The most important element in any treatment of tuberculosis must be the neutralization of unfavorable suggestions which are weighing upon the patient and preventing him from using even the vital forces that he has for resistance against the disease. The popular impression of tuberculosis, happily waning, is that it is an intensely fatal disease.

Though this is true in general, tuberculosis is by no means a necessarily mortal disease in individual cases, and, indeed, a great many more patients recover from tuberculosis than die from it. Papers read at the International Congress on Tuberculosis, in Washington, in 1908, showed from careful autopsy records that practically all adults either actually had had at the moment of death, or had suffered previously from tuberculosis. If there are not active lesions then there are always healed lesions of tuberculosis in the body of almost every human being who has passed the age of thirty. Most people have quite enough resistive vitality to enable them to recover from the disease. It is only those who are placed in very unfavorable circumstances during the initial stage of the disease, or who have some serious drawback against them, who succumb to it. The fact that the bacillus finds a lodgment in so many individual tissues shows that it is not insusceptibility that makes the difference {352} between people, since we are all susceptible, but it is the lack of resistive vitality, and that most of us have, under ordinary circumstances, and all of us can have under favorable conditions, quite sufficient immunizing power to prevent serious developments.

Even in advanced cases it is perfectly possible for the progress of the disease to be stopped and for many years of useful life to be gained. Probably patients who have gone beyond the incipient stage, in whom there has once been a breaking down of pulmonary tissue never are entirely cured, but they may be so much improved that all their symptoms disappear and they are able to follow an ordinary occupation for many years. There is no disease in which the unfavorable prognoses of physicians have been more frequently disappointed than in tuberculosis. In any city hospital dispensary one finds many cases of tuberculosis turning up as relapses of previous conditions, with the story that when they were seriously ill before, some prominent physician, since dead, said they had only a few months to live. The fact that the physician who made the unfavorable prognosis has since died himself adds greatly to the zest with which patients tell their story. Neither the severity of the symptoms nor the amount of lung tissue attacked is quite sufficient to justify an absolutely unfavorable prognosis in the majority of cases of pulmonary tuberculosis.

No Incurable Cases.—Above all, it cannot be insisted on too emphatically that there is never a time in the course of the tuberculosis when a physician is justified in saying to a patient suffering from any form of tuberculosis that his case is hopeless. One is never justified in saying "You are incurable." Practically every town of any size in this country has a number of cases in which patients were told by physicians that there was no hope, and yet they have recovered to chronicle as often as they get the chance the fact that they have outlived their physician. To say that no case of tuberculosis can be confidently declared incurable will seem to many an exaggeration. There are patients in whom the prognosis is so unfavorable as to be almost hopeless. There are never cases of which it should be said there is no hope. When patients are told, as they so often are, that they are incurable, absolutely no good is done and harm is inevitable.

Heredity of Resistance.—When the disease has developed very rapidly in patients in whom there is no previous history of tuberculosis, and in whom there is no history of previous cases in the family, the outlook is always serious. These cases come as near being incurable as any the physician sees. But the most apparently hopeless of these will sometimes recover, contrary to all anticipation. In spite of the opposite impression so commonly accepted, the most helpful element in these cases is the presence of a trace of tuberculosis in the family history. This always means the existence of some immunity against the disease and there may be a turn for the better even when the case looks absolutely hopeless and when it seems to just be verging on its fatal termination. Probably the most discouraging are the cases in which miliary tuberculosis is at work and conditions are about as unfavorable as possible. There are cases of this kind on record, however, with the most startling contradiction of anticipation, in which undoubted miliary tuberculosis produced high fever for weeks and even months, then gave rise to pleurisy, to peritonitis, to various cutaneous abscesses and to abscesses of bone, in which patients lost one-third of {353} their weight or even more, and yet after the external lesions began to discharge freely, recovery occurred.

Slow Cases.—As for slow-running cases in which there is a distinct history of tuberculosis in the family, not even the most experienced physician can state with any certainty that a fatal termination is inevitable and that recovery cannot occur. Some of the most expert diagnosticians have been deceived in these cases. After half a dozen physicians have given a man up, some gleam of hope has buoyed his feelings and a turn for the better has come. Men with cavities in three lobes, even in four lobes and occasionally it is said in all five lobes, have survived acute stages, have recuperated to a considerable degree and have been able to return to work or at least to take up some useful occupation for a time. Where the lung lesion progresses slowly it is surprising how small an amount of healthy lung tissue is needed to support life. Only those familiar with many autopsies on the tuberculous can appreciate this. Ordinarily we are apt to think that when more than half the pulmonary tissue is involved so as to be of little or no use for respiratory purposes, death must be inevitable. On the contrary, one-fourth the ordinary lung capacity will serve and all of one lung may be quite out of commission and only a portion of a single lower lobe be available, yet the patient may survive for a prolonged period.

The Specter of Heredity.—The most serious contrary suggestion that patients suffering from tuberculosis are likely to have is that their affection is hereditary and that, therefore, there is little hope of its cure. It is in the family strain and cannot be obliterated. This idea, fortunately, does not carry the weight it used to. It should, however, have no unfavorable influence at all and this needs to be emphasized. We discuss the subject more fully in the chapter on Heredity. We know very definitely now that the hereditary element in tuberculosis is so small that it is quite negligible. There are good authorities who do not hesitate to say that heredity plays no role in the causation of tuberculosis and does not even produce a predisposition. Some remnant of the old superstition (for superstition, from the Latin, superstare, means a survival from a previous state of thinking, the reasons for which have disappeared) always remains, and predisposition is the last rule of outworn opinion.

We know now that contagion is the important element. The possibilities for contagion vitiate all proofs of the predisposition idea. Especially is this true when we recall that thirty years ago practically no one took proper precautions to prevent the dissemination of tuberculosis, and very few took them even fifteen years ago. Even at the present time many tuberculosis patients cough around the house with open mouth, spreading tubercle bacilli all around them. We are caring for the sputum, but many other avenues for the diffusion of the disease are open. Children acquire the infection, overcome it, but retain the seeds of it in them and then in some crisis in life, as after puberty, or when they are over-working and over-worrying, or during the first pregnancy, an opportunity is given to still living tubercle bacilli to find their way out of sclerotic confinement. Other forms of contagion count in the absence of a case in the immediate family. We can trace the contagion only too easily, even if there is no consumptive member of the home circle. Scrub-women, laundresses, those who are careless in their attendance upon the tuberculous, workers in dusty places or in factories, where there are others who cough, all {354} these get the disease. Predisposition counts for so little that it is a vanishing factor.

Patients can be assured at once then that they need not worry that the hereditary factor will make their affection less curable. On the contrary, our recent careful studies in tuberculosis show just the opposite of the old false impressions. The children of parents who had tuberculosis are much more likely to possess resistive vitality to the disease than those whose parents never had it. As we emphasize in the chapter on Heredity, the nations that have had the disease the longest among them are the most resistant to it. When the affection is newly introduced into a tribe or race it carries off a great many victims. This immunity, however, is not a function of heredity or of the increase of resistive vitality by the inheritance of an acquired character from the preceding generation, but tuberculosis takes the non-resistant, weeds out all those who have not some immunity against it, and consequently those that are left possess some immunizing power. Tubercular heredity, then, instead of being a source of discouragement should rather be a source of hope. It is surprising to note what a relief to many patients' minds is the explanation of this newer view of heredity in tuberculosis; it lifts a burden from many and makes them eat and sleep better for days.