Psychotherapy

Air and Comfort.—Next to food, the most important adjuvant is fresh air. Often patients find many objections to this. It is too cold for them; they are shivery and become depressed. Most patients need to be dressed much more warmly than is the custom at present, and hands and feet should be covered with woolen gloves and socks and even a woolen hood worn around the head if necessary. There is usually too much covering worn on the chest and too little on the extremities. With fleecy wool garments next the body and sufficient clothing, properly distributed, many a patient who complains of the cold will at once be more comfortable. They must be made to understand that fresh air is absolutely essential. Every extra hour they spend in the air is that much gained; every hour they spend inside is just that much lost in the curative process. If they are uncomfortable, however, they become discouraged, and a discouraged tuberculous patient never resists the progress of his affection. Not only does he not improve, but he inevitably retrogresses. It must not be forgotten, however, that the thin anemic patients who complain bitterly of the cold, when they first take up the habit of living outside, will grow used to it after a time and then will from habit and the accumulation of a ten-pound blanket of fat be able to stand the cold much better than many healthy persons.

Stimulating Examples.—Tuberculous patients need to have their courage kept up. It is true that the toxin of the tubercle bacillus has the definite effect of stimulating its victims so that they are likely to be hopeful, but very often this hopefulness is vague and does not tempt them to eat and to live in the open air, the two things that make their continued resistance to the disease possible. I find that the knowledge of how bravely and how successfully other sufferers from the disease resisted its invasion and succeeded in doing a good life's work is the very best tonic that sufferers from tuberculosis can have. Needless to say, there are any number of examples of heroes of tuberculosis who put to shame perfectly healthy people in the amount of work they succeeded in accomplishing in spite of the drawbacks of their disease. The unfavorable suggestion of the number of deaths from the disease must be overcome by the contrary suggestion of the brave, busy lives lived by those who suffered even the very severe form of the disease and often accomplished the full term of existence in spite of their handicaps from tuberculosis.

Robert Louis Stevenson .—The best example in recent years is undoubtedly Robert Louis Stevenson. In spite of tuberculosis in severe form which prevented his living in the ordinary climates for the last twenty years of his life, he succeeded in doing an amount of work that is simply marvelous and in influencing his generation more widely than most of the perfectly healthy writers who lived in his time. There are over, 2,000,000 published words to the credit of Stevenson, and, when we recall that most of this, owing to his critical care, had been written over and over many times, some idea of the vast amount of work he accomplished will be realized. Perhaps the climax of his cheerful nature, the utter lack of discouragement in the face of what is usually the most depressing possible incident, is to be found in his famous letter to a friend telling him, as he lies in bed, that he cannot write at any great length now but that he will write a long letter next week if "bluidy Jock," his playful name for hemorrhage from the lungs, would only let him.

One of the most striking illustrations of his insatiable appetite for work and his complete refusal to admit that he was being conquered by the disease has been recently told with regard to his unfinished novel, "St. Ives." He had been suffering from certain severe symptoms and had been forbidden to do anything at all, even to dictate brief notes, or anything else that would make any extra work for his respiratory organs. The ideas for chapters of "St. Ives" were in his head and would work themselves out in spite of the doctor's prohibitions. He would not let the thought of his disease overcome him, and so he dictated these chapters to a secretary in the sign language, which he had learned so as to be able to communicate under such conditions. I know nothing that is more likely to make people realize how a brave spirit can overcome every discouragement of body, and how much such a spirit is its own reward, since it secures for its possessor a prolongation of the life of the body that would surely be worn out by depression, by discouragement, and by worry. Undoubtedly Stevenson's interest in his work literally gave him new life. It did use up some nervous energy, but if his mind had been occupied by thoughts of his disease, and its probably fatal consequences, much more of his precious store of nervous energy would have been exhausted in anxiety and worry.

J. Addington Symonds .—After Stevenson probably the most striking example among modern literary men is John Addington Symonds. Comparatively early in life he found that he could not live in England owing to the inevitable advance of tuberculosis when he tried to do so. He took up his residence then at St. Moritz and other places of rather high altitude in Italy and continued his literary work. When we see the row of books that we owe to Symonds' literary activity it is surprising to think that he, too, like Stevenson, had to watch his temperature, that every now and then there were discouraging developments and incidents in his tuberculosis, and that a return to the ordinary habitations of men away from the friendly altitudes of the Italian Alps was always followed by a recrudescence of his symptoms. Symonds' work was not merely literary, but his books are valuable historical monographs on many subjects requiring much reading and diligent study and consultation of authorities. There are few men in perfect health and with abundant leisure who have succeeded in accomplishing as much as did this hero of tuberculosis.

Thoreau .—There are other distinguished literary men of the nineteenth and twentieth centuries the stories of whose tuberculosis has a special interest and tonic quality. One of these is our own Thoreau, another is Francis Thompson, the English poet, whose recent death has brought him even more publicity than did his great poems while he was alive. Both of them are typical examples of another phase of tuberculosis that is interesting to realize. It is probable that if Thoreau had lived the ordinary, practical, everyday life, which those who lived around him thought he should, he would have died of tuberculosis before he was thirty. He had no use for money beyond his present needs and when he had made enough to keep himself very simply he refused to earn any more. He had not time, as he said, to make money. He wanted to live his life for itself and for the interests higher than the material that there can be in it. Accordingly, he set himself to learn all about the birds and beasts and the trees and plants and the waters and their inhabitants around his country home. He introduced the modern taste for nature study in its most beautiful way. He spent most of his time out of doors.

Undoubtedly this out-of-doors life prolonged existence for many years beyond what would have been his term. His biographers say that probably his being out of doors in all sorts of weather laid the foundations of "the cold which settled on his lungs" and eventually carried him off. Those of us who know anything about tuberculosis, as it has been studied in recent years in the tuberculosis sanatoria, are not likely to agree with such an opinion. Our patients in the Adirondacks live outside ten or twelve hours a day and then sleep with their windows open with the temperature sometimes down to zero during the severest winter weather. Rain and dampness are not allowed to interfere with the open air program. Colds that "settle on the chest" so that people die from consumption are not due to exposure to cold but to the bacillus of tuberculosis. Where this once gains a foothold the one hope of prolongation of life is out-door air and the more cold and stimulating that out-door air is, provided he can stand it without discouragement, the better for the patient. Thoreau is an example of a man whose life was prolonged by his out-door habits and by his refusal to live the humdrum, practical existence of other men, just to be like those other men and measure his supposed success by their standards.

CHARACTER AS A THERAPEUTIC ASSET

Recent interest in tuberculosis has taught us that the best possible asset for a tuberculous patient is character. Resistive vitality in the physical order and character in the moral order seem to be co-ordinate factors. If a man will not give in in the fight, if he insists on struggling on in spite of difficulties, discouragement and an outlook that seems hopeless, then he will almost without exception get over his tuberculosis, if there is any favorable factor in his environment. We talk much of immunity inborn and acquired to the disease, but it seems to go hand in hand with a certain capacity to stand the debilitating symptoms of the disease without allowing one's mind to become depressed or one's disposition rendered despondent by them.

Courage and Constancy.—The career of Dr. Trudeau to whom we owe so much of our knowledge of tuberculosis is a striking example of the power of character to enable even an apparently delicate organization to withstand the ravages of the disease. This is all the more striking because he was an advanced case when he finally reached an environment in which he could make head against the disease. The story of his own personal struggle for life at Saranac, in which he both learned himself and taught others what the modern treatment of tuberculosis should be, is one of the best therapeutic documents of modern times. Under circumstances that were quite apt to be discouraging to anyone of less character than he, with the bitter cold of the Adirondacks around him and quite inadequate heating facilities, so that even old-fashioned lamps were in requisition for heating purposes, he yet succeeded in winning back his own way to health and showing others how it could be done. The struggle had to be kept up for long, it had to be renewed again and again, our greatest American authority on tuberculosis had to learn in his own person all the clinical details of the disease, but in the midst of it all he succeeded in accomplishing a life work that will stand beside that of any man of his generation and will probably mean more in the history of American medicine than that of any of his supposedly more distinguished colleagues in our large cities and large teaching institutions.

This is the sort of man whom tuberculosis does not take in spite of every advantage that the disease may seem to have. Two others of our American authorities on tuberculosis had almost the same experience.

Persistence.—Recently I have been in correspondence with a young man who illustrates the same power quite as strikingly. He went to Florida and soon found that the unfortunate fear of tuberculosis that has so unwarrantably come into many minds in recent years made it extremely difficult—indeed, almost impossible—for him to live under such circumstances as he hoped for when he went there. In any boarding-house he went to just as soon as there was question of his having tuberculosis the landlady would either insist on his leaving at once or else plead with him to take his departure, lest her other boarders should desert her. He was coughing, he had some fever, his disease was advancing in the midst of all this disturbance, physical and mental, and the outlook seemed hopeless. His picture of this selfishness of humanity, scared about nothing (for there is practically no danger if tuberculous patients take reasonable precautions, as even nurses in sanatoria do not acquire the disease, though living in the midst of it), constitutes one of the most poignant indictments of human nature in its worst aspect that I have ever had presented to me.

Finally he made up his mind that there was nothing for him to do but to tent out and live by himself. Fortunately he was able to do that and just as soon as he was settled under circumstances where human nature did not bother him, nature began to do him good. He feared that he would die during the first month in the tent, for he was having fever up to 102-1/2 and sometimes more every afternoon; but he laid in a store of provisions which with the milk and eggs delivered to him every day enabled him to stay in bed for a week, opening up the flap of the tent in the middle of the day. Then he went out and got another stock of provisions and stayed in bed for another week. His thoughts were gloomy enough, he had only some old illustrated newspapers to give him a few fresh thoughts every day, he had no one to visit him, but he hung on and kept up his habit of rest and forced feeding in spite of disinclination. At the end of two weeks he had no temperature in the afternoon. At the end of the third week he made for himself a reclining chair and sat in the sun outside of his tent wrapped in a blanket. At the end of four weeks he had gained five pounds in weight. From that on all was plain sailing. It was his character that conquered his tuberculosis.

SUGGESTION AS TO SYMPTOMS

Besides the value of suggestion for the general condition in tuberculosis many of its symptoms can be treated best by changing the mental attitude of the patient towards them and giving him a proper appreciation of their significance. Most symptoms are likely to produce exaggerated reactions, especially in patients who are over-solicitous about themselves. Not a few of the symptoms are really nature's attempts at compensation, or the result of conditions which show a natural disposition to bring about a cure. Fever, for instance, produces lassitude and great fatigue on exertion, and patients are prone to think that this means weakness or exhaustion. It is really only an indication of the necessity for rest, and is brought about by nature's refusal to supply all the demands of the muscles for nutrition, at a time when the febrile condition is burning up a lot of extra material. Far from being a disadvantage, weakness is a decided advantage in this condition.

Hemorrhage.—Probably no symptom that occurs in connection with tuberculosis is more influenced by the mental attitude than hemorrhage. It is a most disturbing incident. Even in quite small amounts it upsets the patient seriously and, of course, in large amounts it is a source of profound disturbance even to the most placid of patients. Excitement always adds to it. Probably no physical means that we have at command can be depended on to control it. Ergot used to be popular, but such physiological action as it exerts, so far as we know the drug, would seem to be likely to do as much harm as good.

Other remedies have gradually lost favor in the hands of those who have had most experience with the symptom and gallic acid and supra-renal extract, the older and newer remedy, are now little depended on. Two things are important—to secure lower blood pressure and lessened pulmonary activity. For these opium in some form is undoubtedly the best drug; and then a placid state of mind on the part of the patient must be secured as far as possible. The scare in these cases, in so far as it is relaxing, is rather favorable than unfavorable for the patient. In addition, it is necessary to insist on absolute quiet and silence and then to allay all reactionary excitement. It is important to make patients realize that while hemorrhage is a serious complication, it is by no means so serious as is usually thought.

Many cases of tuberculosis that eventually run a slow course are ushered in by hemorrhage, or have it as a very early manifestation. It is surprising how many people have had hemorrhage as a symptom and live to tell of it thirty or forty years later. This was not due to any mistake of diagnosis, for a generation ago tuberculosis was more likely to be missed when actually present than to be diagnosed when absent. Indeed, this tendency for the cases in which hemorrhage occurred to run not so fatal a course as others was a fact that seemed to an older generation of physicians to require explanation. They suggested that possibly the hemorrhage swept out with it some of the virulent elements from the lungs and so lessoned the infection. From what we now know this is a doubtful explanation, but it seems not unlikely that a frank hemorrhage might reduce the amount of toxins in the circulation and so in an early stage of the disease give nature a fresh start in resistive vitality.

What is much more likely, however, is that the occurrence of early hemorrhage made it easier for the patients to appreciate the seriousness of the affection and brought them to accept advice as to proper precautions. Under ordinary circumstances it is difficult and used to be even more so in the past to make the patient understand at the beginning of the affection the necessity for giving up indoor occupations and living the outdoor life with the care for nutrition that is so important if the case is to be improved. Hemorrhage scared them into submission. In the old days it was the first positive symptom of consumption. Now we have many others, and instead of following the advice of over-solicitous relatives that we should not tell patients what is the matter with them, we tell them frankly and secure such care of the health as will bring about improvement. Probably nothing illustrates so well the necessity for thus influencing the patients' minds into caring for themselves as the fact that the hemorrhagic cases, as a rule, do better than the others. All of this can be used to make the minds of patients much less disturbed than they would otherwise be by this alarming symptom.

Cough.—In the chapter on Coughs and Colds we have outlined how much coughing may depend on suggestion, or habit, or on the tendency to yield to slight bronchial irritation when there is no real necessity for it. Most tuberculous patients cough much more than is necessary. This is always somewhat dangerous for them since it disturbs their lungs, has a tendency to distribute tubercle bacilli in their lungs, or in the air around them, and may by efforts at expulsion lacerate affected blood vessels and produce hemorrhage. Whenever cough is productive it should be indulged in, for it removes material that should not be allowed to accumulate. Unproductive coughing, however, can usually be controlled by training.

It is particularly at the beginning of phthisis that the control of coughing by suggestion is important. There are many little coughs, "hacks" as they are sometimes called, frequently repeated by those in a very early stage of pulmonary tuberculosis and which are consequent upon irritation either of pulmonary nerves or of pulmonary tissues, but that are quite unnecessary, as a rule, if a little attention is paid to suppressing them. As a warning sign they are excellent, but the patient should be taught not to indulge in them. Coughing tends to prevent nature's curative reaction and the contraction of pulmonary tissues which may take place around a lesion. In beginning consumption, even where there is but slight infiltration, we know from the observation of the movements of the diaphragm either by the X-ray or directly by Litton's method that its excursions on the affected side are shortened. Coughing is in direct opposition to this setting of the lung at rest and therefore should be controlled; however, as our drug remedies are likely to disturb the stomach, whose healthy function is so important in these cases, the use of the mind in the control of the cough is of the greatest value.

Thoracic Discomfort.—Complaints are often made by the tuberculous of pains in the thorax. Ordinarily the discomfort is supposed to be due to the lung condition, and it is assumed that it is either actually in the lung itself or in the pleura, or communicated from them by reflex to the muscles. In most cases, however, patients complain of pain on the side that is either not affected at all or least affected. If they have been told that the other side is suffering most from tuberculosis, they are prone either to think that now the well side is being invaded or else that their physician is making a mistake, and both thoughts are seriously discouraging. The reason for the pains on the well or the better side, however, are easy to understand. As far as possible, as can be readily demonstrated by the X-rays or seen in the observation of the so-called Litten's phenomenon—the excursions of the diaphragm—nature puts the ailing lung at rest and the diaphragm moves much less on that side than on any other. In order to make up for the lack of breathing in this side the other lung does compensatory work. This over-stretches the muscles of the thorax on the well side and causes some over-work in them. The consequence is a tiredness which may become fatigue; in damp weather this may be even painful. Just why damp weather has this particular effect on muscles is not surely known. Muscular action is probably accomplished with more difficulty in damp weather because of the relaxing effect of moisture on tissues and circulation. Reassurances may be given them, then, that will keep them from thinking seriously of the significance of these pains except as an index of nature's compensatory efforts. The painful conditions instead of causing discouragement will, then, be a source of encouragement. It must not be forgotten that rubbing with some gentle stimulant, soap, liniment, or the like, will greatly improve the thoracic muscles in these cases, but the rubbing must be done gently and by someone else beside the patient, for it is only beneficial if done from before, backwards, in order to help the return venous circulation which runs in that direction in the external respiratory muscles.

Altitude.—There is a marked difference between the amount of water which finds its way out through the lungs at varying altitudes. At sea level an ordinary patient will lose during the night about 300 cc, that is, something more than half a pint of water, through his respiratory tract. At an altitude of 5,000 feet, however, this amount is almost doubled, and at 10,000 feet is almost trebled. At 2,000 feet it is half as much again as it is at sea level. This copious giving off of water has a marked effect on the lungs. It constitutes one of the reasons why altitude is a favorable element in the treatment of tuberculosis. Only beginning cases of tuberculosis, however, are able to stand the additional work thus put on them, though a slight elevation, up to 2,000 or even 3,000 feet, rather seems to be of benefit to all cases. How far-reaching the effect of this extra loss of fluid is, is appreciated from the concentration of blood which takes place and which produces a blood count of 8,000,000 red cells at a mile of altitude in patients who, at the sea level, have no more than 4,500,000. Such patients, of course, need much more water and fluids generally to be comfortable than when living lower down.

Suggestion and Treatment.—There are many accessory suggestions with regard to food that serve to confirm the patient in the idea that abundance and variety of food must be taken if the battle with the disease is to be won. To patients who find milk difficult to take, it must be explained that a copious amount of fluid in the system is needed in order to make coughing easier. So milk serves a therapeutic as well as a nutritional purpose. In the same way it may be explained that fats, such as bacon and cream, help to keep the bowels from becoming constipated and constipation inevitably disturbs the appetite.

Explanations as to the advisability of being out of the city and in a portion of country not very thickly populated, in order to avoid the possibilities of secondary infection with other respiratory diseases and bacteria of various kinds, will make a patient understand the necessity for leaving town. It may be helpful, also, to insist on the value of living at some elevation above sea level as an aid to expectoration.

Cough is the symptom that many of these patients fear most, and a promise of any amelioration of it by a simple change of location helps them to make the sacrifice of city life for a while. Some patients who have been benefited by a stay in a sanatorium come back with a relapse of their symptoms. They dread to return to the sanatorium and think they can care for themselves as well at home, since they know what the regulations are, though it may be evident to the physician that they are losing ground in their city environment. It is well worth while to give them a careful explanation of what we know of the effect of altitude upon consumptives who have sufficient reactionary power to stand it.