COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 34741 RC311.1 .R91 Report of five more RECAP REPORT OF FIVE MORE APPARENT CURES OF PULMONARY TUBERCULO- SIS OCCURRING IN WORKING PEOPLE WHO WERE TREATED AT A DISPEN- SARY WITHOUT INTERRUPTION TO THEIR WORK. BY JOHN F. RUSSELL, M.D. NEW YORK, SEPTEMBER. 1906 Columbia Untoertfttp intljeCitpofltegark College of ipfjpgtciang anb burgeons iUfcrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/reportoffivemoreOOruss REPORT OF FIVE MORE APPARENT CURES OF PULMONARY TUBERCULO- SIS OCCURRING IN WORKING PEOPLE WHO WERE TREATED AT A DISPEN- SARY WITHOUT INTERRUPTION TO THEIR WORK. BY JOHN F. RUSSELL, M.D. NEW YORK, SEPTEMBER, 1906 "RC3/I.I AS mentioned in a recent paper, the work of treating self-sup- porting consumptive working people is being carried on at my rooms, 239 Thompson Street, two doors below Fourth Street (South Washington Square). Physicians are cordially in- vited to send suitable patients for treatment who are deserving and who are able and willing to fulfill all the requirements for membership in the class. Patients who reside elsewhere than in the Borough of Manhattan and the lower Bronx are unable to obey the rule requiring all patients to report at the rooms twice a day (no exception is made be- cause of weather), and are therefore ineligible. The object of this and previous reports is to show that uncom- plicated pulmonary tuberculosis occurring in working people is cur- able in the home climate by dispensary methods, without inter- ruption to their work. That this result is accomplished by careful attention to the details of daily life, particularly in the matter of fresh air and sunlight, diet and, in so far as possible, the regulation of exercise. No medicines, except cathartics, are employed. These patients are working people and must continue to work while under treatment in order to obtain means of livelihood. This is an unchangeable condition. The treatment of their disease is ever secondary to the struggle for subsistence. How to obtain the great- est number of hours of fresh air and sunlight, what to eat, when to eat, how much to eat, how to regulate exercise and still continue to work, must be determined by the kind of work, the number of hours of labor, and the conditions surrounding the patient while at work. It is hoped that the good results reported, obtained under such manifest disadvantages, will encourage general practitioners every- where to establish dispensaries similar to this for the treatment of patients who are striving under like conditions, and also, to treat in private practice in the home climate those to whom fortune has been more kind, but who cannot, without great sacrifices, seek climatic or sanatorium treatment. To treat consumptive working people in a dispensary without interruption to their work, is to maintain them as self-supporting; to enable them to keep their families together and educate their children; to teach them how best to live according to their means; to teach the precautions necessary in their relations with the healthy, a class of consumptives who can be reached in no other way. ANY patient with uncomplicated pulmonary tuberculosis in any stage of the disease who is able to come to the rooms twice each day and to obtain suitable food, shelter and clothing, is accepted for treatment. The most common complications which bar treatment by this plan are tuberculous laryngitis, old cases of emphysema upon which tuberculosis has become engrafted, cardiac complications and cases in which there is continued high tempera- ture with or without repeated profuse hemorrhages. Patients of the last-mentioned type require rest treatment. About all the patients have more or less hemorrhages before they get well, but in ordinary cases the attacks are not severe enough to send them to bed for any length of time and hence do not interfere seriously with the routine. All patients are required to come to the rooms twice each day, in the morning any time between 7 and 8.30 o'clock and in the even- ing between 7 and 8.30 o'clock. At such times they drink the emul- sion of mixed fats and vegetable juice and are given a supply of ca- thartics and calcium chloride mixture; they are also questioned and advised. Sunday morning patients report at ten o'clock when all are stripped, weighed and examined. Women are weighed in their night dresses. They are taught to sleep in a sunny room if possible and always with windows wide open, in all weather. A constant supply of fresh, cold air is insisted upon. Five-hour intervals between meals are arranged. The value and importance of cathartics is impressed upon them. Excepting walking in moderation, no unavoidable exercises are allowed. Exercises which include movements of the arms and upper part of the body undertaken solely as exercise and all "breathing exercises" are strictly forbidden. The purpose of this rule is to prevent violent or forcible expansion of the thorax and pa- rietal pleurae, which must drag upon adhesions or cause additional friction of inflamed surfaces. This consideration is quite distinct from that which forbids exercise of any kind carried to the point of fatigue because fatigue induces fever. Violent arm movements frequently cause exacerbation of the disease and greatly increase ex- tent of inflammation. Because these patients are working people it occasionally happens that a patient's occupation is of such a char- acter that undesirable movements of the arms cannot be avoided during labor. The rule is not enforced under these circumstances. They are taught to avoid over-clothing, particularly of the chest, and "chest protectors/' plasters and wraps about the neck are for- bidden. Men are apt to wear too many undershirts, turn up their coat collars or wear special neck wraps. Women are forbidden to wear corsets, fur tippets and coats with high collars. The feet are to be kept dry and warm. Overshoes are recommended in wet weather. Places of amusement are to be avoided and if possible nine hours sleep obtained at night. Alcohol in any and all forms, tea, coffee, chocolate, cocoa, beef-tea, broths, beef-juice, meat extracts, vinegar, are forbidden. Tobacco, if not wholly prohibited, is allowed in mod- eration. Soups made of peas, beans and vegetables are allowed. The rules are strictly enforced and patients are made to under- stand that they must obey. The foregoing is but a very brief review of the treatment and must necessarily be so in such a report. The subject is covered more fully in my published papers and I shall be happy to send these to any physician who wishes further information, upon his request. I desire to state most emphatically that these papers are not designed for, and should not be placed in the hands of, laymen. Physicians are also invited to study the method of treatment at my rooms. The fats of the emulsion of Mixed Fats are made up of equal parts of beef fat, cocoanut, peanut and olive oils and compose about 42 per cent, of the whole. In addition there are about three drops of clove oil to each ounce of emulsion. The manufacturers of the emulsion have experienced the greatest difficulty in securing unadulterated oils of good quality. This does not apply to beef suet and cocoanut oil, but is true of peanut and olive oils. It is always difficult to detect adulteration, particularly in the case of olive oil when mixed with high-grade cottonseed oil, and in many instances practically impossible. Excellent peanut oil is now obtained from abroad, but after years of experience it is found almost impossible to secure sweet unadul- terated olive oil. These uncertainties and difficulties which arise with each importation of olive oil, have led me to urge the manufac- turers to employ cottonseed oil of high finality instead of olive oil, because this oil can be obtained perfectly pure without rancidity, and because I have determined from experiments that its nutritional value is in no way inferior (<> olive oil. The beginning dose of emulsion is one-half ounce increased every 3 three days by one-half ounce until two ounces are taken night and morning. The emulsion is always diluted with hot water and drunk as hot as possible. The dose of vegetable juice is two ounces night and morning. IN arranging diets for dispensary patients very explicit directions are given concerning the kind and quantity of a few articles of food, and only the most general regarding others. There are many reasons for this, but chiefly because it is all-important that the patient receive sufficient quantities of proteid and fat and the necessary amounts of these are commonly in excess of appetite and therefore, not eaten. Foods containing these constituents in quantity, particularly if combined, are also expensive and not numer- ous. Vegetables on the other hand are to be had in large number, are comparatively inexpensive and, with the exception of wheat and the pulses, usually thought of as sources of carbohydrates and salts alone. The main sources of proteid are raw eggs, milk, bread and meat; of fat; raw eggs, milk, butter and emulsion. Excepting corn meal and wheat (as bread), no directions are given for eating cereals. The pulses, peas and beans, are recommended in the form of soups, but are practically ignored in estimating the amount of proteid con- sumed, though very rich in this constituent. Ordinarily no special instructions are given with regard to the quantity of meat except to limit its use to one or two meals a day or prohibit its use altogether. Practically then specific directions for the consumption of a daily amount are confined to the following foods, viz. : raw eggs, milk, bread, butter, emulsion, vegetable juice and occasionally meat. With the exception of emulsion and vegetable juice, the amounts of which remain fixed, the daily quantities of these foods are determined by the gain or loss of weight of the patient. It will, therefore, be under- stood how necessary it is that patients should be weighed regularly. THE best results do not follow when all the above-mentioned articles rich in proteid and fat are employed in the same diet. Certain combinations appear to act better than others. For example, meat and raw eggs are well borne and so likewise are milk and bread and butter. Meat, raw eggs and milk are not well borne. Milk and raw eggs, if both articles are given in quantity, do not act well. A large number of eggs and a small quantity of milk may be taken com- fortably for a long time, but in such case the milk is insignificant in amount. Bread and butter may be eaten in all combinations, but are of the greatest value when taken in quantity with milk in quantity. These are most general considerations. No rule of feeding will apply to all patients or to the same patient, under all circumstances. Patients who are fond of milk, bread and butter invariably gain rapidly. NO change is made in diet the first week of treatment except that all receive emulsion and vegetable juice and abstain from forbidden articles of food. Cathartics are freely administered and an effort made to thoroughly clean the intestinal tract. If the patient has been taking medicines, these are, of course, discontinued. Patients are not expected to gain and frequently lose weight the first week. Beginning with the second week the particu- lar form of proteid decided upon is begun. If eggs, the patient is directed to take one raw egg after each meal and increase this number by one egg after each meal every three days. The total number of eggs prescribed for each day is estimated by the progress of the patient in weight gaining. The number is rarely as great as, never more than, eighteen, rarely fewer than nine. If the patient fails to gain when the daily number of eggs is nine great care should be taken to see that a sufficient quan- tity of bread, butter and vegetables, particularly the former, are consumed before increasing the number of eggs. This is a matter of importance. Many patients early in the treatment concentrate their attention upon the egg portion of their diet and are apt to get the impression that if they swallow eggs enough very little if any other food is necessary Lack of vigilance in this regard was one of my early mistakes. Very few of my patients now take eight- een eggs a day. The lessened number required in order to gain is due to more careful teaching in the matter of greater quantities and variety of the foods just mentioned and the addition of vegetable juice. Patients are instructed to take their eggs immediately after the meal. They are allowed to swallow them without milk (yolk unbroken), or first l>eat them with milk, whichever way is preferred. If milk is used, the daily amount advised is one or two pints. 5 If milk, bread and butter are to be used in quantity, meat and eggs are gradually stopped and milk substituted. One pint of milk and a stated quantity of bread and butter are directed to be taken at each meal. Vegetables are also prescribed, but the quantity not specified. One pint of milk (without other food) midway between breakfast and dinner and again between dinner and supper, if there is failure to gain - without it. It is not always necessary to give a full pint of milk between meals. The amount of bread and butter will, of course, vary with the individual. It would greatly simplify treatment if accurate rules, prescribing the daily amounts of various foods necessary in order to gain weight, could be formulated from the body weight of the patient. For many reasons this is obviously impossible in the case of invalids. The requirements of a healthy individual are discussed in all physiologies. The requirements of a diseased individual are unknown and must be determined by experiment in each case. I shall venture, however, to give the average daily amount of bread and butter, for each pound of body weight, consumed by ten patients, while undergoing the rest treatment, in order that some idea may be formed of the amounts necessary to gain weight under these circum- stances. It should be remembered that the patients were at rest and that the diet during the rest treatment is restricted to milk, bread, butter, emulsion and vegetable juice. This differs from the diet of those who labor and who are not allowed eggs and animal flesh only in that less milk is administered and no vegetables. The lung lesions in these ten patients were various and in several in- stances far advanced. They all had fever. The smallest weight was 83 pounds (woman), the greatest 135£ pounds (man); the average 115.8 pounds. Treatment lasted eight weeks. The smallest gain was 10 pounds; the largest, 31 pounds; the average 19.3 pounds. The smallest average daily amount of bread eaten by any one patient was 33 grains, and of butter, 6 grains, for each pound of body weight; the largest, 64 grains of bread and 12.5 grains of butter. The daily average of the ten patients was 45 grains of bread and 8.7 grains of butter for each pound of body weight. THERE may be no physical signs of disease of the chest othei than a few localized rales which are persistent. No appre- ciable abnormal change in percussion, breath sounds, voice and fremitus. In addition, tubercle bacilli may not be found in the 6 sputum. In a given case where this state of things exists it should be remembered that the probabilities of the case being one of tuber- culosis are so overwhelming that the burden rests in proving the negative. Treatment should be begun at once and continued until all doubt is removed. PATIENTS should be told at the first interview that treatment lasts a long time and is tedious and that the result largely depends upon their own efforts; upon an intelligent and persevering practice of the rules. They should, therefore, be told with entire candor that they have consumption, otherwise they cannot be made to appreciate the im- portance of making as great an effort as is required in most cases. It is impossible to treat patients successfully without their hearty co-operation. Pulmonary tuberculosis is curable in the great majority of cases by systematic treatment, and to withhold knowledge of their condition from these sufferers is to rob them of the spur to effort which such knowledge inspires. Patients who are not told the truth early in the disease usually discover it themselves before the end, often too late for treatment; commonly with bitter denun- ciation of those who deceived them. APPETITE is not indispensable for successful treatment. It is certainly very desirable, but not necessary. UNLESS patients gain weight the treatment is wrong in some particular. There are instances when it is only necessary to gain a few pounds, but increase in weight, even if slight, is important as an indication of improved nutrition. The fact that a patient and various members of his or her family have always been under weight is not a good reason for failure to gain. All patients should gain weight. Continued loss of weight is a certain indication of failure. Regular weighing (once a week at least) is absolutely necessary if the treatment is to be carried out intelligently. The patient should always weigh at the same hour, dressed in the same clothes and use the same scale. FRUIT is a negligible article of food. There is no obj< to a small quantity if the patient desires. Except in vegetable juice it is never prescribed. 7 THE following patients came under my care before I stopped work at the Post-Graduate Hospital Dispensary, December 31, 1905, and were, therefore, examined by the committee of inspection. This is the explanation, also, of the first examination of their sputum by Prof. H. T. Brooks, the bacteriologist of that institution : Case LVI. — Harry B e, age 25 years; single; native of United States; clerk in newspaper office; wages, eighteen dollars a week. Began treatment September 14, 1905. Patient lives alone but supports an invalid mother in another city. Total income, eighteen dollars a week. Works at night, eight hours. Family History. — Father, aged 52 years, mother aged 40 years, two brothers, aged 23 and 21 years respectively, and one sister aged 26, all living and, with the exception of the mother, in good health. Personal History. — Pneumonia ten years ago. Cough began three years ago. Expectoration scanty. No hemoptysis or loss of flesh. Appetite and digestion good. Weight, 119£ pounds'. Examination of sputum by Professor H. T. Brooks, who reports "occasional tubercle bacilli, also streptococci and staphylococci." October 17, 1905. Examined by the committee. "Right supra and infra-spinous scapular region, broncho-vesicular breathing, fine and coarse moist rales." November 16, 1905. Sputum examined by Professor H. T. Brooks who reports "sputum of Harry B e shows no tubercle bacilli." November 20, 1905 (by the committee). "Chest free of all signs of disease." Time under treatment, about two months. Weight on admission, 119^ pounds. Weight November 26, 1905, 126J pounds. Total gain, 7 pounds. Has lost no time from work during treatment because of illness. Diet included eggs and animal flesh. 8 CASE No. LVI. The following cuts show location and superficial extent of lesion: Case LVII. — Hattie G. F r, age 35 years; married; native of United States; housewife. Began treatment September 14, 1905. Family consists of patient, father, mother, husband and two chil- dren. Husband's wages, thirty-five dollars a week. Family History. — Father, aged 72 years, mother aged 65 years, two sisters, ages 38 and 33 respectively, living and in good health. Personal History. — No previous serious illnesses. Cough began about fifteen months ago, growing worse last June. Expectoration slight. Hemoptysis to-day first time, pure blood. No pain or night sweats. Small loss of flesh, four or five pounds. Appetite good. Sleeps well. Constipation. Marked loss of strength. Weight, 109 pounds. Examination of sputum by Professor H. T. Brooks, who reports "rarely tubercle bacilli." October 16, 1905. Examined by the committee. "Right lung anteriorly, from clavicle to third rib; left lung anteriorly to second rib; right lung posteriorly, supra and infra spinous region; broncho- vesicular breathing, fine and coarse moist rales." February 20, 1906. Sputum examined and reported free from tubercle bacilli. April 4, 1906. Sputum again examined and reported free of tu- bercle bacilli. May 3, 1906. Sputum again examined and reported free of tu- bercle bacilli. This patient's lungs no longer show signs of disease. Time under treatment, to date of disappearance of tubercle bacilli from sputum, a little more than five months. Weight on admission. 109 pounds. Weight, May 13, 1906, 137£ pounds. Total gain 28£ pounds. Diet included eggs and animal flesh. Lost no time from work because of illness while under treatment. This patient applied for treatment because of pulmonary hemor- rhage. 10 CASE No. LVII. The following cuts show location and superficial extent of lesion: 11 Case LVIII. — Ida Z r, age 35 years; married; native of United States; ribbon clipper; wages, five dollars a week. Began treatment June 6, 1905. Family consists of patient and three children. Total income, five dollars a week. This patient's income was increased by charity. Work is done at home. Family History. — Father died of consumption at the age of 45, mother died of consumption at the age of 40. One brother aged 32 and one sister aged 38, living and in good health. Personal History. — Several attacks of lumbago in the past three years. Cough began May, 1904, growing worse the following Decem- ber. Expectoration moderate. Hemoptysis five times since April. No night sweats. Some pain in left mammary region. Loss of flesh, seven or eight pounds. Appetite good. Sleeps fairly well. Not constipated. Weight, 111 pounds. Examination of sputum by Professor H. T. Brooks, who reports "numerous tubercle bacilli and innumerable streptococci and staphy- lococci." June 29, 1905. Examined by the committee. "Left lung an- teriorly from clavicle to fourth rib; left lung posteriorly, whole scapular region, broncho-vesicular breathing, fine and coarse rales. Right lung posteriorly, supra-spinous scapular region, broncho-vesicular breathing, fine and coarse rales." February 22, 1906. Sputum examined and reported free of tu- bercle bacilli. April 6, 1906. Sputum again examined and reported free of tu- bercle bacilli. May 3, 1906. Sputum again examined and reported free of tu- bercle bacilli. This patient's lungs no longer show signs of disease. Time under treatment, to date of disappearance of tubercle bacilli from sputum, about eight and a-half months. Weight on admission, 111 pounds. Weight May 20, 1906, 132£ pounds. Total gain, 2\\ pounds. Lost no time from work while under treatment because of illness. Diet included eggs and animal flesh. This patient applied for treatment because of pulmonary hemor- rhage. 12 CASE No. LVIII. The following cuts show location and superficial extent of lesion: 13 Case LIX. — Delia K n, age 37 years; married; native of Ireland; housewife. Began treatment June 5, 1905. Family consists of patient, husband and one child. Husband's wages, eighteen dollars a week. Family History. — Father died at the age of 85 years. Mother, aged 75, three brothers, ages ranging from 50 to 33 years, three sisters, ages ranging from 42 to 28 years, all living and in good health. Personal History. — Cough began last January with an attack of pneumonia. Expectoration slight. Hemoptysis once in January and again yesterday. No night sweats. Pain in left axillary region. Loss of flesh, 22 pounds. Appetite poor. Sleep not disturbed by cough. Not constipated. Marked loss of strength. Weight, 117 pounds. Examination of sputum by Professor H. T. Brooks, who reports "numerous tubercle bacilli and streptococci and staphylococci." June 29, 1905. Examined by the committee. "Left lung ante- riorly from clavicle to fourth rib, left lung posteriorly supra and infra spinous regions, broncho-vesicular breathing, fine and coarse moist rales." February 27, 1906. Sputum examined and reported free of tu- bercle bacilli. April 4, 1906. Sputum again examined and reported free of tu- bercle bacilli. May 3, 1906. Sputum again examined and reported free of tu- bercle bacilli. This patient's lungs no longer show signs of disease. Time under treatment, to date of disappearance of tubercle bacilli from sputum, nearly nine months. Weight on admission, 117 pounds. Weight May 20, 1906, 164 pounds. Total gain, 47 pounds. Lost no time from work because of illness while under treatment. Diet included eggs and animal flesh. This patient applied for treatment because of pulmonary hemor- rhage. 14 CASE No. LIX. The following cuts show location and superficial extent of lesioa: 15 Case LX. — Elizabeth E n, age 19 years; single; native of United States; dressmaker; wages, twelve dollars a week. Began treatment April 13, 1904. Family consists of patient, mother, sister and nephew. Sister is a wage earner. Total income of family, twenty dollars a week. Work hours, 9 a.m. to 6 p.m. Family History. — Father died by accident at the age of 36. Mother, aged 46, living and in good health. One brother, aged 30, suffers with pulmonary tuberculosis. Two brothers died in infancy. Two sisters, aged 25 and 17 respectively, living and in good health. One sister died of pulmonary tuberculosis, aged 22 years. Personal History. — No previous serious illnesses. Cough began six months ago, growing worse three weeks ago, when there was an hemoptysis. Blood-stained sputum for one week succeeding this attack. Expectoration slight. No pain or night sweats. Loss of flesh, about four pounds. Appetite poor. Not constipated. Marked loss of strength^. Weight, 123£ pounds. Examination of sputum by Professor H. T. Brooks, who reports "small number of tubercle bacilli and numerous streptococci and staphylococci." April 28, 1904. Examined by the committee. "Right lung anteriorly from clavicle to third rib; right lung posteriorly, supra and infra spinous scapular region, bronchial breathing fine, and coarse moist rales.. Left lung anteriorly between first and second ribs, bronchial breathing, fine and coarse moist rales." Signs of disease having disappeared, specimens of sputa were examined as follows: February 28, 1906. Specimen reported free of tubercle bacilli. April 5, 1906. Specimen reported free of tubercle bacilli. May 4, 1906. Specimen reported free of tubercle bacilli. This patient's lungs no longer show signs of disease. Time under treatment, to date of disappearance of tubercle bacilli from sputum, one year and eleven months. Weight on admission, 123J pounds. Weight May 20, 1906, 140 pounds. Total gain, 16| pounds. With the exception of first eight weeks, has lost no time from work because of illness. Diet for one year included eggs and animal flesh. Diet for four months was free of eggs and animal flesh. This patient sought treatment because of pulmonary hemorrhage. 21 West Eleventh Street. 16 CASE No. LX. The following cuts show location and superficial extent of lesion : 17 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special arrange- ment with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C2S(l14l)M100 R91 Russell ; v-t c 5 - 'ive 1?C3//I "RSI