View from the past

Physicians beginning their clinical practice today do not worry about an occupational hazard in the form of a devastating infectious disease. Human immunodeficiency virus, although devastating, is very rarely acquired through medical practice, and hepatitis is avoidable through immunization and prevention measures. Neither appears threatening to the medical staff. It was not always this way, for at mid century it was estimated that 2% to as much as 4% of medical school classes developed clinical tuberculosis. The remarkable extensions of biologic understanding, on which effective and reliable treatment is now based, have changed this outlook and almost completely erased the memory of when it was not uncommon for a clinical career to be interrupted or a life to be lost because of tuberculosis. Back then, everyone understood that there was no effective or reliable treatment. Today, in contrast, tuberculosis is a disease treated effectively with antibacterial agents in the workplace or at home, or with the occasional operation. It is very likely that patients can continue a normal life while being treated. It is no longer a disease treated in isolation over long periods, during which career development is put on hold and opportunities are lost, perhaps permanently. It is clear that tuberculosis weighed particularly heavy in the thoughts of those entering their medical careers in the middle of the past century. At that time, not only was tuberculosis without an effective treatment, destroying careers and causing death, but it also carried with it the specter of lonely isolation, which was inherent in the accepted treatment of the day. “Taking the cure” in those days meant treatment with rest, fresh air, and food, with those exposed being isolated in a sanatorium, such as the now historic Trudeau Sanatorium in Saranac Lake, New York. During their stay, they were separated from friends, family, and work for extended periods, usually lasting more than a year. The disease itself, the enforced isolation, the uncertainty of outcome, and the inevitable changes brought about in one's career produced profound effects on those who had tuberculosis. Sanatorium treatment, largely consisting of bed rest in confined but open-air quarters morning, noon, and night, prevented activity but provided extensive time to read, think, and work through the anxieties generated. Events such as the upcoming reading of the next monthly follow-up x-ray film, which could signal relapse, resolution, or arrest that determined the course of treatment for the next period, as well as long-term prognosis, are examples of stresses generated. These extensive contemplative periods of time were often productively used by the patients to constructively consider the state of their world and to think about and plan for the future. As a result, it was unusual for a person not to be intellectually enriched by the sanatorium experience. Most rose to become more tolerant, wiser, broader in views, more constructive, and more productive. Today, the specter of tuberculosis, as an occupational disease in clinical medicine with its treatment regimen of bed rest, fresh air, and isolation in a sanatorium, has disappeared. However, it is worth examining the effects on the men and women involved. Further, it is important to recognize that the reactions of patients were brought on by the methods of treatment, as well as by the disease itself, in order to avoid similar errors. In this regard, the article by Zuidema and Sloan in this issue of the journal (2001;130:866-81), which describes Alfred Blalock's and Norman Bethune's anxieties, reactions, and altered approaches to their lives, provides a clear and accurate description of the effects that tuberculosis, together with the methods of sanatorium treatment used in the past, had on physicians in the early phases of their medical career. The drawings, poems, and captions from Norman Bethune are particularly illustrative of a patient's anxieties, frustrations, fears, and responses used to achieve equilibrium. These experiences are useful lessons in every journey through life.