Part 43

There were those who believed that every case should be sent to a T.B. hospital, absolutely isolated from his family and the world in general. Then the pendulum began to swing back, and we came to a sensible conclusion,—that while T.B. is an infectious disease, it is only slightly so to the adult; and if virulent at all, it is so only among children and the adolescent. This being so, we had to change from the separate and isolated hospital for T.B. It has been accepted that every general hospital should receive its quota of T.B. patients, T.B. being one of the most common forms of illness, and that in sending out patients to a strictly T.B. hospital; they should be sent only after the presence of the disease has been fully well proven.

The control of T.B. is after all the big problem before all of us in T.B. work today. I have often heard it said that any benefit that comes to the individual is necessarily more or less incidental, and that the big object we are laboring for is the control of the disease and the care of the general public health. Be that as it may, the problem that faces us in the care of the veteran of the World War is the actual care of the sick.

The question of prevention of T. B. must be dealt with, first, upon educational grounds,—to educate the public and the individual to the point where we can more or less limit the spread of the infection; secondly, and perhaps more important,—by a campaign for the improved living conditions of our people in general, especially in childhood.

As a matter of fact, when you get right down to it, T.B. is a social disease; it is a social problem even more than it is a medical problem. We know that when the good Lord made us, he put into us a certain amount of quality which, for lack of a better term, we have called natural resistance. If we can keep that natural resistance at a high point,—build it up,—the infection, though it may strike us, will not produce the clinical disease, T.B.

In the second place, we come to the actual treatment of the sick. This, too, is largely a hygienic measure. Since time immemorial, those interested in T.B. have been searching, have been praying for a specific cure. Every now and then somebody bobs up with a story of how he is going to cure T.B. overnight by this or that injection, treatment, etc. In each of these cases there is a grain of fundamental truth. We have got to put these things together; and when we get down to the final conclusion we can not get away from the fact that the treatment of T.B. is the building up, the bringing back to normal, and in fact if you can, the reaction to the point beyond the normal, of that quality I spoke of, natural resistance.

In order to accomplish this, I believe one of the most important points lies in the word, morale; and to encourage your morale, it is wise to get your classes classified, and to get your T.B. patients working together in classes in sufficiently large numbers so that you get that inspiration that comes from what my friend used to speak of as “the psychology of the crowd.” The thing the soldiers know as the touch of the elbow; there is a certain magic in it. It is easier to get farther when you know that somebody besides yourself is going through the same thing. I think we men in charge of hospitals feel that. That is one of the inspirations that comes to me from meeting with such a crowd of my fellows here. Away off there in the swamps of Louisiana there comes a sort of feeling, “We are here alone; it is hopeless”. When we are all here together exchanging experiences, there comes the inspiration, “We are not alone”.

In your general hospitals you have T.B. beds; have them in sections by themselves,—not because you are afraid of the spreading of the disease, not because the T.B. patient is an outcast,—but because you can do more successful work for the patient, not by segregation, but by classes.

In your T.B. sections, have your sub-divisions; have your places to which you are going to send your ambulatory cases, your far advanced, etc. Keep them far apart. Use the class system, but be sure that your personnel is sufficient, so as not to get away from the personal touch.

Perhaps a little outline of the organization of at least two of the hospitals with which I am familiar will illustrate my point.

The first essential thing when a patient enters a hospital is a complete examination. Do not let that examination be routine because it is a T.B. patient. Do not be satisfied with punching the man in the chest and sticking your ear to his heart. Have somebody who understands neurological conditions, test his nerve reactions; have someone to test his mental reactions, as well as the surgical and general medical. Have your examination ward in which this can be done.

Next is your general medical and, possibly, observation ward. I don’t care how you try to keep observation cases out of T.B. hospitals,—they are going to get in. If a patient, after being in a month, is found to be a T.B. case, he is apt to say, “I caught it here”. Put him where you can answer, “You did not get it here. You have not been in sufficiently close contact with the disease to catch it.”

Have your surgical ward; and then your strictly T.B. section.

Have first your infirmary or hospital.

The T.B. man needs special treatment, nursing care and dietetic care. One of the chief things to give to a T.B. infirmary is good dietetic care;—place the food before your patient in an appetizing manner; too much will disgust him.

Then have your ambulant section and sub-divide it into the section in which there is clinical activity of the disease, and into the section in which the clinical condition of the disease is quiescent. By doing this you can give your people graduated exercises, whatever diets they may need, periods of rest, and occupational therapy; and you can do it in an organized, scientific way, and get away from the everlasting complaint, “You let the fellow in the next bed do it; why won’t you let me do it?”

You have got to study the psychology of your patient. It may be a little out of the line of segregation of cases. We have heard the talk here of cases, of hospital management, and all that; but be sure in dealing with the ex-service man, or any other case, that you do not treat him merely as a case; that you do not segregate the medical officer in charge. I find there in the South that one of my life-savers is the fact that my office door is open to any patient. When I first got to be understood there was a line-up. I gave an hour every day. Now, since the patients know that everyone can come to me, I have possibly three or four in a day. And I don’t do it either by reversing the decisions of my ward surgeon and my executive officer; I back them up.

* * * * *

DR. KLAUTZ (N.H.D.V.S., Johnson City, Tenn.):

The subject of occupation in connection with T.B., is not only an extremely important one but an extremely difficult one to administer, particularly in the large government institution, and especially in connection with the psychology of the ex-service man, which has been referred to a number of times. He is apt to misunderstand and to be resentful toward any application of work; and yet at the same time, if we are going to measure the results of the sanitarium treatment of T.B. by the functional restoration to activity and usefulness, we still find that it results in a great many failures. That has been one of the complaints on the part of T.B. workers not only in government but in civil institutions as well.

We still find relapses occurring after the patient has been discharged from the sanitarium or T.B. hospital. Men go into training, and in a short time undergo another course of treatment, and so on. The reason for that is that they have not been given the necessary physical rehabilitation while still in the sanitarium, while under institutional protection and medical supervision.

The question of occupation is so broad that it is impossible to take it up extensively here today. We can point out one or two of the basic principles in connection with its application in the treatment of T.B. One very important feature brought out this morning is the psychotherapeutic object,—the point of view of relaxation or recreation, that is, giving the man something to occupy his mind and improve his morale, helping him to forget his home anxieties and anxiety about compensation.

The second point, or 2 A, deals with muscular reconstruction,—conversion of recently acquired adipose tissue into working force by rebuilding flabby muscular tissue which has resulted from the long period of rest.

2 A is the acquiring of a tolerance for T.B, toxins. This is important. We do know that in the recently toxic stage, exercise or work does produce a reaction which is shown by a rise in pulse rate. We know that if exercise is begun in small doses and gradually increased, the time will come when the patient can be made to take a fairly large amount of exercise continuing over a fairly long period of time, without manifesting the symptoms of reaction. Formerly we gave Tuberculin in gradual doses until we reached the point where the man could take an injection which surely would have killed him at the beginning of the course. The main point is if a man leaves the sanitarium before he reaches this toxin tolerance, he is more likely to break down. This is the reason for the man’s frequently returning to the sanitarium for treatment.

The third point deals with applying occupation as a means of training or retraining the man for some new occupation or modification of his former occupation; and here is where a great deal of judgment and study of the individual case becomes necessary. It is very difficult to find out just what is the best kind of work for the man from a physical and mental point of view; but the important thing is to have the man try it out and test it, and begin this physical reconstruction and rehabilitation if we are to get permanent results from sanitarium treatment. I don’t believe we have solved the problem completely, and I believe other agencies will have to be called in.

In this connection the question of dispensary work and social and nursing follow-up work is going to be extremely important. The man who leaves an institution ought to be followed up very carefully, and effort should be made to bring him back to some medical unit for re-examination at least every two months in order to see if there is any relapse of the former activity.

SENIOR SURGEON R. H. STANLEY, USPHS (R): It is always interesting of course, to be told what we ought to do and how to do it, but it seems to me it would be a great deal more interesting to take the little time we have this afternoon and discuss some of our real problems, and I mean by that problems that we as commanding officers of the hospitals have to contend with every day. I know and you know there are thousands of little things come up upon which we would like to have advice. There are many problems I might be able to solve readily; there are others you would be able to solve. I believe it would be worth more to tell how to get rid of some of these problems.

I believe that the success of running a hospital rests entirely upon the confidence that your patients have in you. If you are sincere they know it, and when they know that they will do anything for you. If you are not sincere they are going to know it mighty quick and you are going to have trouble. If you tell the men you are with them, that you are going to be 50–50 with them, if you call them in and talk to them as you would to a son, and if you let them see you are not doing it because of a matter of necessity, you can get by without writing petitions into Washington.

I found the other day a petition had gone to Washington from my hospital. It was necessary to discharge two men for drinking. It was their first offense. They came to me and said, “You have not treated us fair because it is our first offense.” Just before I left my station I received a letter which was addressed to these men by Colonel Forbes. In that letter he said “I have received your petition signed by 27 patients and asking that the hospital be investigated on account of a few patients being discharged for drinking. I wish to state for your benefit that I have given the matter consideration and I am standing right behind the medical officer in charge.” Leaving out the names, I had copies made of those letters and placed one of them on the bulletin board of the hospital.