THE WILL IN PNEUMONIA
"Who shall stay you?--My will, not all the world."
_Hamlet_.
What is true of tuberculosis and the influence of the will has proved
to be still more true, if possible, of pneumonia. Clinical experience
with the disease in recent years has not brought to us any remedy that
is of special value, nor least of all of specific significance, but it
has enabled us to understand how individual must be the treatment of
patients suffering from pneumonia. We have recognized above all that
mentally disturbing factors which lessen the patient's courage and
will to live may prove extremely serious. We hesitate about letting an
older person suffering from pneumonia learn any bad news and
particularly any announcement of the death of a near relative, above
all, a husband or wife. The shock and depression consequent upon any
such announcement may {188} prove serious or even fatal. The heart
needs all its power to accomplish its difficult task of forcing blood
through the limited space left free in the unaffected lung tissue, and
anything which lessens that, that is anything which _disheartens_ the
patient, to use our expressive English phrase, must be avoided as far
as possible.
When a man of fifty or beyond, one or more of whose friends has died
of pneumonia about his age, comes down with the disease and learns, as
he often will in spite of the best directed effort to the contrary,
that he is suffering from the affection, if he is seriously disturbed
by the knowledge, we realize that it bodes ill for the course of the
disease. If a pneumonia patient, especially beyond middle life, early
in the case expresses the thought that perhaps this may be the end and
clings at all insistently to that idea, the physician is almost sure
to feel little confidence of pulling him through the illness. In
probably no disease is it more important that the patient's courage
should be kept up and that his will should help rather than hamper.
Courage is above all necessary in pneumonia because the organs that
are most affected and have most to do with his recovery are so much
{189} under the control of the emotions. Any emotional disturbance
will cause the heart to be affected to some extent and the respiration
to be altered in some way. When a pneumonia patient has to lie for
days watching his respirations at forty to the minute, though probably
he has never noticed them before, and feels how his heart is laboring,
no wonder that he gets scared, and yet his scare is the very worst
thing that can happen to him. It will further disturb both his heart
and his respiration and leave him with less energy to overcome the
affection. He may be tempted to make conscious efforts to help his
lungs in their work, though any such attempt will almost surely do
more harm than good. He must just face the inevitable for some five to
nine days, hope for the best all the time and keep up his courage so
as not to disturb his heart. After middle life only the patients who
are capable of doing that will survive the trial that pneumonia gives.
The super-abounding energy of the young man will carry him through it
much better; and besides, the young man usually has much less
solicitude as to the future and much less depending on his recovery.
A generation ago or even less, whiskey or {190} brandy or some form of
strong, alcoholic stimulant, as it was called, was looked upon as the
sheet anchor in pneumonia. For a generation or more at that time, the
same remedy had been looked upon by a great many physicians as an
extremely precious resource in the treatment of tuberculosis. The
therapeutic theory behind the practice was that in affections of the
lungs a particular strain was placed upon the heart and therefore this
organ needed to be stimulated just as far as could be done with
safety. As alcohol increases the rapidity of the heart beat, it was
considered to be surely a stimulant and came to be looked upon as the
safest of heart stimulants, because, except when used over very long
periods, direct bad effects had not been noticed. In pneumonia, above
all, the heart needed to be stimulated because it had to pump blood
through the portion of the lungs unaffected by the pneumonia, usually
congested and offering special hindrances to the circulation; besides,
a much larger amount of blood than usual had to be pumped through
these portions of the lungs in order to compensate for the solidified
portions.
A number of very experienced physicians came to be quite sure that
alcoholic stimulants {191} were the most valuable remedy that we had
for this special purpose of cardiac stimulation; some of them went so
far as to say, with a well known New York clinician, that if they were
to be offered all the drugs of the pharmacopeia without alcoholic
stimulant for the treatment of pneumonia on the one hand, or whiskey
or brandy on the other without all the pharmacals, they would prefer
to take the alcohol, confident that it would save more patients for
them. They were quite sure that they had made observations which
justified them in this conclusion.
We know at the present time that alcohol is not a stimulant but always
a narcotic. It increases the rapidity of the heart beat, though not by
direct stimulation, but by disturbing the inhibitory nerve apparatus
of the heart and thus permitting the heart to beat faster. Just as
there is a governor on a steam engine, to keep it from going too fast
and regulate its speed to a definite range, so there is a similar
governing apparatus or mechanism in connection with the heart. It is
by affecting this that alcohol makes the heart go faster. Blood
pressure is not raised, but on the contrary lowered, and the effect of
alcohol is depression and not stimulation. {192} In spite of this,
good observers seemed to note favorable effects from the use of
alcohol in both pneumonia and tuberculosis. This appears to be a
paradox until one analyzes the psychic effects of alcohol and places
them alongside the physical, in order to determine the ultimate
equation of the influence of the substance.
Alcohol has a very definite tendency to produce a state of euphoria,
that is, of well-being. The patient's mind is brought to where it
dismisses solicitude with regard to himself. This neutralizes directly
the anxiety which so often acts as a definite brake upon resistive
vitality. The alcoholic stimulant, in so far as it has any physical
effect, probably does a little harm, but its influence on the mind of
the patient not only serves to neutralize this, but adds distinctly to
the patient's prospects of recovery. Without it, the dread which comes
over him paralyzes to some extent at least his heart activity and
interferes with lung action. Under the influence of alcohol, he gains
courage--artificial, it is true--but still enough to put _heart_ in
him, and this is the stimulation that the older clinical observers
noted. The patient can, with the scare lifted, use his will to be well
{193} ever so much more effectively and psychic factors are
neutralized that were hampering his resistive vitality.
This illustrates very well indeed the place of dilute alcohol in some
of the usual forms in therapeutics about the middle of the nineteenth
century. Practically all the textbooks of medicine at that time
recommended alcohol for many of the continued fevers. In sepsis, in
child-bed fever, in typhoid, in typhus, as well as in tuberculosis and
pneumonia and other less common affections, whiskey or brandy was
recommended highly and usually given in considerable quantities. All
of these affections are likely to be accompanied by considerable
anxiety and solicitude with a series of recurring dreads that sadly
interfere with nature's efforts toward recovery. Under certain
circumstances, the scare, to use the plain, simple word, was
sufficient to turn the scale against the patient. The giving of
whiskey at least lifted the scare [Footnote 5] {194} and enabled the
patient to use his vital resources to best advantage.
[Footnote 5: The use of whiskey for snake-bite probably has no other
significance than this lifting of the scare. It used to be said that
the alcoholic stimulation neutralized the depressant effect of snake
poisoning on the heart. Now we know that this is not true, and in
addition, we know of no effect that alcohol in the system might have
in neutralizing the presence of the toxic albumin which constitutes
the danger in snake poisoning. It is only rarely that the bite of a
rattlesnake will be fatal. Experts declare that the snake must be a
large one, its sting must be inflicted on the bare skin, it must not
have stung any one so as to empty its poison glands for more than
twenty-four hours, and the full dose of the poison must be injected
beneath the skin for the bite to be fatal. Very rarely are all these
conditions fulfilled. When a person is bitten by a snake, however,
the terror which ensues is quite sufficient of itself to hurt the
patient seriously and he may scare himself to death, though the
snake poison would not have killed him. The whiskey lifts the scare
and gives nature a chance to neutralize the poison which she can
usually do successfully.]
It is extremely important, then, first to be sure that the patient's
will to be well is not hampered by unfortunate psychic factors and
secondly, that his courage shall be stimulated to the greatest
possible degree. Fresh air is the most important adjuvant for this
that we have. The outdoor air gives a man the courage to dissipate
dreads and makes him feel that he can accomplish what seemed
impossible before. Undoubtedly this is one of the favorable effects of
the fresh-air treatment of pneumonia, for it makes people mentally
ever so much less morbid. The patient's surroundings must be made as
encouraging as possible and there must be no signs of anxious
solicitude, no long faces, no weeping, and as far as possible, no
disturbance about business affairs that might make him think that a
fatal termination was {195} feared. His will to get well must be
fostered in every possible way and obstacles removed. This is why it
has been so well said in recent years that good nursing is the most
important part of the treatment of pneumonia. This does not mean that
a good nurse can replace a physician, but that both must coordinate
their efforts to making the patient just as comfortable as possible,
so that he will feel assured that everything that should be, is being
done for him, and that it is only a question of being somewhat
uncomfortable for a few days and he will surely get well.
Sunny rooms, smiling faces, flowers at his bedside, cheerful
greetings, all these, by adding to the patient's euphoria, bolster up
his will and make him feel that after all, thousands of people have
suffered from pneumonia and recovered from it, and there is no reason
why he should not, provided that he will not interfere with his own
recovery.
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