between the exposure and the development of the disease is so long that many cannot be brought to see the connection between the two. They cease to believe what they have been told and fall into an attitude of indifference from which it is impossible to rouse them.

The most dangerous cases are the advanced ones, for even if they are disposed to take every precaution, they are too weak to do so, and at this stage they furnish the greatest number of germs. Then, too, the constant attention which the patient requires at this time results in the sickroom becoming a sittingroom for the members of the family. For the protection of

the family I always try to persuade them to keep such cases in bed out on their porches until death relieves the household of further care. Out of doors the natural germicides, sunlight and air, soon destroy the bacilli. Toward the end the patients frequently complain of cold, except in the warmest weather; nevertheless, they should be kept out of doors, for although this may seem unkind, I believe that it results in the greatest good to the greatest number.

Another class of cases which is a source of unending worry to physicians and nurses is the so-called arrested or improved cases, who have been discharged from the sanatorium with the permission to do light labor. They come to the dispensary with the request that suitable occupation be found for them. Many of these patients by nature and training are fitted only for hard manual labor; or if they are capable of doing the kind of work allowed, the question of the danger of infecting others must be considered. It is comparatively easy for a patient sitting on a veranda of a sanatorium to remember to put his handkerchief in front of his mouth when he coughs, and to wash his hands if exposed to contamination, and in other ways to avoid the risk of carrying infection. It is quite another thing to make that same individual follow out these rules when both hands are engaged in some occupation-often piecework, where his earnings depend on the amount of work done per day.

We have seen with how much danger to the family and the community the home treatment of tuberculosis is fraught. Let us now consider the patient. While the home is not the ideal place for a tuberculosis patient, it is less hard for him than for his family. Occasionally, when the home is well situated and has a good porch where the air is not contaminated by smoke, the patients do remarkably well, especially if they have had the advantage of a few weeks' residence in a sanatorium. But it is exceedingly difficult to get them to spend sufficient time out of doors during the winter months-not that they avoid the cold, for they soon become accustomed to it; but they lack the stimulus of having others around them who are taking the