Psychotherapy Part 43

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 superst.i.tion (for superst.i.tion, 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 p.u.b.erty, 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 a.s.sured 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 a.s.surance 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 appet.i.te 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 ATt.i.tUDE

The most important element in any cure or successful treatment of the disease is a favorable att.i.tude 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 succ.u.mb to the disease.

Eating.--Eating is often more a question of exertion than appet.i.te or anything else for consumptive patients. They have no active appet.i.te 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. b.u.t.ter 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 sc.r.a.ping 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 acc.u.mulation 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 ill.u.s.trations of his insatiable appet.i.te 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 alt.i.tude 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 alt.i.tudes 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.

_Th.o.r.eau_.--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 Th.o.r.eau, 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 Th.o.r.eau 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. Th.o.r.eau 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 a.s.sET

Recent interest in tuberculosis has taught us that the best possible a.s.set 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 doc.u.ments of modern times. Under circ.u.mstances 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 inst.i.tutions.

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 ill.u.s.trates 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 circ.u.mstances 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), const.i.tutes 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 circ.u.mstances 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 ill.u.s.trated 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.

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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 att.i.tude 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 la.s.situde and great fatigue on exertion, and patients are p.r.o.ne 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 att.i.tude 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.

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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 circ.u.mstances 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 ill.u.s.trates 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.