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Home , Big Nose Kate, Doc Holliday, Mithridate, Stagecoach, The High Chaparral, Wyatt Earp

Volume 12, Issue 11 December 2012

PRACTICAL PAIN MANAGEMENT The journal with the practitioner in mind ’s Pain Story

A Case of TB In the Wild West

Also in This Issue • Overview of CRPS • Cervical Cord Compression • Shockwave Therapy

A Vertical Health, LLC publication | www.PracticalPainManagement.com FEATURE

“Doc” Holliday: A Story of Tuberculosis, Pain, and Self-medication In the Wild West

Forest Tennant MD, DrPH Intractable, Pain Management West Covina, Editor in Chief Practical Pain Management

s many of our readers know, “Doc” Just Who Was “Doc” Holliday? Holliday was a professional gambler Holliday was born August 14, 1851 into an who worked the saloon and gambling aristocratic southern family in the tiny town of Griffin halls of the cattle and mining towns (See Timeline, pages 40-41).2 Holliday had a clas- of the Frontier between sical upbringing and was educated at the Valdosta Institute, 1873 and 1887.1 What readers might a school for sons of southern gentlemen, in Valdosta, not know was that Holliday also suf- Georgia.2 Besides math and science, he was taught Greek, A fered from debilitating pain caused , and French. When Holliday was a boy, his uncle by chronic tuberculosis (TB) infection.1-8 Doc Holliday John Stiles Holliday, MD, who was a physician, gave him arguably was the most intriguing and colorful characters an 1851 Colt , which he learned to use expertly. of the “Wild West” era, and a review of his life, health, When he was a teenager, Holliday moved into his uncle’s and pain problems provides a unique educational opportu- house, where a young Mulatto servant named Sophie nity. It might surprise you, but this icon teaches us a great Walton taught him and his brother how to play cards. deal about pain. He could be the poster child of the proto- She taught them games called “Up and Down the River” type patient who has a chronic disease, eventually develops and “Put and Take,” which were similar to the card game intractable pain, and knows he has a short time to live. Faro. She taught them how to count the cards in the dead- It’s rare that we have the opportunity to dissect and study wood (discard) pile and to remember which cards were yet the history of a pain patient from birth to death—Doc unplayed. Holliday had an intensive competitive spirit, as Holliday left us this gift. well as a remarkable memory and mathematical ability. To be a better pain practitioner, read about the instruc- Holliday attended the Pennsylvania College of Dental tive case of Doc Holliday. After studying his case, you will Surgery in his late teens, earning his degree on March 1, never approach a chronic pain patient quite the same way. 1872.2 He practiced in Georgia before moving,

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December 2012 | Practical Pain Management 39 “Doc” Holliday: A Story of Tuberculosis, Pain, and Self-medication in the Wild West

1882-1887—Travels around , includ- November 8, 1887—Dies at age 36 ing Gunnison, as a professional gambler. in Glenwood Springs, Colorado.

1880—Travels around Arizona as professional gambler (Prescott and Tombstone).

October 26, 1881—Gunfight at OK Corral, Tombstone; receives minor hip wound.

John Henry 1879—Sets up as professional gambler “Doc” Holliday’s in , . Life Journey 1877—Seriously wounded in gunfight in reakenridge, Texas.

40 Practical Pain Management | December 2012 “Doc” Holliday: A Story of Tuberculosis, Pain, and Self-medication in the Wild West

1876-1877—Travels around Colorado () and the as Faro dealer and professional gambler.

1878—Moves to Dodge City; March 1, 1872—Graduates from sets up dental practice. Pennsylvania College of Dentistry in .

August 14, 1851— Born with cleft lip in Griffin, eorgia.

1872— Begins to practice dentistry in ; develops cough, weight loss—diagnosed with consumption.

1866—Mother Alice dies of consumption (tuberculosis) in Valdosta, Georgia.

1866-1870—Attends Valdosta Institute; practices pistol shooting and card playing.

1873—Moves to to practice dentistry, where the climate is drier and better for his consumption.

1874—Takes up gambling professionally.

1875—Meets Kate Elder in Texas.

December 2012 | Practical Pain Management 41 “Doc” Holliday: A Story of Tuberculosis, Pain, and Self-medication in the Wild West

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in 1873, to Dallas, where he became which lasted all of 30 seconds, Doc The e is disagreement over which a dental partner with Dr. John A. Holliday and likely would photos of “Doc” are legitimate.7 His Seegar. Within his first year of dental have died in obscurity. As it turned true image has been dramatically practice, Holliday started frequenting out, this gunfight has long captured altered in the many movies about him, gambling establishments and found the intrigue and fascination of the so I have included a number of quotes that gambling was more profitable American public.1-8 Countless mov- by various persons in an attempt to and exciting than dentistry. Holliday ies, books, articles, and songs have capture the truth. Perhaps the best got the nickname “Doc” from his been written about it, which often quote to separate fact from fiction is friends and acquaintances in the makes telling fact from fiction diffi- one by W.B. (Bat) Masterson, sheriff gambling saloons, who preferred to cult (see Fact from Fiction, below).1-12 of Dodge City and Pueblo, Colorado, call him “Doc” rather than Dr. John Because so much has been writ- who personally knew Holliday. Holliday. ten about Doc Holliday, much of it Considering Doc’s TB, Masterson conflicting, it often is difficul to get described him as a physical “weak- Life as a Gambler a clear picture of his personal appear- ling who could not have whipped a The life of a professional gambler in ance, demeanor, and behavior.1-8 In healthy 15-year-old boy in a go-as- the Western Frontier was danger- his memoirs, Wyatt Earp described you-please fist fight ” Contrast this ous—losing players were often inebri- Holliday this way: “He was a dentist with the number of robust actors ated, took umbrage, and were ready whom necessity had made a gambler, Hollywood chose to play Doc includ- to fight. Along the way, Holliday had a gentleman whom disease had made ing , , developed a reputation as a deadly a frontier vagabond, a philosopher , Caesar Romero, and gunfighte . His long-term notoriety whom life had made a caustic wit, a . primarily stems from his participa- long, lean, ash-blond fellow nearly Just how much his pain and health tion in the gunfight at the OK Corral, dead with consumption and at the problems influenced his temperament which took place in Tombstone, same time the most skillful gambler and behavior will always be a matter of Arizona, on October 26, 1881.1,5 Had and the nerviest, speediest, deadliest debate, but it appeared to this author it not been for this singular event, man with a six-gun I ever knew.”7 to be paramount in shaping his short

Separating Fact From Fiction academics.4-6 These authors have researched newspapers, court records, census rolls, and interviewed numerous A major problem in researching the pain and health people, leaving no stone unturned to piece together the problems of “Doc” Holliday is all the sensational biog- history of the events and happenings of the 14 years that raphies, semi-fiction books, and movies regarding the Holliday roamed the Western Frontier. The e are two “Wild West.” Theyhave distorted the image and behav- excellent historical summaries of Doc Holliday, as well as ior of Holliday and others. The e have been, however, some on Kate Elder, that now are available online.7,8,10,11 several serious attempts to write factual bibliographies Perhaps the best first-person account was written by about Holliday, and these serve as the primary basis W.B. (Bat) Masterson, who wrote a series of articles on for this treatise.1-8 One bibliography, “Doc” Holliday, a the gunman he knew when he was Sheriff of Dodge Family Portrait, is written by Karen Holliday Tanner, City and Pueblo.12 In his later years, he retired from the who was a distant cousin of Holliday and had access Western Frontier and moved to the East to become a to many family records.2 Another, “Doc” Holliday, the journalist and newspaper man. He published his articles Life and Legend, by Gary L. Roberts, was written with in Human Life Magazine in 1907. His collection of arti- direct communication and advice from Holliday fam- cles was republished in book form in 1957 and again in ily descendants.3 Other bibliographies have been writ- 2009 under the title, Famous of the Western ten by serious and renowned Western historians and Frontier.12

42 Practical Pain Management | December 2012 “Doc” Holliday: A Story of Tuberculosis, Pain, and Self-medication in the Wild West

life. The e is remarkable consistency among “Doc’s” serious biographies regarding his health problems, which have allowed this author to medically analyze and report his case from a pain practice perspective.1-8

Doc’s Health and Pain History Holliday’s health problems began at birth—he was born with a cleft lip and possibly a cleft palate.2 His lip was surgically repaired and the Holliday family took the time and effo t to teach him to speak properly. Whether there was a genetic aspect to his birth defect will never be known, but it is commonly believed that genes and the environment play a role in the Photo courtesy of the Centers for Disease Control and Prevention. Figure 1. Image depics two smooth, chromogenic colonies of Mycobacteria, which causes tuberculosis. development of these orofascial clefts. The second major, but critical, event in Holliday’s life was the death of his mother Alice from TB in 1866 bacillus (Mycobacterium tuberculo- Seegar. Due to his consumption con- when he was 15.2 He had been very sis) as the agent responsible for TB dition, which often brought about close to his mother, because during (Figure 1).14 The treatment recom- coughing episodes, as well as a long many of his formative years his father mended by Holliday’s uncle was that depression, he couldn’t build much of was away fighting for the South in proffe ed by Dr. George Bodington a dental practice. Thus, he turned to the Civil War. At the age of 21, (1799-1882) and the renowned Dr. the “sporting life.” while practicing dentistry in Georgia, Benjamin Rush of Philadelphia.13,14 It Holliday started to lose weight. He consisted of a climate of warm, dry About TB initially attributed this to his active air combined with a nutritious diet, According to the Centers for Disease schedule. About 6 months later in a moderate amount of wine, and pro- Control and Prevention (CDC), a the summer of 1873, he developed longed rest during convalescence. Of total of 10,528 TB cases (a rate of a nagging cough that forced him to course, Doc did not follow this advice 3.4 cases per 100,000 persons) were take some time off from his dental completely considering that he spent reported in the United States in practice. When the cough did not a great deal of his life staying up late 2011.15 Both the number of TB cases subside, he sought out his uncle, Dr. and living in smoke-filled rooms. Of reported and the case rate decreased John Stiles Holliday. Using a stetho- extreme importance is that Holliday compared to 2010, representing a scope and a bronchoscope he diag- was told if he remained in Georgia’s decline of 5.8% and 6.4%, respec- nosed Holliday with pulmonary TB,2 hot and humid climate he would live tively. This is the lowest recorded which at the time was commonly about 6 months, but he could extend number since 1992, when the resur- called “consumption” or “phthisis this time to 2 years if he moved west gence of TB peaked in the United pulmonales.”13,14 to a drier, arid location. In other States. The increase of TB predomi- Although the science of contagion words—his hand was forced; he had nantly has been seen among the for- was poorly understood at the time, no other choice but to move. eign-born US population. The CDC the Holliday family believed his prob- On a hot and humid Atlanta day reports that 62% of TB cases reported lems were somehow related to the TB in September 1873, he boarded the in 2011 occurred in foreign-born that killed his mother. It was not until Western and Atlantic Railroad; desti- persons. The TB rate among foreign- 1882 that Robert Koch, who already nation—Dallas, Texas.2 The e was no born persons (17.2 cases per 100,000) had identified the bacterial cause return ticket. He was met at the Dallas was approximately 11.5 times higher for anthrax, identified the tubercle train depot by his dental partner Dr. than among US-born persons (1.5

December 2012 | Practical Pain Management 43 “Doc” Holliday: A Story of Tuberculosis, Pain, and Self-medication in the Wild West

cases per 100,000). of night drenched in sweat. In the drinking up to 4 quarts of whiskey Although less common today than morning, choking, coughing, and per day.1,3,4 He is called an alcoholic during the mid-to-late 19th cen- spitting up, at first watery fluid, later by several writers. The e is another tury, TB remains a horrible, painful blood and chunks of lung tissue, side, however, to their claims. His disease. The disease may be acute or rack the suffe er. The chest feels as common-law companion, Kate Elder, chronic and generally attacks the if it were imploding and the pain of reportedly said this about his alco- respiratory tract, although other parts it all leads many to alcohol for tem- hol intake: “He was not a drunkard. of the body, such as the brain, the kid- porary respite. To crown it all, many He always had a bottle of whiskey neys, and the spine, may be affected. thought the illness a result of moral but never drank habitually. When he The symptoms (fever, loss of weight, laxity. Compounded with terror of needed a drink, he would take only a etc) are caused by the toxins produced contagion, the consumptive becomes small one.”5 Considering that he had by the infecting organism, which also something of a pariah—a ‘lunger’ to be alert to count cards, profession- cause the formation of characteristic despised in and for his infirmit .” ally gamble, accurately wield a gun nodes consisting of a packed mass of As has been reported, Holliday was and knife, and ride a horse, it is dif- cells and dead tissue. physically impaired by his consump- ficult to believe that Doc spent much In most cases today, TB is treatable tion disease throughout his 14 years as time being inebriated. It is quite likely and curable. Despite improvement in a professional gambler on the Western that Holliday suppressed his cough- medical management, however, TB Frontier. He could hardly fight with ing and pain with a daily maintenance remains a deadly infectious disease. fisticuffs so he apparently became the dose of alcohol. For example, he likely The CDC reported that there were most deadly and feared gunman of knew that a certain daily dosage taken 529 deaths from TB in 2009, the the era. John C. Jacobs, a fellow gam- on a regular interval schedule kept most recent year for which these data bler and casino operator said of Doc: him stable. Unfortunately, alcohol are available; this represented a 10% “Thisfellow Holliday was a consump- is difficul to manage as a medicine decline compared to 2008.15 Another tive and a hard drinker, but neither because it is a volatile compound and confounding factor today is the emer- liquor nor the bugs seemed to faze Doc, like other pain patients who gence of multidrug-resistant TB and him. He could at times be the most use it therapeutically, overdosed on extensively drug-resistant TB, which genteel, affable chap you ever saw, occasion. the weakest patients with very and at other times he was sour and Historians agree that Doc’s health few treatment options. surly, and would just as soon cut your began to dramatically fail in about Pain from the disease comes as the throat with a villainous-looking knife 1884.1-5 While working as a Faro tubercle bacilli invade nerve tissue; he always carried, or shoot you with dealer in Leadville, Colorado, he additionally, incessant coughing may a 41-caliber double-barreled derringer began to deteriorate into what is cause fractured ribs, ruptured lung he always kept in his vest pocket.”3 called stage 2 TB. This stage is char- tissue, and irritation of the phrenic, Jacobs describes a volatile man who acterized by severe weight loss, men- vagus, and intercostal nerves. The has exacerbations of intolerable pain tal confusion, extreme fatigue, and noted Western writer and historian, as well as mood swings and hostility. weakness. It was later discovered that Bob Boze Bell, gives a description of “Doc” Holliday lived until age 36, tubercle bacilli like to invade the adre- “consumption” in his 1994 book, The some 14 years longer than he was nal glands and produce symptoms of Illustrated Life and Times of “Doc” predicted to live. His major medici- Addison’s disease or adrenal failure. At Holliday.5 It would be difficul to nal treatments were alcohol and one point in history, TB was the most better describe untreated TB, so it is . Additionally, he likely took common cause of adrenal failure.16 It given here verbatim: “bugleweed,” a standard treatment was most likely the cause of Holliday’s “Consumption can go undetected for TB in the 1800s.14 For the cough severe late-stage debilitation and his for some good time, especially if and pain of TB, which is a disease of death. Today, with the waning of the tendency towards denial is fol- exacerbations and remissions, alco- TB, autoimmune disease and iatro- lowed. Fatigue is more and more hol and opium were the only potent genic corticoid administration are the pronounced as one’s appetite seems available treatments at the time.13,14 major causes of adrenal insufficien . to disappear. One feels ‘out of sorts’ Much has been written about “Doc’s” When Doc started to severely and clammy. Periods of fever come alcohol intake including references deteriorate, he began the regular and go. One wakes up in the dead to his being intoxicated at times and use of the opium formulation called

44 Practical Pain Management | December 2012 “Doc” Holliday: A Story of Tuberculosis, Pain, and Self-medication in the Wild West

laudanum.17 Nearly all consump- to endure, is that patients who have likely kept alcohol in his blood pretty tives used some form of opium to severe pain assuredly will take what- much throughout the 24-hour cycle quiet their cough, control diarrhea, ever medicinal agent is available— to suppress his cough and pain. reduce stress, and relieve the pain of including alcohol and illicit drugs.19 Holliday undoubtedly exceeded his TB.13,14,18 As he deteriorated, observ- Furthermore, they will incessantly alcohol maintenance blood level at ers could see that Doc could no harangue the medical system and even times due to accident or intent, and, longer deal cards or work as a gam- commit unsavory acts to obtain pain consequently, became intoxicated at bler. Consequently, he was unable relief. In summary, it is pure igno- times. Such is the problem when alco- to make much of a living and lived rance and foolishness for any physi- hol is used as a chronic pain treatment on odd jobs in Denver, Leadville, cian, regulator, and insurance payer agent. The lesson here for pain prac- and Trinidad, Colorado. When Doc to withhold adequate pain treatment titioners is simple. If alternate, safer was really sinking, Leadville druggist with a cavalier, naive attitude that the pain treatments are not provided, Jay Miller provided Doc with lauda- patient should “tough it out” or “its the pain patient may well resort to num at no charge. With his health only psychological.” Colonel John alcohol. The author once asked two failing, he checked himself into T. Devers reportedly asked Holliday Alcoholics Anonymous members the Glenwood in Glenwood about his life: “Doctor, don’t your who were patients in his pain clinic to Springs, Colorado. He had heard that conscience even trouble you?” Doc survey their local support groups and the sulfur springs in the town might replied, “I coughed that up with my find out how many drank to relieve bring relief. This was not to be. He lungs long ago.” their pain because they couldn’t get became bedridden, lapsed into a Here are some historical and sci- adequate pain relief. The answer they coma typical of TB patients, and died entific notes about Doc’s self-help gave—about 30%. within a few weeks, on November 8, medications. 1887. Opium Alcohol Opium preparations for medicinal “Doc’s” Self-help Program Alcohol has been used for centuries use date back 2,500 years. Various As noted, Doc used alcohol and as a pain reliever. During both the formulations, including a head opium to treat his symptoms of TB. American Revolution in the 1700s soaked in water, have gone under the Before you think this was a ridicu- and the Civil War in the 1800s, a sol- names meconium, , diascor- lous notion, be aware that Dr. John dier with an arm or leg that had to be dium, mithridate, philonium, and Fothergill, regarded by many to be amputated was given alcohol before diacodium. Laudanum is known the world’s most prominent physician the surgeon sawed off the appendage. today as “tincture of opium.” The in the late 1700s, recommended alco- Surveys today indicate that as many laudanum formulation used in the hol and opium for the management as 28% of people with chronic pain 1800s contained not only opium of TB. He wrote: “Fresh white poppy use alcohol as a pain management but also wine, and was fla ored with [opium] seeds, in the proportions of strategy.20 Out of a series of 401,512 or saff on.17 It was pri- half an ounce to a pint of Bristol [alco- urine specimens collected from pain marily used in Doc’s time as a pain hol], make an excellent emulsion. patients throughout the United killer, sleep aid, and tranquilizer— The cough will abate and gradually States, 28,086 (6.9%) contained just like modern-day prescription cease entirely.”18 In today’s world of ethyl sulfate, an alcohol metabolite, opioid preparations. Because lau- high-powered pharmacology, it seems with levels indicating they had con- danum could be taken orally, it was almost ludicrous to think of these two sumed more than 24 grams of alco- easily administered. Essentially no chemicals as a treatment. Be clearly hol (equivalent to at least two to other pain medication was available advised, however, that Holliday didn’t three glasses of whiskey) the previous because only was available have any choice. Aspirin wasn’t even night.21 as an injectable compound. Other invented until about 1895, some 8 Doc’s behavior indicates that he opioids were not developed for oral years after Doc died. The e were no primarily used alcohol as a mainte- pain treatment until some years such things as antibiotics or neuro- nance drug. Please recall, he was an after Doc’s death. Opium was sold pathic agents or antidepressants. The accomplished gambler, gunfighte , without a prescription, and it was a point to be made, particularly to those and horseman. These feats are not primary ingredient in the so-called who believe pain is just a nuisance compatible with intoxication. He “patent” medicines sold in the 19th

December 2012 | Practical Pain Management 45 46 Adapted from Gray H. Anatomy of the Human Body/Bartleby.com. hsi ufruae bcue he because unfortunate, is Holliday.This Doc by used opium and alcohol of frequencies and dosages out the1800s. through TB for treatment standard “heaven-born gift.”“heaven-born WolfgangGeorge cian Wedel, a been physi century 16th the of words the in has, opium used, historically been has formulation which or called is it and other opioids. Regardless of what small amounts of , morphine, century.Opiumpreparations contain which can transmit pain signals. pain transmit can which nerves, phrenic and vagus the of connections numerous the Note lung cage. in the Nerves 2. Figure “Doc” Holliday:AStory ofTuberculosis, Pain, andSelf-medication intheWildWest Unfortunately, we do not know the Practical Pain Management 17 Opium was the was Opium - - | December 2012 oe patients. some in immunity increase and infections dence that opioids may evi suppress new some some is e The rooms. filled smoke- in days his spending despite time, considerable a live to managed nw b mn nms includ archangel, names horehound, Virginia many ing is by bugleweed known is virginicus, name Lycopus botanical the Although Bugleweed life withopium. his extended have may HollidayDoc 22 f hs s h case, the is this If - - that pain in the postoperative period postoperative the in pain that an Management. Pain post-thoracotomy newsletter,pain the in pain of problem the agonizing. described and Frost and Slater Recently, visceral, deep, as ditions has been described by patients bypassing thespinalcord. and brain,the directlyto phrenicnerves) (vagus system autonomic the through as well as cord spinal and intercostal noxious the through stimuli pain transmit condition therefore, lung a may, with patient A diaphragm. and pericardium, num, mediasti the from stimuli noxious transmits nerve phrenic The nerves. are phrenic and vagus the by innervated parenchyma lung and pleural visceral the pathway, same this intercostals, use the nerves, wall chest peripheral by nerves and the spinal cord. Although brain the to mitted trans are spine and foot, knee, wrist, the from signals pain example, For originate in the extremities (Figure 2). that sources pain common more the from ent diffe quite and complex are cage its and lung the in nerve connections the because manage, to ficult dif and severe be can wall chest or and/ lung the from emanating Pain Lung andChest Wall Pain patients inthe19thcentury. consumption by hemoptysis for used routinely was botanical This clock. the around herb this given and bed to put was patient The lung. the into bleeding with rupture vessel blood a had patient a par if used was In it ticular, properties. narcotic mild and astringent, sedative, has It tures. tinc and extracts make to used was herb whole from The September. wering to July fl damp, and ground low, shady in growing America, North in weed common very a wort. is It gypsy and foot, wolf’s green Thepain associated with lung con- Thepain 23 hypit out point They 14 14 Topicsin - - - - -

“Doc” Holliday: A Story of Tuberculosis, Pain, and Self-medication in the Wild West

is notable for its intensity and dura- tion. Chronic lung and chest wall Table 1. Today’s Common Causes pain can be difficul to treat and may Of Chronic Lung and Chest Wall Pain require a high opioid dosage as well as a variety of neuropathic agents • Post surgery and local measures such as admin- • Post radiation istration of electromagnetic energy. • Post infectious or inflamm tory neuropathies o Pneumonia The fact that the patient must con- Histoplasmosis stantly breathe in and out irritates a o o Sarcoid pain focus and makes it difficul to • Autoimmune neuropathies find elief. Although not as prevalent as arthri- tis and other extremity problems, lung and chest wall pain are prob- as I told them—the bugs would get me are hopeless remorse and depression, lems in every pain practice. Lung and before the worms did.”5 On the day of which only worsen the pain. The chest wall pain can occur due to TB his death, his nursing attendant stated hostility, remorse, and fear that pain (sarcoid) and trauma as well as after he woke up for a moment and asked patients develop often get in their way surgery, radiation, and infections for a drink of whiskey.2 He looked at and bar them from making the criti- (Table 1). his bare feet and said, “This is funny.” cal decision to find some happiness Fortunately, TB in America today is Apparently, he expected to lose a gun- (Table 3, page 49). The e is no ques- a more treatable disease. This contrasts fight somewhere along the way and tion that Holliday found some happi- with the form that produced the hor- die with his boots on. ness and quality of life. He lived about rendous, unstoppable coughing spells Mary Dorian Russell is an anthro- 14 years longer than his doctor pre- tinged with blood that plagued Doc pologist who has written a semi-fi - dicted. In contemporary terms, he Holliday. I recall from my early career tion book simply called Doc about carried out his “bucket list.” He loved TB patients who would present with Holliday and Kate in Dodge City.24 to gamble and found a woman he broken ribs, ruptured blood vessels, She theorizes that one reason gamblers could love and with whom he could and exhaustion. Opioids always have love to gamble is that the split-second travel. She was someone who par- been the standard for cough and pain. throw of a card or roll of the dice pro- ticipated in and accepted his lifestyle The brain centers that control cough vides an anticipation that removes the and risky existence. May we practitio- and pain apparently are one and the individual from the toils and fears ners help all our patients achieve the same. Severe cough from tumors or of life. Maybe the thousands of “life happiness and satisfaction I believe infections still occasionally can be seen exits” of Doc Holliday is a major “Doc” found. in clinical practice. Just remember that reason he lived beyond his doctor’s What can the pain practitioner do opioids may be needed because they predictions. to help patients find happiness? How directly and effecti ely suppress the should patients be approached? First cough centers. Chronically Ill Patients and foremost, let patients know you An increasing number of chronically are with them all the way—through “Doc” Found Some Happiness ill and palliative care patients are thick and thin. Get to know the When “Doc” was dying in Glenwood seeking treatment in pain practices. patients’ families and friends. I have Springs, he asked Kate to come see Rather than TB, patients have a vari- a page in my offic visit form that an him. It is not known, however, for how ety of genetic, infectious, and autoim- intractable pain patient must com- long she stayed or whether she was at mune diseases that, in their late stages, plete at every visit. I review this form his bedside when he died. Prior to this, produce pain and cause premature with the patient and demand they they had split over her false accusa- death (Table 2, page 49). Pain practi- find activities to keep their mind and tions about the robbery in tioners who deal with intractable pain body active and develop social inter- Tombstone (see Doc’s Woman, page patients with a short life span must actions. Patients are told that pain 48). In the end, however, they were encourage them to find some “hap- medications don’t work very well if reunited. She claims that among Doc’s piness” and “quality of life” in the the patients are just lying around the last words were: “Well, I’m going just time they have left. Theother options house.

December 2012 | Practical Pain Management 47 “Doc” Holliday: A Story of Tuberculosis, Pain, and Self-medication in the Wild West

and began living together as husband and wife. In 1878, “Doc’s” Woman they moved to Dodge City and registered at the famous Dodge House Hotel on Front Street as Dr. and Mrs. John H. Holliday. Little is written or recorded about their life in Dodge City, but Holliday is believed to have done well at Faro and poker, as well as kept a part-time dental practice. One source believes Kate would find him poker games that he could exploit.24 The e also is a report that says Kate would sit behind him when he played poker and give him only tea to drink unless he began a severe cough- ing spell that demanded a bit of alcohol. Bibliographies all state the couple had occasional and ferocious fights 1-8 One observer said they were inseparable until they had to be separated. I can find no credible details of the cause or nature of these quarrels. At one point in Tombstone, Kate was so furious with Doc that she became grossly inebri- Mary Katherine Haroney ated and to “get even” she falsely signed an affidavi stat- 1850-1940 ing that Doc took part in a stagecoach robbery. Just what she was trying to get even about is unknown. It may have been over another woman who pursued Holliday.5 linicians who practice pain medicine and see Even though their relationship may have been rocky at tragically afflicte pain patients know that the times, they stayed together for about a decade and traveled diffe ence between misery and finding some to , Colorado, South Dakota, Arizona, and New Ccomfort, relief, and happiness may be keenly tied to a Mexico. Holliday was a very intelligent, educated man, relationship with a significant other. “Doc” Holliday and was able to find his intellectual equal, and happiness, with Kate Elder’s relationship was one of great affection and Kate Elder. support that allowed these two vagabonds on the Western Kate reportedly made some comments about Doc Frontier to find some happiness, thrills, love, and longev- that paint a revealing portrait of him that is not generally ity they would not otherwise have experienced. The ups appreciated. “Doc was close to 6 feet tall, weighed 160 and downs of their relationship is something I’ve come to pounds, fair complexion, very pretty mustache, blue-grey frequently observe in many of my current patients with eyes, and fine set of teeth. He never boasted of his fightin intractable pain. qualities. He was a neat dresser, and saw to it his wife was Kate Elder was born Mary Katherine Haroney, on dressed as nicely as himself.”5 November 7, 1850.10,11 She was born, like Holliday, into After Doc’s death, Kate remarried and ran a boarding an aristocratic family in Budapest, Hungary. She was highly house in Globe, Arizona. In 1940, she died at age 90 educated, literate, and spoke several languages, including with the name of Kate Cummings. She was living at the Hungarian, French, Spanish, and English. Her father was Arizona Pioneer Rest Home, in Prescott, Arizona. She a renowned physician who accepted a post as Maximilian apparently tried to sell her story, but there were no takers of Mexico’s personal surgeon. When Maximilian’s govern- in the 1920s and 1930s. The Western Frontier craze had ment began to crumble, Haroney moved his family to not yet hit. Davenport, Iowa. For unknown reasons Kate’s mother The Kate and Doc “lesson” for pain practitioners is to and father died shortly after reaching Iowa. Afterword, at be tolerant of the marital relationships of pain patients. age 14, she was shipped from one guardian to another. One sees the good, bad, and the ugly. Some couples can’t Thenext historical record of Kate is in Wichita, Kansas, stay together when one of them has intractable pain. where she worked in a “sporting house” run by James and Others can only tolerate each other in small dosages. In Bessie Earp.1,3,5 She also worked as a prostitute for the other cases, love and affection grows longer and stronger. Earps in Dodge City. She moved to Fort Griffin Texas, in The e is no “one size fits all” when it comes to pain and 1871 and met “Doc” in 1875. Theyimmediately hit it off marital relationships.

48 Practical Pain Management | December 2012 “Doc” Holliday: A Story of Tuberculosis, Pain, and Self-medication in the Wild West

Summary Pain practitioners seldom get to Table 2. Some Common Diseases With Late-stage a know a patient’s history from birth to Pain and Early Death death. Doc Holliday gives us a most insightful opportunity to perform • Multiple sclerosis • Diabetes a “pain history autopsy.” Although • Autoimmune diseaseb death from TB has essentially dis- • Genetic disease appeared from the American scene, • Lymphocytic leukemia we now have other chronic illnesses • Arteriosclerosis that may produce severe pain when • Human immunodeficiency viru Cirrhosis of liver the disease enters its late stages. • • Porphyria When patients with these underly- ing diseases develop severe pain, they instinctively know that they may have a This is not a complete list. b Includes fibromyalgia, systemic lupus, scleroderma, etc. a shortened life span. These patients now are prevalent in pain practices, and they need aggressive medical treatment lest they self-medicate with Table 3. Some Common Beliefs, Perceptions, and Characteristics of Pain whatever agent they can grab, includ- Patients With a Short Life Spana ing alcohol and illegal drugs. Besides medication, these patients need our • Remorseful caring and counseling to find some • Crying happiness, contentment, and qual- • Blame themselves ity of life in whatever time they have • Feel they are a “bad” person • Can’t live a normal life left. Doc Holliday started his life as • Few friends an accomplished health professional. • Can’t have a normal marital life I suspect he would be tickled to know • Hostility—may want “revenge” that the study of his life, pain, and ill- • Believe the “devil” haunts them ness will help us to help other persons • Don’t know what to do with their time who now face the same challenges he faced. a The above are personal observations of pain patients who have shortened life spans.

References 1. Guinn J. The Last Gunfigh . New York: Simon & Schuster; 2011. 14. Dubos R, Dubos J. The White Plague: Tuberculosis, Man, and Society. New 2. Tanner KH. Doc Holliday: A Family Portrait. University of Oklahoma Press; 1998. Brunswick, NJ: Rutgers University Press; 1952. 3. Roberts GL. Doc Holliday: The Life and Legend. Hoboken, NJ: John Wiley & Sons, 15. Centers for Disease Control and Prevention. Tuberculosis. http://www.cdc.gov/tb/ Inc.; 2006. publications/factsheets/statistics/TBTrends.htm. Accessed November 8, 2012. 4. Lynch SD. Aristocracy’s Outlaw: The Doc Holliday Story. New Tazewell, TN: Iris 16. Sanford JP, Farour CB. Interrelationships between Addison’s disease and active Press; 1994. tuberculosis: a review of 125 cases of Addison’s disease. Ann Intern Med. 1956;45(1):56-65. 5. Bell BB. The Illustrated Life and Times of Doc Holliday. Phoenix, AZ: Tri Star-Bose Publications, Inc.; 1995. 17. Hodgson B. In the Arms of Morpheus. Buffalo, NY: Firefly Books; 2001 6. Earp W. Wyatt Earp Speaks. New York, NY: Fall River Press; 2009. 18. Fothergill J. Remarks on the cure of consumption. In: Complete Collection of the Medical and Philosophical Works of John Fothergill. , UK: John Walker, 7. Wikipedia. Doc Holliday. http://en.wikipedia.org/wiki/Doc_Holliday. Accessed Pater-Nofter-Row; 1781, p399. October 20, 2012. 19. Tennant FS. The use of and maintenance as a last resort 8. The High . John Henry “Doc” Holliday. http://www.thehighchaparral.com/ by intractable pain patients. Presentation at the College on Problems of Drug historic10.htm. Accessed August 13, 2012. Dependence, Scottsdale, AZ: 2001. 9. Wikipedia. Long depression. http://en.wikipedia.org/wiki/Long_depression. 20. PainACTION.com Alcohol and pain. http://www.painaction.com/members/article. Accessed October 19, 2012. aspx?id=5224. Accessed September 3, 2012. 10. Tombstone Times. Kate Elder, her true story. http://www.tombstonetimes.com/ 21. Data provided by Millennium Laboratories, Rancho Berneardo, CA. stories/kate.html. Accessed October 21, 2012. 22. Nabavighadi K, Brown M, Poluatskaya Y, et al. Chronic opioid consumption and 11. . http://en.wikipedia.org/wiki/BigNoseKate. Accessed 10/21/12. perioperative infections. Presentation at the American Academy Pain Medicine 12. Masterson WB. Famous Gunfighters of the Western Frontier. Mineola, New York: annual meeting, Palm Springs, CA; February 2012. Dover Publications; 2009. 23. Slater B, Frost EAM. Pain management after thoracic surgery. Topics in Pain 13. Bodington G. An Essay on the Treatment and Cure of Pulmonary Consumption. Management. Hotgerstown, MD: Lippincott, Williams, & Wilkins; 2012. London, UK: Dime, Brown, Green, and Longmans; 1840. 24. Russell MD. Doc. New York, NY: Random House, Inc.; 2011.

December 2012 | Practical Pain Management 49 PRACTICAL PAIN MANAGEMENT

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