Psychotherapy

Some ten years ago I first saw another of these cases of fast heart, with a family history of the affection in a preceding generation. He was a man who had not taken good care of himself and had been especially over-indulgent in alcohol. This indulgence consisted not in rare sprees but in the persistent daily taking of large quantities of straight whiskey. In spite of warnings, he has not given up this habit; yet at the age of sixty-five he is apparently in good health and is able to fulfill the duties of a rather exacting occupation.

Persistent rapid pulse often occurs in connection with some disturbance of the thyroid gland. The larval forms of Graves' disease occur particularly in young persons, though they are sometimes seen in those beyond middle life. They seem to be due to a lack of development of the thyroid in consonance with the rest of the tissues, though occasionally, especially after the menopause, they seem to be connected with some degenerative process out of harmony for the moment with other forms of degeneration. When they occur in young persons they may, of course, represent the beginning of incipient Graves' disease, but they are often only functional and the symptoms may pass away entirely. The rapid heart action may come and go, though usually the attacks last for some days and oftener for a week or more at a time.

Paroxysmal Tachycardia.—A rapid heart may not only exist continuously in an individual for many years without any impairment of general health or shortening of life, but there may be spasmodic attacks of this condition with the pulse running up so high as to deserve the name of paroxysmal tachycardia; yet the patient may live for many years and die from some affection not connected with his heart. Perhaps the most remarkable case of this kind on record is that reported by Prof. H. C. Wood of Philadelphia. The patient was a physician in his later eighties when he came under Dr. Wood's observation. His first attack of paroxysmal tachycardia came in his thirty-seventh year. These attacks had apparently always been similar to those he then suffered and were abrupt in onset and the pulse would rise rapidly to 200 a minute. The original prognosis had been, of course, very unfavorable. The physician had outlived all the prophets of evil in his case, however. When large numbers of these cases were studied, it was found that they always last more than ten years, and, while heart failure in such cases is reported, it is doubtful if this occurs with more frequency in these patients as the result of strong reflexes than in the general run of patients, for it must not be forgotten that there is a certain average number of deaths from so-called heart failure in people supposed to be in good health.

In connection with these attacks of paroxysmal tachycardia, there often come intense feelings of depression and even local disturbances of circulation. It is probable that in many cases there is a serious factor at work. MacKenzie has suggested that they are due to nodal rhythm of the heart in which the heart beat does not start at the root of the sinus as is usual, but in some other portion of the musculature and as a consequence there is serious interference with the regular rhythmic action. In a number of cases of heart failure, tachycardia becomes a prominent feature and it is probably due to some such disturbance as this. Such cases often look very serious for a time, yet frequently recover completely after a brief interval. This must not disguise the fact, however, that many of these cases, especially where acute dilatation of the heart can be demonstrated, are extremely dangerous and may end in a sudden fatal termination. The patient seems so much prostrated that occasionally the physician may doubt whether it is worth while to put him to the bother necessary in order to diagnose the acute dilatation of the heart. It always is, however. If it were nothing else but the occupation of the patient's attention with the doctor's manipulations, as far as that is possible, the effect would be good, besides whatever irritation may be caused to the heart muscle itself by percussion of the heart area will probably do mechanical good.

The most important element evidently is that the patient shall not be allowed to lose courage or to think that nothing can be done for him. Something must be done, and a combination of swallowing movements and deep breathing, as far as that is possible, with counter-irritation through the chest wall should be carried out. Drugs also should be employed and the aroma of strong coffee with the irritating effect of ammonia upon the nostrils should be employed. These act upon the vagus so as to stimulate the heart, but above all they act upon the mind, and nothing so stimulates the heart as reawakened hope.

CHAPTER VII

BRADYCARDIA

Bradycardia, or persistent slow pulse, is much rarer than the persistent rapid pulse discussed at the beginning of the chapter on tachycardia. Cases are, indeed, sufficiently rare to be medical curiosities. Prof. Clifford Allbutt has called attention to the fact that the status of bradycardia or brachycardia, as Osler (following Riegel because of the analogue tachycardia) prefers to call it, is very different from that of tachycardia. In the latter, especially, in the specific sense of the term, the symptoms occur paroxysmically, endure for a definite length of time and then there is a return to the normal pulse rate. For this, or at least for the condition known as essential tachycardia, there is no well-defined cause and no definite pathological lesion. Bradycardia or brachycardia, however, is usually present as the result of some known physiologic or pathologic condition; it endures as long as the cause continues to act and then ceases, usually not to return unless the same cause gives rise to it again.

There are some cases, however, of slow pulse that cannot be traced to any definite lesion and in which the pulse is much slower at certain times than at others, though without its being possible to trace any definite immediate cause. These cases seem to be physiological analogues of tachycardia. In tachycardia there is an irritation of the accelerator nerves to the heart, in brachycardia of the inhibitory nerves.

Depressed Mental States.—Occasionally the reason for this can be found, though it is rather vague. In depressed mental states, for instance, a pulse between fifty and sixty is common. In people who suffer from periodic fits of depression it is not unusual to find that in the early morning the pulse is not more than fifty-five. I have seen patients who were worrying about their hearts present records of early morning pulse before they got up that were always below sixty. This is probably in a certain number of people quite normal. I remember a series of observations made on the attendants in the Charite Hospital in Berlin in which it was clear that the normal German morning temperature at seven a.m. was below 97 F., while the pulses were always below sixty. A reassurance of this kind is helpful to patients who have acquired the bad habit of taking their own pulse and have been disturbed by finding it so much below what they consider normal.

Illustrative Case.—A number of cases of persistent slow pulse seem to be congenital or produced by some definite pathological lesion, yet do not prove serious for the patient. Some years ago I described one of these cases in a paper read before the Section on Medicine of the New York Academy of Medicine28 and I have had the opportunity to follow it for about fifteen years. Though the patient's pulse is usually below forty and even after a rapid walk does not rise above fifty, she is in reasonably good health and during those years has buried two husbands. When I saw her she was compelled to go up and down stairs frequently and yet did not experience much difficulty. While patients suffering from palpitation would find it impossible, because of the discomfort produced, to make the journeys up and down stairs that she did, she felt only about as much respiratory discomfort as would come to a woman of her size. Her respirations were somewhat hurried—22 to 24 to the minute—but her general health was very good. Her urine was normal, her liver not enlarged, her ordinary organic functions were not disturbed and there was no sign of arterial degeneration.

With the pulse rate as low as this one might expect to find the patient phlegmatic, slow of movement and not readily moved to emotion. On the contrary, she has always been rather nervous and high-strung and inclined to be excitable. Her cardiac condition was first noted just after the first grip epidemic in this country, though her attention was not called to it during the course of the grip. It seems probable that the heart condition was acquired as a consequence of some irritative lesion affecting the inhibitory nerves to the heart that developed at that time. After her heart condition had been discovered she was for a time a skirt dancer and frequently danced for the amusement of her friends. She was always lively and active and after her first husband's death, when it became necessary for her to earn her own living, she was on the stage for a time and danced without any embarrassment of either heart or respiration. As a consequence of running down in weight and general health, owing to conditions since her husband's death, she noticed that dancing proved exhausting to her and she gave it up.

In general, she considered herself quite as capable as any of her friends for the ordinary duties and amusements of life. When I first saw her her digestion had been somewhat disturbed by worries and unsuitable nutrition taken at irregular intervals and this, I think, accounted much more than her heart for her complaint of tiredness on exertion. Later, after her second marriage, when she was in better circumstances, all her symptoms disappeared and even her heart rate rose so that it was seldom below forty, and after exertion always went to fifty. What was needed in her case more than anything was a change of environment, the satisfaction of mind that comes with freedom from worries and the cares of making her own living, and the improvement in digestion due to regular meals of good, simple, nutritious food.

Compatibility with Health and Activity.—The above case is interesting as illustrating mental influence upon such a serious condition as bradycardia. Most people who suffer from it are likely to be over-depressed and this reacts to disturb digestion and also further to disturb the heart itself. What these patients need above all, then, is reassurance with regard to their condition. There are some striking examples in history and in medical literature of bradycardia or persistent slow pulse in persons who are able to accomplish a large amount of work and whose general health and capacity for accomplishment were not at all disturbed by this physical condition. Above all, they were not depressed and did not lack initiative. Napoleon I, whose pulse is said normally to have been about forty, rising during the excitement of battle to fifty, is a typical example. Medical literature records a number of patients with congenital slow pulse without any discernible heart lesion who lived long and successful lives. One of these was a very successful English athlete. The prognosis of these cases is not as bad as it might seem to be and the mental state of the patient is more important than anything else in the treatment.

SECTION VIII

RESPIRATORY DISEASES

CHAPTER I

COUGHS AND COLDS

Cough under most conditions is so completely a natural reflex due to irritation from material which demands expectoration that to talk of the application of psychotherapeutics to its treatment would seem almost an abuse of words. This is true if we think of the curing of an ordinary catarrhal or bronchitic cough by suggestion. We know now, however, that, as a rule, we do not cure diseases, we only relieve their symptoms and thus enable nature to overcome the affection. The ordinary cough remedies do two things: they cause more liquid to exude into the lung tissues and thus soften and liquefy thick mucous material so as to make it easier to expectorate, or they lessen irritation and soothe the cough by making the nervous system less reactive. This second function of our remedial measures directed against cough can at least be assisted very materially by psychotherapeutics. Direct suggestion may be of great help, while the first function, that of softening the cough by liquefying the sputum, can be materially aided by certain suggestions to the patient of natural means and ways by which his cough may be relieved, its secondary symptoms modified, and its course abbreviated.

Cough and Suggestion.—Much of the coughing indulged in is quite unnecessary and might well be dispensed with. At many of the German sanatoria for consumption there is a rule that patients must not cough at dinner, and no coughing is heard in the refectory. Without such a rule the midday meal, if taken in common by the large number of consumptives present, would be a pandemonium of coughing. Cough is largely influenced by suggestion. Most of the respiratory reflexes follow this same rule. To see another yawn tempts us to yawn; to hear another cough tempts us to cough. In church or in a theater after an interval of interest one cough will be followed by a battery of coughs. People who have colds think they have a right to cough, and so they often cough much more than is at all necessary. Of course, when material accumulates in the lungs it must be coughed up, but not a little of the coughing might easily be dispensed with—it is unproductive coughing. A distinguished German medical authority who is accustomed to talk very plainly once said that it is quite as impolite and injustifiable to cough unproductively as to scratch the head unproductively. Only results justify either procedure.

Dry coughing, when persistent, is greatly a matter of habit acquired by yielding to slight irritation. When children scratch their heads we train them not to, and the same thing should be done with regard to yielding to reactions from slight irritations of their lungs.

Even when material has to be expectorated there is often much more fuss and effort made over it than is needed. Most men a generation ago insisted on their right to expectorate in public because it was better for them to rid themselves of offensive material than to retain it. The difference between men and women in this respect has always been distinctive. Women practically never expectorate in public, men do it frequently, or rather, let us hopefully say, used to. It seems to be thought the exercise of a manly privilege to spit and the boy learns the habit. It seemed almost a necessity in the past, yet now we have come to a point where, by legal regulation, we prohibit spitting in public and it seems likely future generations, not far off, will hold it as a rule that instead of the sexes being essentially different by nature in this respect, the habits formed by the enforcement of recent legal regulations will show their essential similarity and we shall have no "expectorating sex."

Unnecessary Coughing Harmful.—Coughing, unless it is necessary, always does harm. It irritates the mucous membrane, already rendered somewhat hyperemic and tender by the inflammatory process at work, to have the breath pass over it in such an expulsive way. This is one case where nature's indications are not to be followed. It is like itchiness in eczema: it needs to be restrained. The cold will get better sooner, the inflammatory process will run its course with less disturbance and in briefer time than if it was not disturbed in this way or disturbed only as little as possible. This is a point that is not often explained to patients and most sufferers from colds are inclined to think that the more they cough the better, even though the cough, like the scratching in eczema, evidently produces a roughening and sensitizing of inflamed tissue. Of course, this principle of the limitation of cough may be carried to excess and indeed sometimes is when opium is administered to quell coughing. This is not the idea, however, of the suggestion made here, which is only to restrain the cough within the limits necessary for the removal of material that should be evacuated.

The history of most of the tuberculous patients who suffer from hemorrhage for the first time shows that they had been coughing unproductively, and then, after coughing in this way rather severely, there came the flow of blood due to the rupture of a minute artery. In these cases the tuberculosis process has been at work for some time and has prepared the tissue for this arterial rupture, but there is no doubt, however, that the coughing itself, far from doing good, rather helped in the destruction of lung tissue, or at least made it more difficult for natural processes in the lungs to wall off the bacilli and prevent further damage. Practically every adult is in some danger of lighting up an acute tuberculous process in his lungs if he racks them by coughing. There are many similar examples in nosology of this possibility of some habit predisposing to or favoring the development of disease.

After measles and whooping cough tuberculosis is especially likely to develop. In both of these diseases, but especially in the latter, coughing is an element of the affection that probably predisposes to the implantation of the tubercle bacillus so commonly present in the air of our cities. The lesions produced in the extreme expulsive efforts of the paroxysm form favorable niduses for the micro-organism. Children particularly, if at all encouraged, are likely to cough more than is good for them. On the slightest irritation they cough. It is almost impossible to restrain them from scratching when they are suffering from eczema, yet we take rather elaborate means to do so, and quite as much must be done to prevent them from coughing when there is no special reason for it. This does not refer to cases in which material is being abundantly expectorated. Elimination can only be secured by a proper expulsive effort. Very often, however, children notice how much solicitude their little dry cough arouses. They like to be the objects of attention. They are dosed with various cough remedies, more or less pleasant, whenever they cough. Instead of being told that they should restrain their cough except when it is necessary, they are rather encouraged to cough whenever there seems to be the slightest occasion.

Reflex Coughs.—There are a number of coughs that are said to be reflex because they are not induced by any lesion of the lungs or of the larynx, or, indeed, of any of the air passages. In these cases some pathological condition is often found in another organ or set of organs, usually one of those connected with the vagus nerves. The wide distribution of these pharyngo-laryngo-esophago-pulmano-cardio-gastric nerves gives ample opportunity for reflexes. We hear much of reflex cough. There is a stomach cough and an intestinal cough, a uterine cough, an ear cough, etc. These coughs are always dry, though often very irritating to patients, and especially may be a source of dread and disturbance of mind and health because they seem to signify some serious pathological condition. As a rule, these coughs can be restrained to a great degree and frequently suppressed entirely by suggestion and discipline. In many cases there is some temptation to cough consequent upon irritation of nerve endings communicated through some devious paths to the nerve supply of the respiratory tract, but this tendency is not very strong and can be easily overcome. It may be said that this is asking too much of human nature, and that, just as sneezing carries with it a certain satisfaction and so is apparently worth the trouble of indulging in, coughing should be permitted, at least, if not encouraged, but the reasoning is fallacious.

Habit Coughs.—An interesting cough that comes to the physician is that in which there is absolutely no pathological reason to account for it. There is an irritation of the mucous membrane somewhere along the respiratory tract but it is very slight and somehow the habit has been acquired of yielding to the reflex that it occasions. I have seen these coughs in children in cases where I was sure that they were nothing but tics. I have seen so-called hacking coughs in girls of twelve to sixteen that were explained as ovarian, or sometimes as puberty coughs, that were really nothing more than habits. A slight hyperemia of the mucous membrane in the upper respiratory tract due to an ordinary cold began in a very slight degree the irritation, and then the habit of coughing was not given up. Of course, I know the danger of treating such cough as habit coughs. Tuberculosis in its initial stage may exist for a prolonged period before it produces any increase of secretion and at a time when none of the ordinary physical diagnostic signs are present, except possibly a little prolongation of expiration over the affected area. At this stage tuberculosis will sometimes produce gastric disturbance, and, as I have already said, these are spoken of as stomach coughs when there really is something much more serious than them at work. When there has been no running down in weight, and, above all, no special opportunity for contagion, then, if there are no physical signs in the lungs, these coughs will be best treated as habits and gradually be made to stop by suggestion. The limitation of coughing will do good in any case.

Coughs as Tics.—Some coughs are not really due to any difficulty in the respiratory tract, but are caused by nervous irritability. There are certain habits in the matter of clearing the throat that sometimes become pronounced and apparently impossible to stop. As I have said, these are tics rather than true coughs. Many of these neurotic coughs very seriously alarm patients and also their friends. They are dry, as a rule, rather harsh and inclined to be brassy. Occasionally they are only what is known as "hacks," as if the patient were trying to clear the throat of some offending material. Of course, at no time must the significance of cough be made light of unless a careful investigation of the patient's condition has been made.

Diagnosis.—Names for these coughs should not be too readily accepted which, by satisfying legitimate curiosity and lessening proper apprehension with regard to them, will stop further investigations. Besides stomach coughs, one often hears of intestinal and even uterine or ovarian coughs. In many cases the real condition is one of an incipient tuberculous condition and there may be no sign of this except a disturbance of the pulse and perhaps a slight variation of the temperature range for the day (two degrees or more Fahrenheit in the twenty-four hours). Such coughs should always be carefully investigated for the possibility of incipient tuberculosis. At once the patient should be warned about coughing without necessity, since this only tends to disseminate the tuberculous process and may help to break down nature's wall of protective lymph.

Where there is no disturbance of pulse or temperature and the patient is not under weight and there are no signs in the lungs, then the cough is merely a habit and partakes of the nature of a tic. Sometimes these habits are rather difficult to break; always, however, much can be done by suggestion, by a habit of self-control, by self-discipline, and by thorough persuasion of the patient. Drugs are likely to inveterate the condition if not allied with suggestion.

Removing Unfavorable Suggestions.—For the ordinary coughs and colds of the winter time there are many unfavorable suggestions that deserve to be eliminated. For instance, most people are sure that exposure to the air will inevitably make their cold and cough worse. This is a relic of the olden time when the confinement of patients to their rooms was supposed to be the best remedial measure for all respiratory diseases. Tuberculosis patients were kept in and died without any chance. Now these patients, even while running a temperature, or suffering from pleurisy, or the intercostal painful conditions that are often serious complications because of the irritability and discomfort produced, and which are so often supposed to be due to drafts, are put out on the porch, or on the roof of a hospital, or allowed calmly to lie in bed between two open windows, without the slightest hesitation. They begin to improve under such treatment much sooner than if they were confined, and indeed the whole prognosis of tuberculosis has been completely changed by the modification of the old-time habit of confinement to that of perfectly free access of outer air and even cold air that has taken its place.