50 February 1955

Sanatorium Treatment By GEORGE DAY

Mundesley Sanatorium

Today

Before discussing the Place of the Sanatorium in the Treatment of Tuberculosis it would be well to examine the nature of the illness we are endeavouring to treat.

I am afraid that some of you are going to find my concept of tuberculosis absolutely infuriating. You are almost bound to. Basically we all would agree upon certain inescapable facts such as appear in all the textbooks; but our own individual, special- ized, fields of observation, although over- lapping to a large extent, must differ in their centring, in their focal points; and so must the interpretation we put upon our observed data and the pattern in which we arrange it in order to give it coherence and direction. My concept, my pattern, is bound to be different from that of the general prac- titioner, the Medical Officer of Health, the Chest Radiologist, the Chest Specialist at the clinic. The concept of a bull elephant arrived at by a narrow-sighted gentleman concentrating on its trunk must be very different from that of the no less short sighted (such as myself) who may have grasped it by the udder.

In this way one man's axioms are another man's antigens, to be rejected with an angry violence proportional to his allergy towards them. I can only hope your re- actions won't be too blistering.

Axiom number one: Our aim and object in the treatment of

tuberculosis is the utmost stabilization of tuberculous lesions. I do not use the word 'cure' or 'complete healing', because under civilian wartime conditions we have all seen lesions reactivated after ten, twelve or even fifteen years' quiescence: lesions which we might reasonably have considered as completely healed. These cases were rare in this country but quite common in the lands of concentration and labour camps.

So we must make a qualification and define a lesion as stable if it does not break down or cause disease while the patient leads a reasonable average normal sort of life (which I won' t attempt to define).

This is not merely a clinical observation. As far back as 1936 a high official of a large assurance company discovered that ex- patients who had maintained a stabilized lesion for seven years were actually less likely to develop active disease than were members of the general populace of similar age groups. This may be read in several ways. It may mean merely that ex-patients who had survived seven years had been leading such exemplary post-graduate lives and had held fast to such hygienic habits that they were healthier and perhaps wiser than the unintiated. Or it may mean that the possession of a bit o f - n o t 'healed' but safely congealed tuberculosis, with a few tubercle bacilli locked up in s ide - r a the r like a lavender s ache t - i s the best protec- tion against infection, reinfection, super- infection, call it what you will. There is just enough slumbering disease to keep the organism on the qui vive, to maintain a high degree of resistance.

I favour the latter explanation. To me it has become axiom number two. After all, why else do we vaccinate and re-vaccinate with BCG? How else can one account for the survival rate of post-thoracoplasty cases being so outstandingly high? Surely it must be due to their retention of a messy sort of lesion, shut off, squashed down, immobi- lized, rendered n e a r - i n e r t - b u t retained.

Don' t think that I am necessarily de- crying resection. Resection may be a very good thing indeed. I just don't know. I believe it is de rigueur for members of the teaching profession and would-be emi- grants: almost a sine qua non, you might say,

*A paper read to the B.T.A. on September ~4, I954-

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like circumcision among the Jews. But I must admit that I am scared when a resec- tion successfully removes all the disease, and the patient's Mantoux becomes negative. I see no reason why such a patient should not be pretty vulnerable thereafter, unless plied with BCG from time to t i m e - until he develops sarcoidosis. Usually, however, it is only the parent, main, or open lesion which is resected and thcre are small daughter lesions left behind to carry on the good work. But these daughter lesions have to achieve stability, don't forget.

Very well then, either you accept my axiom that the arrest of tuberculosis depends upon the arrest of tuberculosis; or else you don't. In the latter case you presumably mutter to your surgical colleague 'Chop it out, Ko-Ko. Chop it out.'

But I warn you, you'll find your surgical colleagues getting restive after a bit: two or three pulmonary emboli occurring in hale and hearty patients who practically vaulted on to the table, put them off amazingly. And moreover once a thoracic surgeon gets his finger into a mitral valve, you won't see him a g a i n - ( h e ' s gone off like a rocket before you can say 'Brock's Benef i t ' ) - and your surgical waiting list will return to its normal unwieldly length. There's a saying in Neo-Slavonia, 'The operation of mitral valvotomy has preserved the symmetry of countless tuberculous patients'.

It's time for another axiom. Axiom number three (or is it four?): The stabiliza- tion of a tuberculous lesion is a function of time. We know of no sure way of expediting it, although there are many well-tried ways of delaying it.

When I was a house-surgeon a fractured femur took one hundred days to heal, and the patient spent those hundred days on his back with his Ieg in a Thomas ' splint sus- pended from a Balkan beam. Nowadays what with pins and plates and grafts the patient is walking about practically as soon as the anaesthetic wears off. But the bone still takes one hundred days to heal securely, does it not? In the same way any surgical

measure which brings about a high degree of rest and relaxation to the focus of disease will enable the patient to become ambulant - e v e n to earn a living w a g e - within a few months; but don' t let us kid ourselves that his lesion is utterly and reliable stabilized until some years have passed.

Why does it take so long? Really I am quite embarrassed at having to relate such elementary home-truths to such an august body. To answer this question we must study the post-diagnostic history of an ordinal T case with fairly advanced active disease. His x-ray, let us say, shows so much excavation and fluffy infiltrative disease on both sides that it's quite useless showing it to a surgeon. The patient is clapped firmly into b e d - and nowadays he would be given antibiotics and perhaps a pneumoperitoneum, to cool things down. Nevertheless it is a safe bet that in a month's time the condition of his lungs will be worse. His E.S.R. will have increased further and his x-ray will show further deterioration. In two months his condition may be worse still . . . . But some time (let us hopc) a turning point is reached, after which all the omens start to improve.

From this can we not safely postulate that so.mething has slowed down his pro- gressive disease process, and that this something, hitherto lacking, has been develop- ing until it caught up with and overtook tile disease? As the months go by, so the omens go on improving. His temperature lyses, his E.S.R. diminishes, he puts on weight, the soft fluffy shadows disappear from tile x-ray picture or harden and contract, but the cavities are still there and his sputum is still positive. Then comes a time when he can get out of bed and venture abroad a little way. (He might even be glanced at by the surgeons, but even now they won' t start spitting on their hands.)

What has happened? One can only say that during all these months his resistance to the disease has been increasing. I f you will forgive me for being so old fashioned, I 'd like to speculate about resistance for a few minutes. I think it is a great pity that

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nowadays it is so apt to be ignored. People don't like talking about it, because in these scientific days it lets the party down: it cannot be measured. And we do like to talk about things which are measurable in milli- amps, degrees, percentages and so forth. The E.S.R. is not a measure of resistance but rather, if anything, of its l a c k - o r the consequences of its lack when disease is present. The E.S.R. is, so to speak, a measure of the patient's overdraft, what- ever may be the cause. The Mantoux test measures sensitivity with considerable a c c u r a c y - b u t not resistance. It indicates how angry a patient's body tissues become when encountering the tubercle bacillus or its products. Unfortunately the higher his degree of allergy the angrier are his tissue reactions, and here as elsewhere angry reactions are violent, reckless, and apt to do more harm than good . . . . By way of comparison I picture 'resistance' as a force, wise, gentle, alert, and ubiqui tous- like our Metropolitan Police.

And the only evaluation of resistance I can offer is to say that when a patient can do things with impunity which previously would have brought about exacerbation of his disease, his resistance has increased; and during these very months (as my colleague, Dr Ellis, has shown) his quantitative Mantoux reaction is diminishing.

I repeat, it is really most remarkable how chary people are of talking about resistance.

They may occasionally say, 'This patient obviously has a high resistance', or 'Being a diabetic his resistance is not all it might be' - as if it were a static condition like red hair or Irish blood; but rarely (except among sanatorium physicians) as if it were a

fluctuant in the individual patient, the failure of which initiated his disease process, upon the revival of which depends his recgvery, and upon the maintenance of which depends his future stability and freedom from recrudescence.

Basically, I submit, the problem of tuberculosis has always been the problem

of resistance; and still i s - o r have things changed While I wasn't looking?

Every three months the Tuberculosis Index records, in its Immunity Section, dozens of papers about Resistance acquired by BCG injections, but never a hint that it can be self-engendered by a chap's own private collection of bacilli.

What has all this got to do with sana- torium treatment? And sanatorium treat- ment in particular as opposed to the domiciliary or short-term hospital treat- ment? It is really quite obvious; but I'll tell you all the same.

Granted that the foregoing picture of tuberculosis is true, it is obvious that Time for developing resistance is the most im- portant factor in its treatment. In different cases the length of time varies, but it's always longer than you think, and much longer than the patient e x p e c t s - i f he's a first offender.

Antibiotics have really done very little to shorten the time schedule. Mind you, they stop a lot of people going downhill and d y i n g - o r perhaps, to be thoroughly pessi- mistic, they postpone deaths. But this they do, not by strengthening the patient's resistance, but by temporarily weakening the power of the invader. They change a feverish fight into phoney war. During the respite given by the antibiotic barrage it is assumed that the patient will go ahead and increase his resistance so that when this help ceases he may be able to hold his own; and indeed many seem to do so; but we all know of cases which, within a week or two of completing long courses of anti- biotics, start deteriorating. They have not utilized the phoney war period for re- armament. Some of us have had to send such patients home on what threatens to be a life-sentence of PAS and I N A H - a s with the pre-I9I 4 A.P.s, simply because we are afraid to stop them.

In spite of every modern advance, there appears to be only one way in which to develop resistance: Prolongcd rest followed by slowly increasing and carefillly graduated

February 1955 T U B E R C L E 53

exertions. The prescription of Rest raises its own problems. Where can the patient rest best? The perfect philosopher, I suppose, could rest and r e l a x - e v e n s l e e p - a t a gathering such as this. But most of us have to be taught how to rest; - what real resting entails; and to cultivate patience. Theo- retically a patient can rest and be nursed at home. This is all right for short-term illnesses, but as a steady diet over six to nine months it is apt to be far too disruptive of domestic relationships. It is painfully hard for a patient to lie abed at home where everyone else in his immediate circle is w o r k i n g - a n d working extra hard to keep him comfortable. Sooner or later a time comes when he looks and feels much better than do those who are ministering to his wants, and sooner or later he realizes i t - or is made to realize it. Then, unless he has enormous resolution, he will weaken and start doing things for himself to case the tension.

By frequently repeated domestic visita- tion by doctors, nurses, social workers and whatnot it may be possible to kecp things going sweetly. Every home becomes a private sanatorium unit with its own kitchen, its own domestic and nursing staff, and its own rules and regulations, its own discipline - or interpretation thereof. A man- nificent c o n c e p t - a n d yet I feel somehow there's something to be said for combining all these units and getting them under the same roof. It would at least save petrol and shoe leather.

Moreover it is obviously very much easier to rest and relax in a sanatorium where all around are doing the same thing and where nursing and domestic attention can be demanded without arousing guilt feelings.

On the level of intelligence the sanatorium patient absorbs much more fundamental knowledge about the disease, its course and its management than hc could possibly pick up at home by reading pamphlets and remembering to ask questions at the doctor's next visit. His own case in particular he can

envisage much better if he has a background of other people's conditions and progress rates for reference. Education in a boarding school is very different from that derived from Home Correspondence Cour se s - even from itinerant ushers.

On an emotional level, moreover, the comradeship of others suffering from the same trouble brings courage, the spectacle of stabilized patients leaving for home raises hope and confidence, and the grape- vine news of other patients' setbacks creates a salutary respect for the disease and helps the patient to face his own setbacks, should they occur, with greater equanimity.

So much for the introductory or resting phase of treatment. It may be punctuated by A.P.s, P.P.s, streptomycin injections and similar capers. These measures at least give the patient the feeling that Something is Being Done for him and they relieve us doctors of those feelings of guilt and impot- ence we suffer if we do nothing. But do remembcr what Dr Morriston Davies, our pioneer chest surgeon, said in his swan- song. He said in effect, 'Those patients whom I can get to heal themselves without my having to do anything, I regard as my greatest triumphs'. And believe me, it is not only laziness which inspires those who agree with this sentiment.

The resting phase is followed after three, six or nine months by surgery or graduated exercise. For surgical operations patients have to be transferred on loan to a surgical block with its own special team of nurses, and its own somewhat different morale. Nevertheless there are argument as to why the patient should have his operation at his own sanatorium, rather than being pushed off to the vet's; but I haven't time to go into them now. Let us assume that he comes back from the operation. However long he is kept on post-operative bed rest, there comes a time when he must start doing more and more things for himself and embarking on graduated exercise.

What does graduated exercise do for a chap, you may ask? In passing let us glance

54 T U B E R C L E February 1955

at Marcus Paterson's theory of graduated exercise and auto-inoculation, although it has been discredited these many years. Marcus Paterson maintained that if one deliberately provoked a small flare-up of the disease in a patient's lungs the patient was the better for it.

In practice therefore the patient was set to work at digging a fish-pond; his tempera- ture would shoot up; he would take to his bed for a day or two; his temperatme would fall; and this auto-inoculation would be found to have increased his resistance so much that he could be got out of bed again and made to dig two fish-ponds. Paterson published a most convincing volume full of temperature charts with these characteristic spikes and photographs of the fish-ponds. Unfortunately nobody has been able to repeat his performances and get the same results. His successors and imitators found that bursts of energy made patients con- siderably worse for more than just a day or two: it took them months and months to get over it.

So his theories have been thrown over- board together with his practices.

Nevertheless I sometimes wonder whether there may not be something in his theories, and that although nowadays graduated exercise means increasing the patient's energy-expenditure as rapidly as we dare without provoking spikes of temperature or any similar bad omens, there may also be an element of auto-inoculation at work during the process.

There is one aspect of graduated exercise which is sadly overlooked. It trains the patient in the way he should go if he wants to keep well. I t teaches him to discover and accept his limitations and to live within them. It gets him into hab i t s - distressingly selfish habits judged by standards ofetiquette and social usage, but habits of both body and mind which will stand him in good stead when he gets back into the world of

bustle and competition: The habit of avoiding fatigue; of claiming a full night's sleep, of taking exercise in the fresh air; of eating leisurely meals; of conserving his energies and breaking the day up with short intervals of relaxation.

These habits cannot be developed quickly. They take time and they are developed more easily in a community where all are observing the same traditions.

At the same time (and you must forgive me again for being old fashioned), quite insensibly and usually quite unprompted, the patient almost invariably develops a new sense of values. He'd jolly well better.

It is highly desirable whenever possible to discover why the patient took ill, what circumstances in his life brought about a sufficiently lowered resistance to reactivate a primary infection or to make him sus- ceptible to a superinfection; for those circumstances, whatever they may be, should be avoided in the future. Who, having resuscitated a near-drowned child would push him back into the deep end without making sure he could swim? These circumstances may be external or internal. The fault may lie in How Life has Treated H i m - o r in How he has Treated Life. He may have to evolve a new sense of values, putting away ambition and contenting him- self with what lies within his reach. I f these spiritual changes are not wrought within him, if he does not leave the sanatorium a wiser man, then sanatorium treatment has failed to achieve complete victory; but it is not necessarily ahvays to blame for its failure to make the horse drink.

There is one argument in favour of sana- torium treatment which you will notice I have studiously avoided pressing: the argu- ment that open T.B.q- cases should be segregated. I would close this argument before it is opened by quoting another Nco- Slavonian saying - 'The adequately instruct- ed open case is not a menace to his fellows'.