Psychotherapy

This principle of treatment must be applied for coughs and colds. While patients are running a temperature they must not take exercise, they must not be allowed to work, above all they must not be allowed to get in crowds nor tire themselves in any way. The room in which they are, however, must be thoroughly aired, the window must be open all night and, if possible, they must sit in the sun for several hours a day. This will cure a cough or a cold quicker than anything else. Many coughs that hang on when treated by remedies of various kinds, yield at once if the patient is given an abundance of fluid diet and gets freely into the air. There is no danger of catching another cold, because a cold is not due to a low outdoor temperature, but to dust and microbes, and is a real infection.

Irrational Remedies.—There are an innumerable number of supposed remedies for colds. Scarcely any one who has reached the age of forty apparently feels that he or she is doing the whole duty to humanity unless they have some remedy for colds to recommend. Most of the popular remedies that are employed probably do as much harm as good and many of those that are very popular and are sometimes recommended even by physicians have no rational standing in present-day therapeutics. Perhaps the most popular is a combination of quinin and whisky. The effect of this is to give patients, who are unaccustomed to whisky and who are susceptible to quinin, about as uncomfortable a twenty-four hours the day after they take the remedies as can be imagined. Quinin now has no possible specific therapeutic significance in the cure of the series of infections called colds. In the days when we did not understand malaria and considered it in some way as an essential fever due to the absorption of miasmatic material, quinin seemed to have a specific influence upon several conditions. Accordingly it was employed in all sorts of fevers and, because it is comparatively harmless, also in that short infectious fever which we call a common cold. No physician now employs it (except in small doses as a general tonic) for febrile conditions, unless in malaria. There we know that it acts by killing the plasmodium and is a real specific. We do not think of it any more, however, as a general febrifuge and there is no justification for its use in the slight infective conditions we know as colds.

As for the whisky, if taken in stiff doses as it often is, the reaction is likely to make the patient quite miserable the next day. It seems to be the rule for him to think that if, notwithstanding the taking of the quinin and whisky, he feels thus ill, he would have been ever so much worse without it. Colds, however, when left untreated so far as drugs go but managed by natural means often run a mild course. Some of the reputation of quinin and whisky is due to the fact that not infrequently persons suffer from chilly feelings that seem to portend a cold and take quinin and whisky and the cold does not develop. The remedies are then supposed to have aborted or to have inhibited the development of the cold. Anyone who has seen a number of these cases treated expectantly, however, knows how often it happens that the chilly feelings that seem to announce the cold pass off without incident after a good night's rest.

Rational Treatment.—The old rule of getting the emunctories at work must be the basis of any rational therapy of colds. A mild opening of the bowels, especially if there is some constipation, a hot drink on going to bed so that there is some sweating and perhaps the use of a mild diuretic will almost surely affect these cases favorably. Patients have to be careful, however, next morning to stimulate the circulation in their skin to activity so that the cutaneous muscles shall react upon the capillaries and the capillaries themselves tonically contract in order that there may not be too much blood near the surface of the body, or the patient may easily be chilled in cold weather. This chilling of the blood when much of it is near the surface seems to lower its vitality and the patient easily reinfects himself or, if he goes into dusty or crowded places, catches a fresh dose of infectious material. This is the process which is called catching a fresh cold.

The removing of the unfavorable suggestions of remedies that do harm rather than good and the giving of favorable suggestions founded on our present-day knowledge of what a cold is and just what we need to do in order to benefit it, is the most important element in the treatment. Above all, however, the patient must sleep in an airy room and must be sure that he is neither breathing his own expired air nor that of anyone else. With thorough ventilation, however, and the stimulating effect of the cold air and the confidence due to proper directions, colds rapidly get better.

There can be only one reason for keeping patients indoors who are suffering from cold. That is, if they are suffering from fever, the being out involves exertion. In that case, of course, patients must rest and must avoid exertion, but there is no reason why they should not have all possible fresh air. The unfavorable state of mind towards fresh air and especially night air in these patients was cultivated by the profession up to a generation or two ago, but is quite unjustified by our present knowledge. Night air is probably a little better than day air because it is freer from dust. It is because of malaria that night air was supposed to be detrimental, but we have found that the only good reason for this was that the mosquito travels at night. There are no other constituents of night air that produce any serious effect.

As a rule, patients suffering from colds need more sleep than other people and above all need more sleep than they ordinarily take, for this will increase their resistive vitality and enable them to throw off the infection. A good rule is to add two hours of sleep to the usual quota. The unfortunate habit of keeping people indoors and of keeping fresh outdoor air away from them, because it is feared they will catch a fresh cold, often seriously disturbs sleep and delays recovery. In a word, many a cold that hangs on does so mainly because of unfortunate suggestions of one kind or another that have come to occupy a place in the supposed therapeutics of the condition. The removal of these and the insistence on just as much recourse as possible to the therapeutic means at nature's command constitute the basis of successful therapy of these very common infections, which probably are the source of more morbidity in the community because of their wide diffusion and frequent recurrence than all the other infectious diseases put together.

CHAPTER II

TUBERCULOSIS

Tuberculosis, in spite of all our efforts against it, remains in Defoe's striking phrase the "captain of the men of death." Pneumonia has preempted its place in the statistics of mortality, but this is to a considerable extent because tuberculosis at the end masquerades as an acute pneumonic exacerbation. Not less than one in eight, probably more, of all those who die, die from tuberculosis. It is the most serious of diseases. In spite of its eminently physical character it probably affords the best possible illustration of the place of mental influence in therapeutics. We have had any number of new cures for tuberculosis, introduced by serious physicians who were sure from the results they had secured that they had found an important new remedy. After a few years each of these cures in succession has been relegated to the limbo of unused remedies because found inefficient. At the beginning they produced a beneficial influence because of the suggestion of therapeutic efficiency that went with them. When this suggestion failed because the physician who administered the remedy lacked confidence, the real place of the supposed specific as merely another mind cure was recognized.

Indeed, many of the remedies that have been introduced have not been merely harmless drugs, but not a few of them have probably had rather a detrimental physical effect than a beneficial influence. In spite of this, the influence on the patient's mind has been sufficient to neutralize whatever of harmfulness there might have been and to arouse new courage and new energy. The consequence of this has always been that the patient was tempted to live more in the open air and to eat more. These are the two efficient remedies for tuberculosis. With the additional life in the open air and increase of food his appetite grew, for nothing so adds to appetite as the exercise of it, and with the gain in weight there was a cessation of cough, a reduction of fever, a disappearance of night sweats and a definite increase in resistive vitality which gradually helped to overcome the disease. Manifestly, then, the use of mental influence in tuberculosis is very significant.

PROGNOSIS AND SUGGESTION

The most important element in any treatment of tuberculosis must be the neutralization of unfavorable suggestions which are weighing upon the patient and preventing him from using even the vital forces that he has for resistance against the disease. The popular impression of tuberculosis, happily waning, is that it is an intensely fatal disease.

Though this is true in general, tuberculosis is by no means a necessarily mortal disease in individual cases, and, indeed, a great many more patients recover from tuberculosis than die from it. Papers read at the International Congress on Tuberculosis, in Washington, in 1908, showed from careful autopsy records that practically all adults either actually had had at the moment of death, or had suffered previously from tuberculosis. If there are not active lesions then there are always healed lesions of tuberculosis in the body of almost every human being who has passed the age of thirty. Most people have quite enough resistive vitality to enable them to recover from the disease. It is only those who are placed in very unfavorable circumstances during the initial stage of the disease, or who have some serious drawback against them, who succumb to it. The fact that the bacillus finds a lodgment in so many individual tissues shows that it is not insusceptibility that makes the difference between people, since we are all susceptible, but it is the lack of resistive vitality, and that most of us have, under ordinary circumstances, and all of us can have under favorable conditions, quite sufficient immunizing power to prevent serious developments.

Even in advanced cases it is perfectly possible for the progress of the disease to be stopped and for many years of useful life to be gained. Probably patients who have gone beyond the incipient stage, in whom there has once been a breaking down of pulmonary tissue never are entirely cured, but they may be so much improved that all their symptoms disappear and they are able to follow an ordinary occupation for many years. There is no disease in which the unfavorable prognoses of physicians have been more frequently disappointed than in tuberculosis. In any city hospital dispensary one finds many cases of tuberculosis turning up as relapses of previous conditions, with the story that when they were seriously ill before, some prominent physician, since dead, said they had only a few months to live. The fact that the physician who made the unfavorable prognosis has since died himself adds greatly to the zest with which patients tell their story. Neither the severity of the symptoms nor the amount of lung tissue attacked is quite sufficient to justify an absolutely unfavorable prognosis in the majority of cases of pulmonary tuberculosis.

No Incurable Cases.—Above all, it cannot be insisted on too emphatically that there is never a time in the course of the tuberculosis when a physician is justified in saying to a patient suffering from any form of tuberculosis that his case is hopeless. One is never justified in saying "You are incurable." Practically every town of any size in this country has a number of cases in which patients were told by physicians that there was no hope, and yet they have recovered to chronicle as often as they get the chance the fact that they have outlived their physician. To say that no case of tuberculosis can be confidently declared incurable will seem to many an exaggeration. There are patients in whom the prognosis is so unfavorable as to be almost hopeless. There are never cases of which it should be said there is no hope. When patients are told, as they so often are, that they are incurable, absolutely no good is done and harm is inevitable.

Heredity of Resistance.—When the disease has developed very rapidly in patients in whom there is no previous history of tuberculosis, and in whom there is no history of previous cases in the family, the outlook is always serious. These cases come as near being incurable as any the physician sees. But the most apparently hopeless of these will sometimes recover, contrary to all anticipation. In spite of the opposite impression so commonly accepted, the most helpful element in these cases is the presence of a trace of tuberculosis in the family history. This always means the existence of some immunity against the disease and there may be a turn for the better even when the case looks absolutely hopeless and when it seems to just be verging on its fatal termination. Probably the most discouraging are the cases in which miliary tuberculosis is at work and conditions are about as unfavorable as possible. There are cases of this kind on record, however, with the most startling contradiction of anticipation, in which undoubted miliary tuberculosis produced high fever for weeks and even months, then gave rise to pleurisy, to peritonitis, to various cutaneous abscesses and to abscesses of bone, in which patients lost one-third of their weight or even more, and yet after the external lesions began to discharge freely, recovery occurred.

Slow Cases.—As for slow-running cases in which there is a distinct history of tuberculosis in the family, not even the most experienced physician can state with any certainty that a fatal termination is inevitable and that recovery cannot occur. Some of the most expert diagnosticians have been deceived in these cases. After half a dozen physicians have given a man up, some gleam of hope has buoyed his feelings and a turn for the better has come. Men with cavities in three lobes, even in four lobes and occasionally it is said in all five lobes, have survived acute stages, have recuperated to a considerable degree and have been able to return to work or at least to take up some useful occupation for a time. Where the lung lesion progresses slowly it is surprising how small an amount of healthy lung tissue is needed to support life. Only those familiar with many autopsies on the tuberculous can appreciate this. Ordinarily we are apt to think that when more than half the pulmonary tissue is involved so as to be of little or no use for respiratory purposes, death must be inevitable. On the contrary, one-fourth the ordinary lung capacity will serve and all of one lung may be quite out of commission and only a portion of a single lower lobe be available, yet the patient may survive for a prolonged period.

The Specter of Heredity.—The most serious contrary suggestion that patients suffering from tuberculosis are likely to have is that their affection is hereditary and that, therefore, there is little hope of its cure. It is in the family strain and cannot be obliterated. This idea, fortunately, does not carry the weight it used to. It should, however, have no unfavorable influence at all and this needs to be emphasized. We discuss the subject more fully in the chapter on Heredity. We know very definitely now that the hereditary element in tuberculosis is so small that it is quite negligible. There are good authorities who do not hesitate to say that heredity plays no role in the causation of tuberculosis and does not even produce a predisposition. Some remnant of the old superstition (for superstition, from the Latin, superstare, means a survival from a previous state of thinking, the reasons for which have disappeared) always remains, and predisposition is the last rule of outworn opinion.

We know now that contagion is the important element. The possibilities for contagion vitiate all proofs of the predisposition idea. Especially is this true when we recall that thirty years ago practically no one took proper precautions to prevent the dissemination of tuberculosis, and very few took them even fifteen years ago. Even at the present time many tuberculosis patients cough around the house with open mouth, spreading tubercle bacilli all around them. We are caring for the sputum, but many other avenues for the diffusion of the disease are open. Children acquire the infection, overcome it, but retain the seeds of it in them and then in some crisis in life, as after puberty, or when they are over-working and over-worrying, or during the first pregnancy, an opportunity is given to still living tubercle bacilli to find their way out of sclerotic confinement. Other forms of contagion count in the absence of a case in the immediate family. We can trace the contagion only too easily, even if there is no consumptive member of the home circle. Scrub-women, laundresses, those who are careless in their attendance upon the tuberculous, workers in dusty places or in factories, where there are others who cough, all these get the disease. Predisposition counts for so little that it is a vanishing factor.

Patients can be assured at once then that they need not worry that the hereditary factor will make their affection less curable. On the contrary, our recent careful studies in tuberculosis show just the opposite of the old false impressions. The children of parents who had tuberculosis are much more likely to possess resistive vitality to the disease than those whose parents never had it. As we emphasize in the chapter on Heredity, the nations that have had the disease the longest among them are the most resistant to it. When the affection is newly introduced into a tribe or race it carries off a great many victims. This immunity, however, is not a function of heredity or of the increase of resistive vitality by the inheritance of an acquired character from the preceding generation, but tuberculosis takes the non-resistant, weeds out all those who have not some immunity against it, and consequently those that are left possess some immunizing power. Tubercular heredity, then, instead of being a source of discouragement should rather be a source of hope. It is surprising to note what a relief to many patients' minds is the explanation of this newer view of heredity in tuberculosis; it lifts a burden from many and makes them eat and sleep better for days.

ANNOUNCING THE DIAGNOSIS

Friends and especially near relatives sometimes come to a physician when there is suspicion that a young person is suffering from tuberculosis and ask that, if there is a ground for a positive diagnosis, it shall not be communicated to the patient. They usually urge that they fear the discouragement will kill the patient. The young are not so easily killed and the reaction on being told the truth and the facing of it bravely is such a magnificent help in therapeutics that the physician should always refuse for the patient's sake alone, quite apart from any ethical obligations in the matter, to enter into any such arrangement. The assurance may be given that the patient's condition will be so stated that, far from the patient being discouraged after due consideration, he or she will look forward with confidence to overcoming the affection.

EARLY DIAGNOSIS

Mental treatment is most valuable in the very early stage of incipient cases of tuberculosis. The time is past when the diagnosis of tuberculosis was made only after the recognition of definite physical signs in the lungs and a considerable loss in weight.

In the Medical News for April 9, 1904, I called attention to the question of "Early Diagnosis of Tuberculosis" from the pulse and the temperature in these cases, and pointed out that a disturbance of temperature need not necessarily be a febrile temperature of over 100 degrees, but that any increase of the normal daily variation of temperature, usually considered to be about a degree and a half, should suffice to arouse serious suspicion at least. If the morning and evening temperatures differ by two degrees, this would indicate the presence of some pathological condition, usually tuberculosis. If in addition to this and the pulse disturbance there is any localized area of prolongation of expiration, then tuberculosis is almost certainly present, even though there may be no other physical signs, no cough, no tubercle bacilli in the sputum, nor any other signs of an active process.

It is in these cases particularly that patients can be benefited. Very often they have a slight hacking cough, frequently repeated, with some disturbance of appetite and of digestion and sometimes some loss in weight. Indigestion is recognized now as one of the early stages of tuberculosis. The cough in these cases, as has been said, is often spoken of as a stomach cough and is supposed to be due to the nervous reflex from the pneumogastric nerve carrying irritative impulses from the stomach to the lungs. It is much more likely to be due directly to irritation of the terminal filaments of this same nerve in the lungs themselves.

FAVORABLE MENTAL ATTITUDE

The most important element in any cure or successful treatment of the disease is a favorable attitude of the patient's mind. He must be told at once that consumption takes away only the "quitters." People who give up the battle or who, though still hoping, do not hope actively—that is, do not make the exertion necessary to get out into the open air and to eat heartily—inevitably succumb to the disease.

Eating.—Eating is often more a question of exertion than appetite or anything else for consumptive patients. They have no active appetite and they simply must force themselves to chew and swallow. Their fatigue from chewing is, indeed, likely to be so disturbing that it is advisable to furnish patients as far as possible with such food as requires no chewing. Milk and eggs and the thin cereal foods, like gruel, and rather thin puddings are the best for this purpose. Patients must be persuaded that they must take these whether they care for them or not. Occasionally they may cough after a meal and vomit it up. The rule in the German sanatoria for consumptives is that whenever this happens they must, after a short interval, repeat the whole meal. Only rarely does it happen that a tuberculous patient vomits without some such mechanical cause as coughing. They must be made to understand that any food that stays down does them good no matter how they may feel toward it.

The actual state of affairs as regards their future must be put before them. It is a question of eating or of death. They face these two alternatives. Eating is objectionable but, as a rule, death is more so. The kinds of food they do not care for, if they are good for them, must be insisted on. Most people who think that they cannot take milk can do so, if it is only presented to them insistently, with at first such slight modifications of taste as may be produced by a little coffee, or tea, or vanilla, or by some other flavoring extract, which modifies its taste. Butter and the meat fats will be taken quite readily if it is only once made perfectly clear to patients that they must take these or else lose in the conflict with the disease.

It deserves to be repeated here that in many of these cases the disinclination to eat is due to the fact that patients find it almost intolerably wearying to make the effort necessary for mastication. This is particularly true if they are asked to eat meat frequently, and especially if asked to eat underdone beef, which usually requires vigorous chewing. Such meat is excellent for them once a day, but it may be made much easier to take by chopping or scraping so that practically no exertion is required. Besides, it is by no means necessary that these patients should eat much meat nor that they should have to chew laboriously at their food. Raw eggs may be the basis of the diet, especially eggs beaten up, and these will be found not only to be very tasty, but eminently digestible. Their vegetables may be taken in purees, so that they require very little chewing effort, though patients must be warned to mix starchy substances well with saliva so as to facilitate their digestion. Their bread may be taken in the shape of milk toast, or in some other soft form—bread pudding for instance. All this helps, without demanding too much effort, to prevent loss of weight and to regain it when it has been lost.