Health Through Will Power

J. Cordy Jeaffreson in his volume "A Book about Doctors", written two generations ago, has told the story of St. John Long's successful application of the principle of community of treatment and its effectiveness upon his patient. Like Mesmer he realized that treating people in groups led them mutually to influence each other and to bring about improvement. St. John Long had in one of the rooms in Harley Street "two enormous inhalers, with flexible tubes running outward in all directions and surrounded by dozens of excited women— ladies of advanced years and young girls giddy with the excitement of their first London season—puffing from their lips the medicated vapor or waiting until a mouthpiece should be at liberty for their pink lips." In our generation of course we had various phases of similar treatment, including nebulizers and compressed air apparatus and medicated vapor, all working wonders for a while, and then proving to have no physical beneficial effect.

What is surprising is to find the number of cures that were worked. St. John Long had so many applicants for attention that he was literally unable to give heed to all of them. The news of the wonderful remedy flew to every part of the United Kingdom and from every quarter sick persons, wearied of a vain search after an alleviation of their sufferings, flocked to London with hope renewed once more. This enabled St. John Long to select for treatment only such cases as gave ready promise of cure. He made it a great preliminary of his treatment that his patients should eat well as a rule and on one occasion when he was called into the country to see a man suffering in the last stages of consumption he said quite frankly, "Sir, you are so ill that I cannot take you under my charge at present. You want stamina. Take hearty meals of beefsteak and strong beer; and if you are better in ten days I will do my best for you and cure you."

It is easy to understand that if he made it a rule for his consumptive patients that they should eat well or not expect relief from his medicine he would secure a great many good results. Especially would this be true in many cases that came up to him from the country, had the advantage of a change of climate, and of environment and very soon found that they had much more strength than they thought they had. They had been dreading the worst, they were now led to hope for the best; they took the brake off their will, they fed well and it was not long then before they proceeded to get well.

As even a little experience with consumptive patients shows it is often difficult for them to follow directions—and keep it up—in the matter of fresh air and good food and here is where the question of the will in the treatment is all important. Many a consumptive has in early life formed bad habits with regard to eating, especially in the direction of eating too little and refusing for some reason or other to take what are known to be the especially nutritious foods. Not infrequently indeed it is their neglect of nutrition in this regard that has been the principal predisposing factor toward the development of the disease. This bad habit must be overcome and often proves refractory.

Then it is never easy to give up the pursuit of a chosen vocation and pursue faithfully for a suitable period the humdrum monotonous existence of prolonged rest every day in the open air with eating and sleeping as almost the only serious interests, if indeed they can be called such, permitted in life. It is only those who have the will power to follow directions faithfully, whole-heartedly and persistently who have a reasonable prospect of getting ahead of their disease and eventually securing such a conquest of it as will enable them to return to their ordinary life as it was before the development of tuberculosis.

Unless patients are ready to follow directions as regards outdoor air and good food the cure, or as specialists in tuberculosis prefer to call it the arrest of symptoms in the disease, is almost out of the question. Above all it is extremely important that those who suffer from pulmonary tuberculosis should be ready to follow directions at an early stage of their disease, before any serious symptoms develop, for it is then that most can be done for them. Many a sufferer from tuberculosis makes his or her cure extremely difficult, certainly ever so much more difficult than it would otherwise have been, because the dread of going to see a physician—lest they should be told that their affection is really consumption and demands immediate strenuous treatment—causes them to put off consultation with some one whose opinion in the matter is reliable.

This is indeed one of the principal reasons why tuberculosis of the lungs still continues to carry off so many victims every year,– because people are afraid to learn the truth. They dare not put the question to a definite issue and refuse to believe the possibility that certain disturbing symptoms represent developing tuberculosis. They defer seeing an expert; they take this and that suggestion from friends; they buy cough remedies which they see advertised, sometimes they tinker with so-called "consumption cures." After a while an advance of their symptoms makes it absolutely necessary to see a physician but often by this time their disease has progressed from an incipient case rather easy to be treated and with an excellent prognosis to a more advanced stage at which cure is ever so much more difficult; or by this time it may even prove that their strength has been seriously sapped and they have not enough resistive vitality left to bring about reaction toward the cure.

The all-important thing for all those who have at any time lived near consumptives, whether relatives or others—for the disease is almost invariably acquired and not hereditary—or who have worked for any prolonged period in more or less intimate contact with those who had a chronic cough or who subsequently developed tuberculosis, is that on the first symptom that is at all suspicious they should make up their minds to have the question as to whether they have tuberculosis or not definitely settled and that they should be ready to do what they are told in the matter. The first symptom is not a persistent cough as so many think, nor continued loss of weight, which is an advanced sign as a rule, but a continued rapidity of pulse for which no non-pulmonary reason can be found.

The old idea that consumptives should not be told what their affection was, lest it should disturb their minds and discourage them so much as to do them harm, has now been abandoned by practically all those of large experience in the care of the tuberculous. The opposite policy of being perfectly candid and making the patients understand their serious condition and the importance of taking all the measures necessary for cure, yet without permitting them to be unnecessarily scared, has been adopted. Their will to get well must be thoroughly aroused. After all, it must be recalled that tuberculosis is an extremely curable disease. It is now definitely known that more than ninety per cent. of humanity have at some time had a tuberculosis process, that is to say a focus of tuberculosis active within their tissues. Only about one in nine of the deaths in civilized countries is from tuberculosis. That means that at least eight other people who have not died from the disease but from something else have had the affection, yet have recovered from it. Instead of the old shadow of heredity with its supposedly almost inevitable fatality, so that young people who saw their brothers and sisters or other relatives around them die from the disease felt that they were doomed, we now know that the hereditary factor plays an extremely minor role if indeed it plays any serious rôle at all in the development of the disease.

No affection is so amenable to the state of mind and the will to be well as tuberculosis. That is exactly the reason why so many remedies have come into vogue and apparently been very successful in its treatment and then after a while have proved to be of no particular service or even perhaps actually harmful so far as their physical effect is concerned. It cannot be too often repeated that anything whatever that a patient takes that will arouse new hope and give new courage and reawaken the will will actually benefit these patients. No wonder then that scarcely a year passes without some new remedy for tuberculosis being proposed. All that is needed to affect favorably patients suffering from the disease is to have some good reason presented which makes them feel that they ought to get better and then at once they eat better and proceed to increase their resistive vitality. The despondency that comes with the lack of the will to be well hurts their appetite particularly and no tuberculosis patient can ever hope to recover health unless he is eating heartily. With better eating there is always a temptation to be more outdoors and the ability to stand cooler air which always means that the lungs are given their opportunity to breathe fresh cool air which constitutes absolutely the best tonic that we have for the affection.

It has been recognized in recent years that the only climates which give reasonable hope of being helpful for the tuberculous are those which present a variation of some thirty degrees in their temperature every day. Whenever this is the case chilly feelings are always produced in those who are exposed to the change, even though the lower temperature curve may not go down to anywhere near freezing. If for instance the temperature at the hottest hour of the day, say three o'clock in the afternoon, is 90° F. and that of the later evening or middle of the night is 60° F., chilly feelings will be produced. Just the same thing is true if the temperature is between 30° F. and 40° F. shortly after the middle of the day and then goes down to near zero at night. These chilly feelings are uncomfortable, but they produce an excellent reaction in the circulation and set the blood coursing from the heart to the tissues better than any medicine that we have. In the midst of this the lungs have their resistive vitality raised so as to throw off the disease.

This is probably one of the principal reasons why mountain climates have been found so much more helpful for the treatment of tuberculosis than regions of lower elevations. Whenever the elevation is more than fifteen hundred feet there will almost invariably be a variation of thirty degrees between the day and the night temperature. There are of course still greater variations, even sixty or seventy degrees sometimes where the altitudes are very high, but this is often too great for the tuberculous patients to react properly to, in their rundown conditions. Besides, the air is much rarer at the higher elevations, breathing is more difficult, because the lungs have to breathe more rapidly and more deeply in order to secure the amount of oxygen that is needed for bodily necessities from the rarified air. The middle elevations then, between fifteen hundred and twenty-five hundred feet, have been found the best for tuberculosis patients, and they are very pleasant during the summer time, though never without the chilly discomfort of the drop in temperature. During the fall and winter, however, many patients become tired out trying to react to these variations of temperature and want to seek other climates where they will not have to submit to the discomfort and the chilly feelings. If they come down to more comfortable quarters before their tuberculosis has been brought to a standstill by the increase of their resistive vitality, it is very probable that they will lose most of the benefit that they derived from their mountain experience. Here is where the will comes in. Those who have the will to do it and the persistence to stick at it and the character that keeps them in good humor in spite of the discouraging circumstances which almost inevitably develop from time to time, will almost without exception recover from their tuberculosis with comparatively little difficulty, if they have only taken up the treatment before the disease is so far advanced as to be beyond cure.

In the older days consumptives used to be sent to the Riviera and to Algiers and to other places where the climate was comparatively equable, with the idea that if they could only avoid the chilly feelings consequent upon variations of temperature it would be better for them. Many of the disturbing symptoms of tuberculosis are rendered less troublesome in such a climate, but the disease itself is likely to remain quiescent at best or perhaps even to get insidiously worse, as tuberculosis is so prone to do. These milder climates require much less exercise of the will, but that very fact leaves them without the all-important therapeutic quality which the lower altitudes possess.

For many people the outdoor life and the sight of nature in the variations produced in scenery during the course of the days and the seasons are satisfying enough to be helpful in making their cure of tuberculosis easy. They are extremely fortunate if they have this strong factor in their favor. It is very probable that we owe the discovery of the value of the Adirondacks and other such medium altitudes in the treatment of tuberculosis to the fact that Doctor Trudeau liked the outdoors so much and was indeed so charmed with the Adirondack region that when death from tuberculosis seemed inevitable, he preferred the Saranac region as a place to die in, in spite of the hardships and the bitter cold from which at that time there was so little adequate protection, to the comforts of the city. He scarcely hoped for the miracle of cure from a disease which he as a doctor knew had carried off so many people, but if he were to die he felt that he would rather die in the face of nature with his beloved mountains all around him than in the shut-in spaces of the city.

His resolution to go to the Adirondacks seemed to many of those who heard of it scarcely more than the caprice of a man whom death had marked for itself. His physicians surely had no hope of his journey benefiting him but they felt very probably that in the conditions he might be allowed to have this last desire since there were so few other desires of life that he was likely to have fulfilled. His will to live outdoors in spite of the bitter cold of that first winter undoubtedly saved his life and then he evolved the system of outdoor treatment which has in the past fifty years saved so many lives and is now the recognized treatment for the disease. It is easy to understand, however, how much of firm determination was required on his part forty years ago, when there were no comfortable ways of getting into the Adirondacks, when the last stage of the journey had to be made for forty miles on a mattress in a rough wagon, when water for washing had to be secured by breaking the ice in the pitcher or on the lake and when the bitter climate must have been the source of almost poignant torture to a man constantly running a slight temperature. He had the courage and the will power to do it and the result was not only his own survival but a great benefit secured for others.

Unfortunately many a consumptive patient who during his first period of treatment keeps to the letter the regulations for outdoor air and abundant food fails to do so if it is necessary to come back a second time. Persistency is here a jewel indeed and only the persistent win out. Many an arrested case fails to keep the rules of living that may be necessary for years afterwards and runs upon relapse. The will to do what is necessary is all-important. Trudeau himself, after securing the arrest of his disease in the Adirondacks, though he lived and worked successfully to almost seventy years of age, found it quite impossible to live out of them and often had to hurry back from even comparatively brief visits to the lowlands. Besides, every now and then during some forty years he had the will power to take his own prescription of outdoor air and absolute rest. It was the faculty to do this that gave him length of life far beyond the average of humanity and the power to accomplish so much in spite of the invasion of the disease which had rendered large parts of both lungs inoperative. Not only did he live on, however, but he succeeded in doing so much valuable work that few men in the medical profession of America have stamped their name deeper on modern medical science than this consumptive who had constantly to use his will to keep himself from letting go.

CHAPTER XII

THE WILL IN PNEUMONIA

"Who shall stay you?—My will, not all the world."Hamlet

What is true of tuberculosis and the influence of the will has proved to be still more true, if possible, of pneumonia. Clinical experience with the disease in recent years has not brought to us any remedy that is of special value, nor least of all of specific significance, but it has enabled us to understand how individual must be the treatment of patients suffering from pneumonia. We have recognized above all that mentally disturbing factors which lessen the patient's courage and will to live may prove extremely serious. We hesitate about letting an older person suffering from pneumonia learn any bad news and particularly any announcement of the death of a near relative, above all, a husband or wife. The shock and depression consequent upon any such announcement may prove serious or even fatal. The heart needs all its power to accomplish its difficult task of forcing blood through the limited space left free in the unaffected lung tissue, and anything which lessens that, that is anything which disheartens the patient, to use our expressive English phrase, must be avoided as far as possible.

When a man of fifty or beyond, one or more of whose friends has died of pneumonia about his age, comes down with the disease and learns, as he often will in spite of the best directed effort to the contrary, that he is suffering from the affection, if he is seriously disturbed by the knowledge, we realize that it bodes ill for the course of the disease. If a pneumonia patient, especially beyond middle life, early in the case expresses the thought that perhaps this may be the end and clings at all insistently to that idea, the physician is almost sure to feel little confidence of pulling him through the illness. In probably no disease is it more important that the patient's courage should be kept up and that his will should help rather than hamper.

Courage is above all necessary in pneumonia because the organs that are most affected and have most to do with his recovery are so much under the control of the emotions. Any emotional disturbance will cause the heart to be affected to some extent and the respiration to be altered in some way. When a pneumonia patient has to lie for days watching his respirations at forty to the minute, though probably he has never noticed them before, and feels how his heart is laboring, no wonder that he gets scared, and yet his scare is the very worst thing that can happen to him. It will further disturb both his heart and his respiration and leave him with less energy to overcome the affection. He may be tempted to make conscious efforts to help his lungs in their work, though any such attempt will almost surely do more harm than good. He must just face the inevitable for some five to nine days, hope for the best all the time and keep up his courage so as not to disturb his heart. After middle life only the patients who are capable of doing that will survive the trial that pneumonia gives. The super-abounding energy of the young man will carry him through it much better; and besides, the young man usually has much less solicitude as to the future and much less depending on his recovery.

A generation ago or even less, whiskey or brandy or some form of strong, alcoholic stimulant, as it was called, was looked upon as the sheet anchor in pneumonia. For a generation or more at that time, the same remedy had been looked upon by a great many physicians as an extremely precious resource in the treatment of tuberculosis. The therapeutic theory behind the practice was that in affections of the lungs a particular strain was placed upon the heart and therefore this organ needed to be stimulated just as far as could be done with safety. As alcohol increases the rapidity of the heart beat, it was considered to be surely a stimulant and came to be looked upon as the safest of heart stimulants, because, except when used over very long periods, direct bad effects had not been noticed. In pneumonia, above all, the heart needed to be stimulated because it had to pump blood through the portion of the lungs unaffected by the pneumonia, usually congested and offering special hindrances to the circulation; besides, a much larger amount of blood than usual had to be pumped through these portions of the lungs in order to compensate for the solidified portions.

A number of very experienced physicians came to be quite sure that alcoholic stimulants were the most valuable remedy that we had for this special purpose of cardiac stimulation; some of them went so far as to say, with a well known New York clinician, that if they were to be offered all the drugs of the pharmacopeia without alcoholic stimulant for the treatment of pneumonia on the one hand, or whiskey or brandy on the other without all the pharmacals, they would prefer to take the alcohol, confident that it would save more patients for them. They were quite sure that they had made observations which justified them in this conclusion.

We know at the present time that alcohol is not a stimulant but always a narcotic. It increases the rapidity of the heart beat, though not by direct stimulation, but by disturbing the inhibitory nerve apparatus of the heart and thus permitting the heart to beat faster. Just as there is a governor on a steam engine, to keep it from going too fast and regulate its speed to a definite range, so there is a similar governing apparatus or mechanism in connection with the heart. It is by affecting this that alcohol makes the heart go faster. Blood pressure is not raised, but on the contrary lowered, and the effect of alcohol is depression and not stimulation. In spite of this, good observers seemed to note favorable effects from the use of alcohol in both pneumonia and tuberculosis. This appears to be a paradox until one analyzes the psychic effects of alcohol and places them alongside the physical, in order to determine the ultimate equation of the influence of the substance.

Alcohol has a very definite tendency to produce a state of euphoria, that is, of well-being. The patient's mind is brought to where it dismisses solicitude with regard to himself. This neutralizes directly the anxiety which so often acts as a definite brake upon resistive vitality. The alcoholic stimulant, in so far as it has any physical effect, probably does a little harm, but its influence on the mind of the patient not only serves to neutralize this, but adds distinctly to the patient's prospects of recovery. Without it, the dread which comes over him paralyzes to some extent at least his heart activity and interferes with lung action. Under the influence of alcohol, he gains courage—artificial, it is true—but still enough to put heart in him, and this is the stimulation that the older clinical observers noted. The patient can, with the scare lifted, use his will to be well ever so much more effectively and psychic factors are neutralized that were hampering his resistive vitality.

This illustrates very well indeed the place of dilute alcohol in some of the usual forms in therapeutics about the middle of the nineteenth century. Practically all the textbooks of medicine at that time recommended alcohol for many of the continued fevers. In sepsis, in child-bed fever, in typhoid, in typhus, as well as in tuberculosis and pneumonia and other less common affections, whiskey or brandy was recommended highly and usually given in considerable quantities. All of these affections are likely to be accompanied by considerable anxiety and solicitude with a series of recurring dreads that sadly interfere with nature's efforts toward recovery. Under certain circumstances, the scare, to use the plain, simple word, was sufficient to turn the scale against the patient. The giving of whiskey at least lifted the scare5 and enabled the patient to use his vital resources to best advantage.

It is extremely important, then, first to be sure that the patient's will to be well is not hampered by unfortunate psychic factors and secondly, that his courage shall be stimulated to the greatest possible degree. Fresh air is the most important adjuvant for this that we have. The outdoor air gives a man the courage to dissipate dreads and makes him feel that he can accomplish what seemed impossible before. Undoubtedly this is one of the favorable effects of the fresh-air treatment of pneumonia, for it makes people mentally ever so much less morbid. The patient's surroundings must be made as encouraging as possible and there must be no signs of anxious solicitude, no long faces, no weeping, and as far as possible, no disturbance about business affairs that might make him think that a fatal termination was feared. His will to get well must be fostered in every possible way and obstacles removed. This is why it has been so well said in recent years that good nursing is the most important part of the treatment of pneumonia. This does not mean that a good nurse can replace a physician, but that both must coordinate their efforts to making the patient just as comfortable as possible, so that he will feel assured that everything that should be, is being done for him, and that it is only a question of being somewhat uncomfortable for a few days and he will surely get well.