Kitabı oku: «Psychotherapy», sayfa 46

CHARACTER AS A THERAPEUTIC ASSET

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

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

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

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

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

SUGGESTION AS TO SYMPTOMS

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

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

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

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

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

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

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

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

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

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

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

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

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.

CHAPTER III
NEUROTIC ASTHMA AND COGNATE CONDITIONS

For the consideration of its psychotherapy asthma may be divided into two forms—symptomatic and essential, or neurotic, asthma. Symptomatic asthma is a difficulty of breathing, the result of some interference with the circulation, as by heart disease, or with the oxidizing power of the blood, as by kidney disease, or various blood conditions, or from direct interference with respiration from some pulmonary affection. Essential asthma is not dependent on any organic condition, but is an interference with breathing without any distinct pathological condition in the lungs themselves or in the general circulation. There may be some emphysema, but not enough to account for the respiratory difficulty. It is spoken of as neurotic asthma, and the most careful investigations made of individuals who have died during a seizure has failed to give any sure pathological basis for the affection. Certain accompanying phenomena are worthy of note. The most interesting of these are Curschmann's spirals, which usually occur in the form of translucent pellets very characteristically described by Laennec as pearls. They are evidently formed in the finer bronchioles and show that the affection extends to the terminal portions of the bronchial system. In connection with these the so-called asthma crystals first described by Charcot and Von Leyden and sometimes called by their combined names are often found. Besides, there are a large number of eosinophiles in the sputum itself entangled within the filaments of the spirals and an eosinophila of the blood.

Etiology.—Not only are we ignorant of the reasons for these phenomena but there is even some doubt as regards the mechanism of the respiratory spasm itself. There is a general impression that the paroxysm is due to incapacity to inspire because of a paroxysmal spasm of the respiratory muscles. Gee in his "Medical Lectures and Aphorisms"²⁹ rather leans towards the explanation that suffering is due not to any inability to fill the lungs but to incapacity to empty them when they have become over-distended with air. He tells the story related by Dean Swift of the old man whose barrel-shaped chest was fixed in spasm so full of air that the patient could not find room for the slightest additional breath. "If I ever get this air that is in me out," the patient declared to the Dean, "I will never take another breath."

It is important to differentiate symptomatic from neurotic or essential asthma. In symptomatic asthma the only assured treatment of the condition must come through amelioration of the organic condition causing the symptoms. Cardiac and renal asthma respond promptly to remedies which relieve critical conditions that may be present in the heart or kidneys. It must not be forgotten, however, that respiration is readily disturbed by mental influences. Where cardiac or renal disease causes interference with respiration this is much emphasized by the patient's unfavorable mental attitude toward it, or much relieved by keeping him from worrying over his condition. Even symptomatic asthma, then, has a definite place in psychotherapeutics, though it would be serious not to recognize the underlying conditions and treat them. If the patient's attitude of mind is one of discouragement, the respiratory difficulties will continue to be a marked symptom of the case, even though the proper remedies for the relief of cardiac or renal conditions are administered.

Symptomatic Picture.—What is likely to be one of the most disturbing experiences of the young physician early in practice, especially if he has not before seen a typical case, is to be called to a patient suffering from a severe attack of asthma. Often the sufferer is sitting up in bed so as to get all the air possible, and, though the windows are wide open, he is gasping for breath, usually pleading for more air with a tense, anxious expression, starting eyes, and the sweat pouring from his forehead, while the accessory muscles of respiration, deeply engaged in moving his thorax to move air enough to keep him from stifling, emphasize his dyspnea. Occasionally a degree of cyanosis develops that is quite startling for the untrained observer. Most of those who see the symptomatic picture for the first time think that death is impending, and the patient himself, if he has not had a series of attacks, will fear a fatal termination. It appears impossible to believe that the next morning, within six or seven hours of this, the patient will, as a rule, be quite well and walking round in the enjoyment of apparent good health.

As a rule, the worse these cases seem in their intensity and the more the patient is anxious, the more surely are they merely of functional nervous origin; above all, the more complaints of lack of air and of fear of impending death that are made, the more likely is the patient to be all right within a few hours. Asthma looks as though it must be due to some serious organic condition. Of course, in many cases of difficult breathing, even with asthma-like attacks, there are underlying serious conditions of heart and kidneys that are extremely dangerous. As a rule, however, these do not produce the woeful pictures of purely neurotic asthma. Even when the basis of the asthma is an emphysema, which of itself is not dangerous and is quite compatible with long life, the attacks, though frequent and severe, are usually not so serious looking as those in which absolutely no pathological condition of the lungs, or heart, or kidneys can be found, and, indeed, in which there is absolutely no organic change to account for the extremely uncomfortable and even terrifying symptoms.

Mental Influence.—In the medical literature of asthma there are abundant proofs that the attitude of mind of the patient towards his affection means very much. There is the story, thoroughly vouched for, of the two friends stopping at a little country hotel late at night. One of them was a neurotic subject, who, whenever he remained for some time in a stuffy atmosphere, was likely to have a severe asthmatic attack. The quarters assigned to them proved to be one of the cramped little rooms with a single small window that occasionally are found in the attics of country inns in England. During the night the patient of asthmatic tendencies had one of his attacks and begged his friend to open the window. The friend, suddenly roused from sleep, did not remember the position of the window and, the night being very dark, he felt for it and finally found it. He could not raise the sash and he could not move it either inward or outward and there seemed no way of getting it open. His friend was insistently clamoring for air with that tone of despair and dread of impending death so characteristic of the young, inexperienced asthma sufferer. Unable to get the window open, the sympathetic companion finally took his shoe and smashed the glass. The relief was immediate. Scarcely had the crash of the broken glass been heard before the patient gave an audible sigh of relief. When his friend went over to him he felt so much better that it was rather easy for the sufferer to persuade him that nothing more would be needed and that he should go back to bed. In the morning, when the friend awoke, his first glance, directed by the sunlight that came streaming into the window, was toward the broken panes of the night before. To his surprise it was not broken. Wondering what had happened, he looked round the room to find that he had smashed two panes in an old bookcase set into the wall, and that it was the breaking of the glass with the suggestion of free ingress of air that it involved and not any real provision of fresh air that had cured his friend's asthma so promptly.

Suggestion .—When much-vaunted cures for asthma are analyzed, many of them are found to depend more on suggestion than on any other element. Various forms of cigarettes are used, comparatively innocuous in themselves, and certainly of no strong therapeutic action, yet they work marvels in loosening the spasm that comes over the lungs in asthmatic attacks. Any sort of a cigarette will do at the beginning. I have seen dried grape-vine stems work very well in the country, especially in young women to whom the idea of smoking anything was strongly suggestive. Cubebs cigarettes have the same effect on older people. Doubtless there is some relaxing action in the smoke. This is not enough, however, to account for the effect produced without mental influence. After cubebs have been tried for a period and begin to lose their efficacy, then other materials that produce a pungent smoke or have a certain sensory action, as stramonium leaves, may be used, and will also have the marvelous power of cubebs. After a time, however, they, too, lose their efficacy, and, as a rule, each successive cigarette that is tried has less power than the first to control the difficulty of breathing.

The more one hears of cures for asthma, and the longer one has experience with these cases, the clearer does it become that there is a large suggestive element in every successful treatment. If a piece of ordinary blotting paper be dipped in a strong solution of saltpeter and allowed to dry, it will, if touched by a lighted match, burn slowly without flame, but with the production of heavy, thick smoke. The therapeutic elements in this are not very strong, but the suggestive element, when a room gets full of it, is intense and is cumulative. Very probably the thick smoke, rich in nitrites, has some tendency to relax the spasm in the lungs which causes the asthmatic seizure, but after a time the remedy fails and something else has to be tried. In many cases, when first used, it almost works a miracle. This is the simplest type of suggestive treatment for asthma.

Mental Shock .—Any strong mental influence, especially if accompanied by the suggestion of assured relief, is likely to do much for asthma of essentially neurotic character, and indeed is more powerful in dispelling the symptoms of the seizure than almost any other means that we have. Sometimes even things absolutely indifferent which produce a profound mental impression, prove curative. There are many stories of men in the midst of a severe asthmatic seizure being suddenly roused by the cry of fire, or an alarm of some kind near them, having the spasmodic conditions disappear as if by magic. Occasionally where attacks of asthma recurred regularly on successive nights for a considerable period, travel on a railroad train or anything else which occupied the attention much, prolonged the interval between seizures and sometimes put an end to the series of attacks. The more one knows of asthma the more one realizes how much its occurrence depends on mental influences of many kinds in association with various reflex irritations, some of them very distant from the respiratory tract and comparatively trivial in their effects on other people.

Loss of Control .—Occasionally in elderly neurotic people over-fatigue induces an attack of asthma about the time that sleep becomes deep. This usually occurs after the first hour or two of sleep. The inhibitory power of the nervous system over spasmodic contraction of the lung tissues seems lost in deep sleep and then the asthmatic condition develops. The greater the effort to breathe the more intense does the contraction become, until the antispasmodic effect of the presence of a lessened amount of oxygen and an abnormal quantity of carbon dioxide in the blood makes itself felt. In many cases these patients will be relieved of the tendency to such spasm by taking a cup of coffee. This stimulates the general circulation and minimizes the reflex tendency which centers in their respiratory tracts. Such patients after taking an amount of coffee that would keep ordinary people awake all night, sink in the course of half an hour into a quiet, restful sleep and awake quite refreshed. This is not entirely suggestive, but suggestion plays an added role in the relief of all the symptoms.