CARDIAC PALPITATION AND GASTRO-INTESTINAL DISTURBANCE
Morgagni, whom Virchow greeted as the Father of Modern Pathology, made
a careful study of the pulse and especially of its irregularities. He
had learned from the most careful pathological studies that marked
intermission and even more decided irregularity of the heart may be
present in life, though there may be absolutely no organic affection
of the heart itself, either of the valves or of the muscle,
discoverable at autopsy. In his opinion the most frequent cause for
such irregularity is flatulency and disturbance of digestion
generally. He went still farther, however, and seems to have
understood very well that constipation was often one of the most
important links in the chain of causes leading up to such heart
disturbance, itself either a cause or an effect of other digestive
symptoms. This idea deserves to be borne in mind when there is
question of the significance of heart symptoms. What Morgagni thus
determined by precise studies in pathological anatomy had been
clinically observed by many of the distinguished old-time
practitioners of medicine, who knew the fatal tendencies of organic
heart symptoms, yet recognized that many cardiac cases associated with
gastric symptoms did not have an unfavorable prognosis.
{329}
In spite of the recognition of these conditions by old-time medical
investigators, there has always been a tendency to fear that heart
symptoms in these cases might be due to a cardiac affection. This has
invariably been true for patients themselves to whom the heart
disturbance became conscious, but has often made physicians hesitate
as to the diagnosis and rendered their prognosis more unfavorable than
is justified by actual knowledge.
Gastro Cardiac Arrhythmia.--What may be called the gastro-intestinal
cardiac neuroses usually run a typical course. As a rule, with young
folks, the beginning of cardiac unrest is found in some stomachic
symptoms. The distention of the stomach with gas is said to be a
mechanical reason for interference with the heart action. Whether this
is really gas that has formed within the stomach, or whether it is to
a great extent, at least, gas which has been diffused from the vessels
of the stomach walls in a disordered viscus, or in some cases at
least, air which has been swallowed because of certain gaspy habits of
neurotic individuals, is hard to determine. In many cases the absence
of all odor of decomposition, or of any disagreeable taste, makes for
serious doubt whether the substance is really due to fermentation.
Certainly the changes that take place in food in the stomach during
the course of an hour or two of digestion are not sufficient to
account for the volume of gas that exerts pressure upon the gastric
walls and is eructated in large mouthfuls. Fermentative processes are
slow gas producers, as anyone with experience in the chemical
laboratory knows.
_Mechanical Cardiac Interference_.--Every physician has seen the young
man who is sure that he has heart trouble when he is really suffering
from indigestion. Many of the feelings of discomfort accompanied by
palpitation and irregularity are really phenomena connected rather
with the stomach than the heart itself. The reason for this is not
always clear. In many cases there seems to be a mechanical
interference with the heart's action. This is due to the presence of
gas in the stomach pressing against the diaphragm. In many cases the
distention of the stomach by a heavy meal, especially if the heart has
been rendered sensitive by the taking of stimulants, will have the
same effect. This is particularly noticeable if the patients lie down
shortly after the meal, when there is distinct discomfort in the
cardiac region and noticeable irregularity of the pulse.
The most frequent phenomenon is a missed beat, or often simply a sense
of discomfort in connection with the heart action that makes its
beating very noticeable. This palpitation, as it is called, is usually
entirely subjective. There is nothing abnormal in the sensation
produced on the hand when the heart is palpated, nothing the most
delicate finger can detect in the apex beat and nothing uniform in the
change in the heart sounds produced in these cases. There is usually a
somewhat over-excited action of the heart, but this is not
characteristically revealed by either palpation or auscultation. The
rhythm is interfered with, but the arrythmia affects only an
occasional beat, usually rather regularly spaced, and does not
interfere with the heart's rate nor with its action in any way. This
represents the most familiar form of cardiac neurosis and may, of
course, be due to such substances as tobacco, or coffee, or tea, where
these are taken in excess. Excess is always a matter of individual
idiosyncrasy.
{330}
_Cardiac Reflexes_.--It is thought by some that this heart
irregularity and palpitation is a reflex action due to irritation of
the gastric terminal filaments of the vagus nerve reflected back along
this nerve and affecting the heart. The doctrine of reflexes is not as
popular, however, as it was, but there can be no doubt of the fact
that the vagus nerve has terminal filaments in all the large organs,
yet is so extremely important to the heart that it has a definite
physiological meaning and doubtless is meant to act in such a way as
to stimulate the heart when these important organs are overloaded or
are laboring in their functions, and, on the other hand, to depress it
or at least to inhibit it somewhat, whenever there is a tendency to
send too much blood to these parts. In any case, whether the positive
factor in the production of the heart trouble be mechanical, as it
surely often is, or whether it be reflex and due to the action upon
the vagus, it must not be forgotten that in all cases where heart
symptoms occur with considerable intervals of absolute freedom from
them and with large subjective elements in the case, the relation of
the stomach or the digestive organs in general to the heart may serve
as their best explanation.
_Gastric Dilatation_.--In dilatation of the stomach there is likely to
be an associated tendency to a cardiac neurosis. Unfortunately, enough
of these cases have not been followed up so as to be sure what the
outcome is and whether there may not really have been some affection
of the myocardium with a premature breakdown of the heart. As a
consequence of the excessive irritation of the terminal filaments of
the vagus nerve in the stomach wall, or because of the mechanical
interference with the heart's action as a consequence of the dilated
stomach pulling upon the esophagus and probably somewhat interfering
with the action of the diaphragm, an irregularity of the heart action
is established and a sense of discomfort in the precordia develops
that is often very marked. These patients sometimes suffer from
pseudo-angina and still more frequently from cardiac irregularity.
This cardiac irregularity is sometimes quite marked, and yet in 24
hours, as a consequence of the emptying of the stomach, will
disappear, so that only slight intermittency remains, which eventually
subsides. I have known a heart affected thus to be pronounced
absolutely without any lesion when examined by a competent heart
specialist within a month after it had been so irregular as to be
quite alarming to both patient and physician.
_Upward Distention_.--There is sometimes a tendency for the stomach to
distend upward rather than to dilate downward and toward the left.
Perhaps this is due to the fact that in certain individuals the
gastric ligaments are much stronger and more unyielding than they are
in others. One thing is sure--that there are great individual
differences in these cases. In some that are without any demonstrable
gastric dilatation, except that gastric tympany extends higher than
usual, there is marked interference with the heart action. The
physician needs to see these cases when they are so irregular that
there would seem to be absolutely no doubt of the existence of a
myocardial lesion and then to examine them some months afterwards when
the stomach had been restored to good conditions, before he is able to
realize how much interference with heart action is consonant with
complete return in a comparatively short time to the normal, at least
so far as heart function goes. This is a very different opinion from
that held by many heart specialists and {331} especially certain
German authorities, who insist that any irregularity of the heart must
be considered as probably representing a muscular lesion; but the
evidence of careful observers may be adduced in support of it, and it
is an opinion that very much reassures the patients.
Old-time Clinicians--Morgagni, Lancisi.--In this subject it has always
seemed to me wise to recur to the opinions of some of the old-time
clinicians who noted symptoms very carefully and studied out
particularly the connection of symptoms with prognosis.
_Morgagni_.--Morgagni, for instance, whose clinical remarks are always
precious, said:
Now that mention is made of the intermission of the pulse which
approaches more nearly to the nature of an asphyxia than even its
slenderness or weakness (for what else is the intermission of the
pulse but a very short asphyxia, or what is an asphyxia but an
intermission which lasts very long?) the causes of this disorder in
the pulse are not to be passed over without examination in this
place, as the greater part of physicians are very greatly terrified
thereby, often with good reason, yet frequently without any; as when
there is some cause of it in the stomach or intestines, which may
even vanish away of itself, or be easily removed by the physician.
For in what manner a palpitation of the heart may sometimes be
brought on by flatus distending these parts, and again carried off
by the dissipation of such flatus, I have already said; and in the
same manner, or one not very dissimilar, it is also evident, that an
intermission of the pulse has sometimes generated, and gone off of
itself, in many whom I have known. At another time, in these very
same viscera, there is a matter which produces the same effect, by
irritating their nerves, with which you know how easily the nerves
of the heart consent. And this matter is sometimes of such a nature
that it may readily be prevented from harboring itself there. Thus I
remember, when I attended to the cure of a young girl who had a
fever, and an intermission of the pulse was added to the other
symptoms contrary to my expectations, I was not at all deterred from
giving such a medicine as I had before determined upon, that the
stomach and intestines might be well cleansed; and even that I gave
it so much the more boldly; and that on the same day after these
parts had been deterged, the pulse returned to its former standard.
But you will read even in the _Sepulchretum_ that Ballonius had not
only seen this disorder of the pulse, but also that of a languid and
small stroke, removed in the same manner. "According to the degrees
to which the purging was carried," says he, "the pulse was
restored." And, indeed, there is an intermission of the pulse, that
is of a far longer continuance as that with which Lancisi says he
had been troubled "for the space of six years"; yet if this
intermission should be, as it was in him, "from a consent with the
hypochondria," it may be entirely and perfectly taken away, by
perfectly restoring those parts.
_Lancisi_.--Lancisi was another distinguished clinical observer who
made special studies in neurotic heart disturbance. These studies are
all the more interesting because he himself was a sufferer from this
affection for many years. He was inclined to think that his heart
intermittency was due to disturbance in his digestive organs and
especially those lying in the upper part of the abdomen. He attributes
it himself to sympathy with these and said that it came _ex
hypochondriorum consensu_, as it were a reflex from his hypochondriac
regions. As Lancisi lived to a pretty good age in spite of noting this
symptom in early middle life, the significance of it will be well
understood. It would be perfectly possible to gather a series of such
cases from among the distinguished physicians of history, and as for
our contemporaries and colleagues, at least one out of four of them
will tell you that at some time he has suffered from an affection of
this kind and has been much worried {332} about it, yet has recovered
without incident and without any serious development.
English Opinion.--The role of the stomach in disturbing the heart is
only less important than that of the nervous system itself. Of course,
individual peculiarities, as I have said, are extremely important.
Some people seem to suffer very little cardiac disturbance from a
distended stomach, while in others all sorts of heart affections may
be simulated as the result of the mechanical interference with the
heart action by the pushing up of the diaphragm. Sir William Broadbent
in the article on "The Conduct of the Heart in the Face of
Difficulties," already quoted from, does not hesitate to say that
heart symptoms secondary to gastric disturbance probably cause more
suffering than does actual heart disease. Expressions of this kind
need to be borne in mind when we reassure patients who have all sorts
of queer, uncomfortable, often even painful, conditions in their
cardiac region, "Heart disease" has been, perhaps, mentioned casually
to them and as a consequence worry is adding a nervous element to
hamper a heart already seriously disturbed by gastric distention. Sir
William Broadbent's own words are given because they carry so much
weight in this matter:
The difficulties arising out of flatulent distention of the stomach
or colon or intestinal canal generally, will require some attention,
since they are the cause of most of the functional derangements to
which the heart is subject, and give rise to the heart complaints
which occasion in the aggregate perhaps more suffering than does
actual heart disease. The heart often tolerates a considerable
degree of upward pressure of the diaphragm, and it is not uncommon
to meet with stomach resonance as high as the fifth space, and to
find the apex beat displaced upwards and outwards to the fourth
space and outside the nipple line, without conspicuous symptoms. But
the heart behaves very differently in different subjects in the
presence of flatulent distention of the stomach. It partakes of the
general constitutional condition of the individual; in the strong,
therefore, it is vigorous; in the weak it cannot be anything but
weak.
Prognosis.--Nothing sends a young person sooner to a physician than
this cardiac unrest and functional disturbance. He comes all
a-tremble, as if to hear the worst. Even in middle age and in those
whose education might be expected to steady them somewhat in the
matter, even in physicians of long experience, there is a tendency so
to exaggerate the condition and its possibilities of fatality as a
consequence of emotion that inhibitory action on the heart becomes
noticeable. It is a rule with very few exceptions that in these cases
when the heart is complained of by young persons who have no history
of rheumatism, the causative condition will be found in the stomach,
or at least in the digestive tract.
I know a number of physicians who have suffered in this way and who
have been badly frightened about themselves, yet who have had no
serious difficulty once they took reasonable care of their diet, and
paid attention above all to regularity of meals and slowness in
eating. Indeed, it is rare to find a physician of a nervous
temperament who has not had some trouble of this kind, and the demands
made on a busy professional man foster this. Some of them are sure
that if their cardiac uneasiness does not signify an actual heart
lesion, valvular or muscular, at least it portends a premature wearing
out of the heart. There are many evidences to show that this is {333}
not so. I have had a distinguished physician, now well past his
seventy-fifth year, tell me of distinct irregularity in his heart
action as a young man which had rather alarmed him, and as this had
been preceded by an attack of acute articular rheumatism there seemed
to be every reason to think that he was a sufferer not from functional
but from organic heart disease; yet he has lived well beyond the span
of life usually allotted to man, has accomplished an immense amount of
work and is now in excellent general health almost at the age of
eighty. The case is all the more striking because, while rest and care
of the health and regular life and conservation of energy are usually
supposed to be essential for these cases, this colleague is noted for
having made serious inroads on the hours which should have been
devoted to sleep in order to accomplish certain medical literary work
while devoting himself to the care of a most exacting practice.
That the good prognosis of these cases which I suggest is not forced
and is not over-favorable nor the result of the wish to soothe
patients may be judged from recent studies of the heart as well as
from the older ones. In discussing extra-systole, MacKenzie in his
"Diseases of the Heart," [Footnote 28] says:
[Footnote 28: "Diseases of the Heart," by James MacKenzie, M. D.,
1910, Oxford Medical Publications.]
Dyspeptic and neurotic people are often liable [to suffer from
them]. That other conditions give rise to extra-systoles, is also
evident from the fact that they may occur in young people in whom
there is no rheumatic history and no cardiosclerosis and whose
after-history reveals no sign of heart trouble.
It is well to note the frequency of such annoying symptoms in those
who have gone through rheumatic fever, and where patients have a
history of this it is well to be cautious, but even in these cases he
says that the trouble is often entirely neurotic and the one important
preliminary to any successful treatment is to get the patient's mind
off his condition, improve his general nervous state, and above all
relieve as far as possible the gastric symptoms that may be present.
He says further:
Some patients are conscious of a quiet transient fluttering in the
chest when an extra-systole occurs; others are aware of the long
pause, "as if their hearts had stopped"; while others are conscious
of the big beat that frequently follows the long pause. So violent
is the effect of this after-beat, that in neurotic persons it may
cause a shock, followed by a sense of great exhaustion. Most
patients are unconscious of the irregularity due to the
extra-systole until their attention is called to it by the medical
attendant. Both being ignorant of its origin, and its being
characteristic of human nature to associate the unknown with evil,
patient and doctor are too often unnecessarily alarmed.
Cardiac Stomach Disturbance.--On the other hand, as a word of warning,
it seems necessary to say here that later in life acute conditions
manifesting themselves through the stomach are often of cardiac
origin. Most physicians have been called to see some old man who had
partaken of a favorite dish which did not, however, always agree with
him and who suffered as a consequence from what at first was thought
to be acute gastritis. The severity of the symptoms and the almost
immediate collapse without any question of ptomaine poisoning,
however, usually make it clear that some other organ is at {334} fault
besides the stomach itself. The real etiological train seems to be
that a weakened heart sometimes without any valve lesion but with a
muscular or vascular degeneration hampering its activity is further
seriously disturbed by the overloading of the stomach. The result is a
failure for the moment of circulation in the digestive organs with
consequent rejection of the contents of the tract, nature's method of
relieving herself of substances that cannot be properly prepared for
absorption. Unfortunately, the condition sometimes proves so severe a
shock to the weakened heart that it stops beating, and the physician
is brought face to face with a death from "heart failure."
In these cases it is important to remember that the gastric
disturbance may so mask the heart symptoms as completely to deceive
the physician. The prognosis of these cases, however, is most serious.
It seems worth while to give a warning with regard to these cases,
because anything that we may have to say as to the relations of the
stomach and the heart and the possibility of lessening the cardiac
depression due to unfavorable mental influence when palpitation occurs
as a consequence of gastric distention, has nothing to do with these
acute cases in older patients where the condition is serious and the
prognosis by no means favorable.
Treatment.--The role of psychotherapy in this form of cardiac
disturbance associated with gastro-intestinal affections is, after the
differentiation of neurotic from serious organic conditions, to give
the patient such reassurance as is justified by his condition. It is
surprising how many people are worrying about their hearts because
their stomachic and intestinal conditions give rise to heart
palpitation, that is to such action of the heart as brings it into the
sphere of their consciousness, sometimes with the complication of
intermittency or even more marked irregularity. The less the
experience of the physician the more serious is he likely to consider
these conditions and the more likely he is to disturb the patient by
his diagnosis and prognosis. Until there is some sign of failing
circulation, or of beginning disturbance of compensation, the
attachment of a serious significance to these conditions always makes
patients worse and removes one of the most helpful forms of
therapeusis, that of the favorable influence of the mind on the heart.
On the other hand, unless the patients' own unfavorable
auto-suggestions as regards the significance of their heart symptoms
are corrected, these people not only suffer subjectively, but bring
about such disturbance of their physical condition as makes many
symptoms objective.
While there are serious affections in which heart and stomach are
closely associated, these are quite rare and usually manifest
themselves in acute conditions and in old people. In the chapter on
Angina Pectoris attention is called to the fact that there are may
forms of pseudo-angina due to cardiac neuroses consequent upon gastric
disturbance and without heart lesion. Broadbent has not hesitated to
say that these forms of angina cause more suffering or at least
produce more reaction on the part of the patient and are always the
source of more complaint than the paroxysms due to serious cardiac
conditions which present the constant possibility of a fatal
termination.
Where the stomach is the cause of the cardiac neuroses psychotherapy
is an extremely important element in the treatment. The continuance
and exaggeration of their symptoms is often due to a disturbance of
mind consequent upon the feeling that they have some serious form of
heart disease. Without {335} definite reassurance in this matter all
the experts in heart disease insist that it is extremely difficult to
bring about relief of symptoms in these patients. Whenever the general
health of the individual has not suffered from his heart affection, it
is quite safe to assume that no organic disease of the heart is
present, no matter what the symptoms, for, as Broadbent and many other
authorities emphasize, gastric cardiac neuroses can simulate every
form of heart disturbance. The older physicians insisted that what
they called sympathy with the hypochondriac organs might produce all
sorts of heart symptoms. The patient must be told this confidently.
The slightest exaggeration of the significance of his symptoms can do
no possible good and will always do positive harm.
After reassurance, the most important thing is, of course, regulation
of the diet and of the digestive functions generally. Unfortunately,
regulation of the diet to many patients and even to many physicians
seems to mean the limitation of diet. I have seen sufferers from
cardiac symptoms have these increased by excessive limitation of diet.
If they are lower than they ought to be in weight they must be made to
regain it. Above all, there must be no limitation of meat-eating
except in the robust. Very often the heart seems to crave particularly
that form of nutrition that comes through meat. It is especially
important that the bowels should be regular. Fast eating is very
harmful. Occupation with serious business immediately after eating is
almost the rule in these cases.
All of these elements of the case need special study in each
individual patient. The needed suggestions can then be made. Above
all, the patient is made to realize that his case is understood and
that it is only the question of a gradual acquirement of certain
habits, including proper exercise, that is needed for the restoration
of his heart to normal.
CHAPTER V
ANGINA PECTORIS
The two forms of this affection, known commonly as true and false
angina, are characterized by pain or anguish in the precordial region
with reflected pains in other portions of the body. It used to be said
that whenever the precordial pain was accompanied by reflected pains
in the neck, or down the arm, or, as they may be occasionally, in the
jaw, in the ovary, in the testicle, sometimes apparently in the left
loin, this was true angina and the patient was in serious danger of
death. We know now that false angina may be accompanied by various
reflex pains and that, indeed, a detailed description of the anguish
and its many points of manifestation is more likely to be given by a
neurotic patient suffering from pseudo-angina than by one suffering
from true angina. True angina occurs in most cases as a consequence of
hardening of the arteries of the heart or of some valvular lesion that
interferes in some way with cardiac nutrition. The definite sign of
differentiation is that in practically all cases of true angina, there
are signs of arterial degeneration in various parts of the body.
Without these, the "breast pang," as the English {336} call it, is
likely to be neurotic and is of little significance as regards future
health or its effect upon the individual's length of life.
Besides the physical pain that accompanies this affection there is, as
was pointed out by Latham, a profound sense of impending death. It
used to be said that this was characteristic of the organic lesions
causing true angina pectoris. It is now well known, however, that the
same feeling or such a good imitation of it that it is practically
impossible to recognize the true from the false, occurs in
pseudo-angina. It is this special element in these cases that needs
most to be treated by psychotherapy and which, indeed, can only be
reached in this way. Where there are no signs of arterial degeneration
and no significant murmurs in the heart, it should be made clear to
these patients that they are not suffering from a fatal disease, but
only from a bothersome nervous manifestation. Especially can this
reassurance be given if the angina occurs in connection with
distention of the stomach or in association with gastric symptoms of
any kind. In young patients who are run down in health and above all
in young women, the subjective symptoms of angina--the physical
anguish and the sense of impending death--are all without serious
significance.
Differential Diagnosis of True and False Angina.--In the diagnosis of
angina pectoris the main difficulty, of course, lies in the
differentiation between the true and false forms, that is, those
dependent on an organic affection of the heart muscle or blood vessels
and those resulting from a neurosis. The neurotic form is not uncommon
in young people and is often due to a toxic condition. Coffee is
probably one of the most frequent causes of spurious angina, though
the discomfort it produces is likely to be mild compared with the
genuine heart pang. It must not be forgotten, however, that neurotic
patients exaggerate their pains and describe their distress in the
heart region as extremely severe and as producing a sense of impending
death, when all they mean is that, because the pain is near their
heart it produces an extreme solicitude and that a dread of death
comes over them because of this anxiety. Coffee and tea, especially
when taken strong and in the quantities in which they are sometimes
indulged in, may be sources of similar distress. Tobacco will do the
same thing in susceptible individuals, or where there is a family
idiosyncrasy, and especially in young persons.
For the differentiation of true and spurious angina Huchard's table as
given by Osler is valuable:
TRUE ANGINA
Most common between the ages of forty and fifty years.
More common in men. Attacks brought on by exertion.
Attacks rarely periodical or nocturnal.
Not associated with other symptoms.
Vaso-motor form rare. Agonizing pain and sensation of compression
by a vice.
Pain of short duration. Attitude: silence, immobility.
Lesions. Sclerosis of coronary artery.
Prognosis: grave, often fatal.
Arterial medication.
NEUROTIC FORM
At every age, even six years.
More common in women. Attacks spontaneous.
Often periodical and nocturnal.
Associated with nervous symptoms.
Vaso-motor form common. Pain less severe; sensation of distention.
Pain lasts one or two hours. Agitation and activity.
Neuralgia of nerves and cardioplexus.
Never fatal.
Antineuralgic medication.
{337}
True Angina and Psychotherapy.--One of the most frequent occasions for
the development of true angina is vehement emotion. The place of
psychotherapy then in the affection will at once be recognized. A
classical example of the influence of the mind and the emotions in the
production of attacks of angina pectoris in those who are predisposed
to them by a pre-existing pathological condition, is the case of the
famous John Hunter. He was attacked by a fatal paroxysm of the
affection in the board room of St. Thomas' Hospital, London, when he
was about to begin an angry reply with regard to some matter
concerning the medical regulation of the hospital. He had previously
recognized how amenable he was to attacks of the disease as a
consequence of emotion or excitement, and had even stated to friends
that he was at the mercy of any scoundrel who threw him into an attack
of anger. Some of the deaths from fright or sorrow at a sudden
announcement of the death of a relative, or even the deaths from joy
are due to angina pectoris precipitated by the serious strain put upon
the heart by the flood of terror or emotion.
Men who are sufferers from what seems to be true angina pectoris must
be made to understand without disturbing them any more than is
absolutely necessary that strong emotions of any kind--worry, anger,
exhibitions of temper, and, above all, family quarrels, must be
avoided. Not a few of the serious attacks of angina pectoris which
physicians see come as a consequence of family jars, owing to the
persistence of a son or daughter in a course offensive to the parent.
A part of the prophylaxis, then, consists in impressing this fact on
members of the family and making them understand the danger. The
disposition that causes the family friction is, however, often
hereditary and will, therefore, prove difficult of control. It is one
of the typical cases of inheritance of defeats.
_Solicitude and Prognosis_.--The distinguished French neurologist,
Charcot, had several attacks of what seemed to be true angina
pectoris. His friends were much disturbed by it. Physicians who saw
him during the attack feared that he was suffering from an incurable
heart lesion. He himself, as his son, Dr. Charcot, told me, refused to
accept this diagnosis, and preferred to believe that what he was
suffering from was a cardiac neurosis--and, of course, he had seen
many of them. He was unwilling to have a heart specialist examine him
very carefully for he did not wish to be persuaded of the worst
aspects of his condition.
What he said in effect was, "This is either a neurotic condition, as I
think it is, or it is an organic condition. If it is organic, my
physicians would be apt to tell me that I must stop working so hard,
and I am sure that if I should do that I would do myself more harm
than good by having unoccupied {338} time on my hands. I want to go on
doing my work. If I am wrong some time I shall be carried off in one
of these attacks. That will not be such a serious thing, for after all
I must die some time and my expectancy of life cannot normally be very
long. I prefer, then, to go on with my work and think the best, for it
does not seem that I could do anything that would put off the
inevitably fatal issue if I am to die a cardiac death." He was found
dead one morning, but he had passed into the valley of death without
being seriously disturbed and without any of the neurotic symptoms
that so often develop in discouraged patients. Curiously enough, one
of our most distinguished heart specialists in this country went
through almost the same experience and preferred to live "the brief
active life of the salmon rather than the long slow life of the
tortoise."
The best possible factor in therapy is secured if patients can be
brought to the state of mind of these distinguished physicians who
calmly faced the future, refusing to disturb themselves or their work,
because they feared that the worry that would come down upon them in
inactivity would aggravate their disease. Where men are occupied with
some not too exacting occupation, that takes most of their attention
and at which they have been for years, it is best to leave them at it,
though the harder demands of it must be modified. If they can be
brought to persuade themselves, as did the two physicians--though
probably only half-heartedly--that their affections may possibly be
merely neurotic and not true angina, it will always be better for
them. Death may come, and commonly will, suddenly, but, after one has
lived a reasonably full life, that is rather a blessing (and not in
disguise) than the terror which it is sometimes supposed to be.
Pseudo-Angina.--The neurotic form of angina is quite compatible, not
only with continued good health but with long life, and even after a
long series of attacks, some of them very disturbing in their apparent
severity, there may be complete relief for years, or for the rest of
life. Exaggeration of feeling due to concentration of attention plays
a large role in these cases, and it is evident that the dread of
something the matter with the heart connected with even a slight sense
of discomfort may readily become so emphasized as to seem severe pain,
though many people have similar feelings without making any complaint.
In spite of reassurances attacks of pseudo-angina are likely to worry
both patient and physician. The only working rule is that in younger
people discomfort in the heart region, even though it may be
accompanied by some sympathetic pain in the arm or in the left side of
the neck, is usually spurious angina. Broadbent goes so far as to say
that this is true also in many older persons. His method of making the
differentiation is interesting because so easy and practical that it
deserves to be condensed here. The earlier attacks of true angina are
practically always provoked by exertion, while spurious angina is
especially liable to come on during repose. Any cardiac symptom or
pain that can be walked off may be set down as functional and due to
some outside disturbing influence, or to nervous irritability. When
palpitation or irregular action of the heart, or intermission of the
pulse, or pain in the cardiac region, or a sense of oppression follows
certain meals at a given interval, or comes on at a certain hour
during the night, there need be little hesitation in attributing the
disturbance, whatever it may be, to indigestion in {339} some of its
forms. Nightmare from indigestion, Broadbent thought, is not a bad
imitation of true angina.
In Broadbent's mind acute consciousness of any heart disturbance lays
it in general under the suspicion of being neurotic in origin. He was
talking to some of the best clinical practitioners in the world and
some of the most careful observers of our generation, when, before the
London Medical Society, he said: "The intermission of the pulse of
which the patient is conscious and the irregularity of the heart's
action--though this can be said with less confidence--which the
patient feels very much, is usually temporary and not the effect of
organic heart disease." This is particularly true, of course, in
people of a neurotic character, and Broadbent went on to say that
"speaking generally, angina pectoris in a woman is always spurious,
and the more minute and protracted and eloquent the description of the
pain, the more certain may one be of the conclusion."
I had the opportunity to follow the case of a young woman who had a
series of attacks of angina pectoris some twenty years ago, so severe
that a bad prognosis seemed surely justified, and though at times the
attacks were rather alarming to herself and friends, nothing serious
developed and for the past ten years, since she has gained
considerably in weight, they have not bothered her at all. She used to
be rather thin and delicate, trying to do a large amount of work and
living largely on her nervous energy. At times of stress she was
likely to suffer from pain in the precordia running down the left arm
and accompanied by an intense sense of the possibility of fatal
termination. With reasonably large doses of nux vomica, an increase in
appetite came and a steadying of her heart that soon did away with
these recurrent attacks. These came back later several times when she
neglected her general condition, but there never were any objective
symptoms that pointed to an organic lesion. After twenty years she is
in excellent health, except for occasional attacks of a curious
neurotic indigestion that sometimes produces cardiac disturbances. Of
course, such cases are not uncommon in the experience of those who see
many cardiac and nervous patients.
For the treatment of pseudo-angina, mental influence is all important.
Of course, the conditions which predispose to the mechanical
interference with heart action that occasions the discomfort, must be
relieved as far as possible. The severity of the symptoms, however,
are much more dependent on the patient's solicitude with regard to
them, they are much more emphasized by worry about them, than by the
physical factors which occasion them. Reassurance is the first step
towards cure. After relief has been afforded from the severer attacks,
the patient's solicitude as to the future must be allayed and the fact
emphasized that there are many cases in which a number of attacks of
cardiac discomfort simulating angina pectoris have been followed by
complete relief and then by many years of undisturbed life. It is
important to make patients understand that, in spite of the fact that
their attacks occur during the course of digestion, as is not
infrequently the case, this constitutes no reason for lessening the
amount of food taken. Nearly always these attacks occur with special
frequency among those who are under weight, and disappear rather
promptly when there is a gain in weight. Solicitude with regard to the
heart must be relieved wherever possible and then with the regaining
of general health the heart attacks will disappear.
{340}
CHAPTER VI
TACHYCARDIA
Etymologically tachycardia means rapid heart. There are two forms of
rapid heart, that which is constant and that which occurs in
periodical attacks. It is for this latter that the term tachycardia
has been more particularly used, though occasionally the adjective
paroxysmal is attached to it to indicate the intermittent character of
the affection. With regard to the persistent type of rapid heart
something deserves to be said, however, because patients' minds are
often seriously disturbed by them. Often it has existed for years,
sometimes is known to be a family trait and probably has existed from
childhood, yet the discovery of it may be delayed until some
pathological condition develops, calling for the attendance of a
physician who may be needlessly alarmed and in turn alarm his patient
by his recognition of it. The cause for this persistent rapid pulse is
not well known and is difficult to determine. Heredity, as has been
suggested, sometimes plays an important role in it. Certain families
have one or more members in each generation with rapid hearts.
Whenever persistent rapid heart is a family trait the patient can be
assured, as a rule, without hesitation, that the general prognosis of
the case is that of the lives of the rest of the family. Usually the
symptom seems to mean nothing as regards early mortality or any
special tendency to morbidity.
Favorable Prognosis.--While a rapid pulse often and indeed usually has
some serious significance, it must not be forgotten that it may be an
individual peculiarity and be quite compatible with long life and hard
work. One of the first patients that I saw as a physician had a pulse
between ninety-six and one hundred. As there was a slight tendency to
irregular heart action also, I was inclined to think that there must
be some cardiac muscle trouble. There was apparently no valve lesion.
He told me that a physician ten years before had noted his rapid pulse
and had made many inquiries about it which rather seriously disturbed
him. He had been an extremely healthy man during his fifty-five years
of life and there seemed no reason to conclude, since his rapid pulse
had been in existence for ten years, that it meant anything serious.
He has now lived well beyond the age of seventy and still has a pulse
always above ninety. Contrary to what might be thought, he is an
extremely placid, unexcitable individual, who, under ordinary
circumstances, will probably live for many years to come. He has no
family history of tachycardia, though there is a history of rather
nervous irritable hearts in other members for two generations.
An interesting case of this kind came under my observation about
fifteen years ago in a clergyman whose pulse was never below ninety,
and who on slight excitement, or after a rapid walk, or after a heavy
meal, would have a pulse of 120. He knew that it was a family trait,
his father having had it yet living to be past seventy. He gave a
history of its having been recognized in his own person more than
twenty years before. His general health, however, was excellent. He
took long walks and, indeed, pedestrian excursions {341} were his
favorite exercise. He was able to go up flights of stairs rather
rapidly without discomfort. He was the pastor in a tenement house
district so he had plenty of opportunity for such exertion. Infections
of any kind, colds and the like, disturbed his pulse very much, if the
ordinary standard was taken, but it was not irregular and the increase
in rapidity was probably only proportionate to the original height of
the pulse in his case. After all, as the normal pulse of sixty to
seventy rises to between ninety and one hundred even in a slight
fever, it is not surprising if a pulse normally above ninety should
rise fifty per cent. to one hundred and thirty-five under similar
conditions. He is now well past sixty, after over thirty-five known
years--and probably longer--of a pulse above ninety, yet he is in
excellent general health and promises, barring accident, to live
beyond seventy.
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.
{342}
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.
{343}
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 Medicine [Footnote 29] 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.
[Footnote 29: _The Medical News_, November 10, 1900.]
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 {344} 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.
{345}
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 {346} 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 {347} 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 {348} 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.
This principle of treatment must be applied for coughs and colds.
While {349} 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, {350} 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 {351} 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 {352} 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 {353} 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 {354} 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 {355} 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, {356} 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.
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 {357} 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. {358} 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 {359} 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.
{360}
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.
{361}
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 {362} 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 {363} 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.
_Negative Suggestions_.--Some suggestions are valuable for the
prophylaxis of complications. For instance, tuberculous patients must
be warned not to indulge in breathing exercises without the express
consent of the physician. So much is said in popular literature as to
the value of breathing exercises that many a patient suffering from
tuberculosis thinks that, not only may they be indulged in with
impunity, but that they will surely do good and can do no possible
harm. Nothing could be more erroneous. Many localized lesions have
been diffused in this way and there is always danger that the strain
will cause hemorrhage. Patients must be warned also to avoid any
possible condition in which they might have to over-exert themselves.
Because of the dust inevitably breathed during automobile riding, this
pleasure must be denied to tuberculous patients as a rule, but even
when they have recovered sufficiently so that this may be permitted
they must be warned not to take long rides into the country lest the
breaking down of the machine should place them under the necessity of
walking a long distance. This idea should also be emphasized for
rowing excursions, or trips by motor boat, for occasionally they lead
to serious and exhausting exposure.
One negative suggestion should be given at the very initial stage to
every patient in whom the presence of pulmonary tuberculosis has been
recognized. This should be a warning to exercise the greatest care
against permitting the development of constipation. Tuberculous
patients must never strain at stool. Almost necessarily a certain
number of tubercle bacilli are swallowed every day whenever pulmonary
tuberculosis is at all active and they are constantly present in the
digestive tract. If tuberculous patients then strain at stool, little
abrasions of the mucous membrane of the rectum are caused in which
tubercle bacilli find a favorable nidus. Ischio-rectal abscesses are
common among the tuberculous and rectal fistulas often give much
bother. When a tuberculous patient develops such a condition, a period
of depression and discouragement will follow, for there is a curious
tendency to depression associated with all lesions of the rectum. A
pulmonary patient who has been doing well will often fail to make
progress for months after the development of even a small
ischio-rectal abscess.
{364}
CHAPTER III
NEUROTIC ASTHMA AND COGNATE CONDITIONS