It has been recognized in recent years that the only climates which give reasonable hope of being helpful for the tuberculous are those which present a variation of some thirty degrees in their temperature every day. Whenever this is the case chilly feelings are always produced in those who are exposed to the change, even though the lower temperature curve may not go down to anywhere near freezing. If for instance the temperature at the hottest hour of the day, say three o"clock in the afternoon, is 90 F. and that of the later evening or middle of the night is 60 F., chilly feelings will be produced. Just the same thing is true if the temperature is between 30 F. and 40 F.
shortly after the middle of the day and then goes down to {181} near zero at night. These chilly feelings are uncomfortable, but they produce an excellent reaction in the circulation and set the blood coursing from the heart to the tissues better than any medicine that we have. In the midst of this the lungs have their resistive vitality raised so as to throw off the disease.
This is probably one of the princ.i.p.al reasons why mountain climates have been found so much more helpful for the treatment of tuberculosis than regions of lower elevations. Whenever the elevation is more than fifteen hundred feet there will almost invariably be a variation of thirty degrees between the day and the night temperature. There are of course still greater variations, even sixty or seventy degrees sometimes where the alt.i.tudes are very high, but this is often too great for the tuberculous patients to react properly to, in their rundown conditions. Besides, the air is much rarer at the higher elevations, breathing is more difficult, because the lungs have to breathe more rapidly and more deeply in order to secure the amount of oxygen that is needed for bodily necessities from the rarified air.
The middle elevations then, between fifteen hundred and twenty-five {182} hundred feet, have been found the best for tuberculosis patients, and they are very pleasant during the summer time, though never without the chilly discomfort of the drop in temperature. During the fall and winter, however, many patients become tired out trying to react to these variations of temperature and want to seek other climates where they will not have to submit to the discomfort and the chilly feelings. If they come down to more comfortable quarters before their tuberculosis has been brought to a standstill by the increase of their resistive vitality, it is very probable that they will lose most of the benefit that they derived from their mountain experience. Here is where the will comes in. Those who have the will to do it and the persistence to stick at it and the character that keeps them in good humor in spite of the discouraging circ.u.mstances which almost inevitably develop from time to time, will almost without exception recover from their tuberculosis with comparatively little difficulty, if they have only taken up the treatment before the disease is so far advanced as to be beyond cure.
In the older days consumptives used to be sent to the Riviera and to Algiers and to {183} other places where the climate was comparatively equable, with the idea that if they could only avoid the chilly feelings consequent upon variations of temperature it would be better for them. Many of the disturbing symptoms of tuberculosis are rendered less troublesome in such a climate, but the disease itself is likely to remain quiescent at best or perhaps even to get insidiously worse, as tuberculosis is so p.r.o.ne to do. These milder climates require much less exercise of the will, but that very fact leaves them without the all-important therapeutic quality which the lower alt.i.tudes possess.
For many people the outdoor life and the sight of nature in the variations produced in scenery during the course of the days and the seasons are satisfying enough to be helpful in making their cure of tuberculosis easy. They are extremely fortunate if they have this strong factor in their favor. It is very probable that we owe the discovery of the value of the Adirondacks and other such medium alt.i.tudes in the treatment of tuberculosis to the fact that Doctor Trudeau liked the outdoors so much and was indeed so charmed with the Adirondack region that when death from tuberculosis seemed {184} inevitable, he preferred the Saranac region as a place to die in, in spite of the hardships and the bitter cold from which at that time there was so little adequate protection, to the comforts of the city.
He scarcely hoped for the miracle of cure from a disease which he as a doctor knew had carried off so many people, but if he were to die he felt that he would rather die in the face of nature with his beloved mountains all around him than in the shut-in s.p.a.ces of the city.
His resolution to go to the Adirondacks seemed to many of those who heard of it scarcely more than the caprice of a man whom death had marked for itself. His physicians surely had no hope of his journey benefiting him but they felt very probably that in the conditions he might be allowed to have this last desire since there were so few other desires of life that he was likely to have fulfilled. His will to live outdoors in spite of the bitter cold of that first winter undoubtedly saved his life and then he evolved the system of outdoor treatment which has in the past fifty years saved so many lives and is now the recognized treatment for the disease. It is easy to understand, however, how much of firm determination was required {185} on his part forty years ago, when there were no comfortable ways of getting into the Adirondacks, when the last stage of the journey had to be made for forty miles on a mattress in a rough wagon, when water for washing had to be secured by breaking the ice in the pitcher or on the lake and when the bitter climate must have been the source of almost poignant torture to a man constantly running a slight temperature. He had the courage and the will power to do it and the result was not only his own survival but a great benefit secured for others.
Unfortunately many a consumptive patient who during his first period of treatment keeps to the letter the regulations for outdoor air and abundant food fails to do so if it is necessary to come back a second time. Persistency is here a jewel indeed and only the persistent win out. Many an arrested case fails to keep the rules of living that may be necessary for years afterwards and runs upon relapse. The will to do what is necessary is all-important. Trudeau himself, after securing the arrest of his disease in the Adirondacks, though he lived and worked successfully to almost seventy years of age, found it quite impossible to live out of them {186} and often had to hurry back from even comparatively brief visits to the lowlands. Besides, every now and then during some forty years he had the will power to take his own prescription of outdoor air and absolute rest. It was the faculty to do this that gave him length of life far beyond the average of humanity and the power to accomplish so much in spite of the invasion of the disease which had rendered large parts of both lungs inoperative. Not only did he live on, however, but he succeeded in doing so much valuable work that few men in the medical profession of America have stamped their name deeper on modern medical science than this consumptive who had constantly to use his will to keep himself from letting go.
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CHAPTER XII
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 s.p.a.ce 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 a.n.a.lyzes 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 ill.u.s.trates 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 quant.i.ties. 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 circ.u.mstances, 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 alb.u.min which const.i.tutes 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 a.s.sured 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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CHAPTER XIII
COUGHS AND COLDS
"The power and corrigible authority of this lies in our wills."
_Oth.e.l.lo_.
It might seem as though the will had nothing to do with such very material ailments as coughs and colds, and yet the more one knows about them, the clearer it becomes that their symptoms can be lessened, their duration shortened, their tendencies to complications modified, and to some extent at least, they can be almost literally thrown off by the will to be well. The idea of a little more than a generation ago that coughs and colds would be most benefited by confinement to the house and as far as possible to a room of an absolutely equable temperature has gradually given way before the success of the open-air treatment for tuberculosis and the meaning of fresh air in the management of pneumonia cases. Fresh, cold air is always beneficial to the lungs, no matter what the conditions present in them, though it requires {197} no little courage and will power to face the practical application of that conclusion in many cases. When it is bravely faced, however, the results are most satisfactory, and the respiratory condition, if amenable to therapeutics, is relieved or proceeds to get better. Of course it is well understood that any and every patient who has a rise in temperature, that is whose temperature is above 100 F. in the later afternoon hours, should be in bed. Under no circ.u.mstances must a person with any degree of fever move around.
This does not mean, however, that such patients should not be subjected to fresh, cold air. The windows in their room or the ward in which they are treated should be open, and if the condition is at all prolonged, arrangements should be made for wheeling their beds out on the balcony or placing them close to a window. The cold air gives them distinctly chilly feelings and sometimes they complain of this, but they must be asked to stand it. Of course if the cold disturbs their circulation, if the feet and hands get cold and the lips blue, the patients are not capable of properly reacting against the cold and must not be subjected to it. Their subjective feelings of chilliness, however, must {198} not be sufficient to keep them from the ordeal of cold, fresh air; on the contrary, they must be told of the benefit they will receive from it and asked to exert their wills to stand the discomfort with just as little disturbance as possible.
People suffering from coughs, no matter how severe, should get out into the air regularly, if they have no fever, and should go on with their regular occupation unless that occupation is very confining or is necessarily conducted in dusty air. Keeping to the house only prolongs the affection and makes it much more liable to complications than would otherwise be the case. Sufferers from these affections should not go into crowds, should avoid the theaters and crowded cars, partly for the sake of others--because they can readily convey their affection to them--but also for their own sake, because they are more susceptible to other forms of bacteria than those already implanted in their own systems and they are much more liable to pick up foreign bacteria in crowds than anywhere else. They should be out in the open air, particularly in the sunlight, and this will do more to shorten the course of a cough and cold than anything else.
{199}
They need more sleep than before and should be in bed at least ten or eleven hours in the day, though if they should not sleep during all of that time, they need not feel disturbed but may read or knit or do something else that will occupy them while they retain a rec.u.mbent position. They should not indulge in long, tiresome walks and in special exertion, but should postpone these until the cough has given definite signs of beginning to remit.
With regard to the cough itself, it must not be forgotten that the action of coughing is for the special purpose of removing material that needs to be cleared from the lungs and the throat and larynx. It should not be indulged in except for that purpose. It requires a special effort, and while the lungs and other respiratory pa.s.sages are the subject of a cold, these extra efforts should not be demanded of them unless they are absolutely necessary. Almost needless to say, people indulge in a great deal of unnecessary coughing. Some of this is a sort of habit and some of it is due to that tendency to imitate, so common in mankind. Every one has surely heard during religious services, in a pause just after heads have been bowed in prayer or for a {200} benediction, a single cough from a distant part of the church which seemed to be almost the signal for a whole battery of coughs that followed immediately from every portion of the edifice. If some one begins coughing during a sermon or discourse, others will almost inevitably follow. Coughing, like yawning, is very liable to imitation.
The famous rule of an old-time German physician was that no one was justified in coughing or scratching the head unless these activities were productive. Unless you get something as the result of the coughing, it should not be indulged in. There are a great many people who cough much more than necessary and who delay the progress of their betterment in that way. Whenever material is present to be coughed up, coughing is not only proper but almost indispensable. It is the imitative cough, the coughs which indicate overconsciousness of one"s affection, the coughs that so often almost unconsciously are meant to catch the sympathy of those around, which must be repressed by the will, and when the patient finds that he really has to cough less than he thinks, he will be quite sure that he is getting better and will actually improve as a consequence of this feeling.
{201}
Coughs need an abundance of fluid much more than medicine, and warm fluids are better than cold; the will must be exercised so as to secure the taking of these regularly. At least a quart of warm liquid, milk if one is not already overweight, should be taken between meals during the existence of a cough. Hot milk taken at night will very often secure much better rest with ever so much less coughing than would otherwise be the case. The tendency to take cough remedies which lessen the cough by their narcotic effect always does harm. Coughing is a necessary evil in connection with coughs, and whatever suppression there is should be accomplished by means of the will.
Remedies that lessen the coughing also lock up the secretions and disturb the system generally and therefore prolong the affection and do the patient harm. Most of the remedies that are supposed to choke off a cough have the same effect. Quinine and whiskey have been very popular in this regard but always do harm rather than good. Their use is a relic of the time when whiskey was employed for almost every form of continued fever and when quinine was supposed to be good for every febrile affection. We know now that quinine has no effect {202} except upon malarial fevers, and then only by killing the malarial organism, and that whiskey is a narcotic and not a stimulant and does harm rather than good. Those who did not take the familiar Q. and W. have in recent years had the habit of administering to themselves or to their friends various laxative or anodyne or antiphlogistic remedies that are supposed to abort a cough or cold and above all, prevent complications. All of these remedies do harm. Every single one of them, even if it makes the patient a little more comfortable for the time, produces a condition that prevents the system from throwing off the infection which the cold represents as well and as promptly as it otherwise would.
It requires a good deal of will power to keep from taking the many remedies which friends and sometimes relatives insist on offering us whenever a cold is developing, but the thing to do is to summon the will power and bravely refuse them. Medicine knows no remedies that will abort a cold. The use of brisk purgatives, sometimes to an extent which weakens the patient very much the next day, is simply a relic of the time when every patient was treated with antimony {203} or calomel and free purgation was supposed to be almost as much of a cure-all as blood-letting. There is no reason in the world to think that the emptying of food out of the bowels will do any particular good, unless there is some definite indication that the food material present there should be removed because it is producing some deleterious effect.
The longer a physician is in the practice of medicine the less he tries to abort infectious diseases, and coughs and colds are, of course, just infections. They must run their course, and the one thing essential is to put the patient in as good condition as possible so that his resistive vitality will enable him to throw off the infection as quickly as possible. It requires a good deal of exercise of will power on the part of the physician to keep from running after the many will-o"-the-wisps of treatment that are supposed to be so effective in shortening the course of disease, but any physician who looks back at the end of twenty years will know that his patients have reason to be thankful to him just in proportion as he has avoided running after the fads and fancies of current medicine and conservatively tried to treat his patients rather than cure their diseases. The patient is ever so much {204} more important than his disease, no matter what the disease may be.
Above all, for the cure and prevention of coughs and colds people must not be afraid of cold, fresh air. A good many seem to fear that any exposure to cold air while one has a cough may bring about pneumonia or some other serious complication. It must not be forgotten, however, that the pneumonia months in the year occur in the fall and the spring, October and November and March and April producing most deaths from the disease, and not December, January and February. The large city in this country which may be said to have the fewest deaths from pneumonia is Montreal, where the temperature during December and January is often almost continuously below zero for weeks at a time and where there is snow on the ground for three or four months in succession. The highest death rate from pneumonia is to be found in some of our southern cities which have rather mild winters and rather equable temperature,--that is, no considerable variation in the daily temperature range. Cold air is bracing and tonic for the lungs and enables them to resist the microbe of pneumonia, and it is now recognized {205} by physicians that personal immunity is a much more important factor in the prevention of the disease than anything else.
Coughs and colds and bronchitis and pneumonia, the respiratory diseases generally, are much less frequent in very cold climates than in variable regions. Arctic explorers are but rarely troubled by them, even though they may be exposed to extremely low temperatures for months. Men subjected to blizzards at thirty and forty degrees below zero may have fingers and toes frozen but do not have respiratory affections. Some years ago, it was noted that one of these Arctic expeditions had spent nearly two years within the Arctic Circle without suffering from bronchial or throat disease and within a month after their return in the spring most of them had had colds. Nansen and his men actually returned from the Arctic regions where they had been in excellent health during two severe winters to be confined to their beds with grippy colds within a week of their restoration to civilization, with its warm comfortable homes and that absolute absence of chill which is connected in so many people"s minds with the thought of coughs and colds.
The princ.i.p.al reason why colds are so {206} frequent in the winter time in our cities and that pneumonia has increased so much is mainly because people are afraid of standing a little cold. Office buildings are now heated up to seventy degrees to make the personnel absolutely comfortable even on the coldest days, and as a consequence the air is so dry that it is more arid--that is more lacking in water vapor, as the United States Public Health Service pointed out--than Death Valley, Arizona, in summer. People dress too warmly, antic.i.p.ating wintry days and often getting milder weather and thus making themselves susceptible to chilling because the skin is so warm that the blood is attracted to the surface. Will power to stand cold, even though at a little cost of discomfort, is the best preventive of coughs and colds and their complications and the best remedy for them, once the acute febrile stage has pa.s.sed.
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CHAPTER XIV
NEUROTIC ASTHMA AND THE WILL
"Great minds of partial indulgence To their benumbed wills."