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Coughs And Colds





Cough under most conditions is so completely a natural reflex due to
irritation from material which demands expectoration that to talk of
the application of psychotherapeutics to its treatment would seem
almost an abuse of words. This is true if we think of the curing of an
ordinary catarrhal or bronchitic cough by suggestion. We know now,
however, that, as a rule, we do not cure diseases, we only relieve
their symptoms and thus enable nature to overcome the affection. The
ordinary cough remedies do two things: they cause more liquid to exude
into the lung tissues and thus soften and liquefy thick mucous
material so as to make it easier to expectorate, or they lessen
irritation and soothe the cough by making the nervous system less
reactive. This second function of our remedial measures directed
against cough can at least be assisted very materially by
psychotherapeutics. Direct suggestion may be of great help, while the
first function, that of softening the cough by liquefying the sputum,
can be materially aided by certain suggestions to the patient of
natural means and ways by which his cough may be relieved, its
secondary symptoms modified, and its course abbreviated.


Cough and Suggestion.--Much of the coughing indulged in is quite
unnecessary and might well be dispensed with. At many of the German
sanatoria for consumption there is a rule that patients must not cough
at dinner, and no coughing is heard in the refectory. Without such a
rule the midday meal, if taken in common by the large number of
consumptives present, would be a pandemonium of coughing. Cough is
largely influenced by suggestion. Most of the respiratory reflexes
follow this same rule. To see another yawn tempts us to yawn; to hear
another cough tempts us to cough. In church or in a theater after an
interval of interest one cough will be followed by a battery of
coughs. People who have colds think they have a right to cough, and so
they often cough much more than is at all necessary. Of course, when
material accumulates in the lungs it must be coughed up, but not a
little of the coughing might easily be dispensed with--it is
unproductive coughing. A distinguished German medical authority who is
accustomed to talk very plainly once said that it is quite as impolite
and injustifiable to cough unproductively as to scratch the head
unproductively. Only results justify either procedure.

Dry coughing, when persistent, is greatly a matter of habit acquired
by yielding to slight irritation. When children scratch their heads we
train them not to, and the same thing should be done with regard
to yielding to reactions from slight irritations of their lungs.

Even when material has to be expectorated there is often much more
fuss and effort made over it than is needed. Most men a generation ago
insisted on their right to expectorate in public because it was better
for them to rid themselves of offensive material than to retain it.
The difference between men and women in this respect has always been
distinctive. Women practically never expectorate in public, men do it
frequently, or rather, let us hopefully say, used to. It seems to be
thought the exercise of a manly privilege to spit and the boy learns
the habit. It seemed almost a necessity in the past, yet now we have
come to a point where, by legal regulation, we prohibit spitting in
public and it seems likely future generations, not far off, will hold
it as a rule that instead of the sexes being essentially different by
nature in this respect, the habits formed by the enforcement of recent
legal regulations will show their essential similarity and we shall
have no "expectorating sex."


Unnecessary Coughing Harmful.--Coughing, unless it is necessary,
always does harm. It irritates the mucous membrane, already rendered
somewhat hyperemic and tender by the inflammatory process at work, to
have the breath pass over it in such an expulsive way. This is one
case where nature's indications are not to be followed. It is like
itchiness in eczema: it needs to be restrained. The cold will get
better sooner, the inflammatory process will run its course with less
disturbance and in briefer time than if it was not disturbed in this
way or disturbed only as little as possible. This is a point that is
not often explained to patients and most sufferers from colds are
inclined to think that the more they cough the better, even though the
cough, like the scratching in eczema, evidently produces a roughening
and sensitizing of inflamed tissue. Of course, this principle of the
limitation of cough may be carried to excess and indeed sometimes is
when opium is administered to quell coughing. This is not the idea,
however, of the suggestion made here, which is only to restrain the
cough within the limits necessary for the removal of material that
should be evacuated.

The history of most of the tuberculous patients who suffer from
hemorrhage for the first time shows that they had been coughing
unproductively, and then, after coughing in this way rather severely,
there came the flow of blood due to the rupture of a minute artery. In
these cases the tuberculosis process has been at work for some time
and has prepared the tissue for this arterial rupture, but there is no
doubt, however, that the coughing itself, far from doing good, rather
helped in the destruction of lung tissue, or at least made it more
difficult for natural processes in the lungs to wall off the bacilli
and prevent further damage. Practically every adult is in some danger
of lighting up an acute tuberculous process in his lungs if he racks
them by coughing. There are many similar examples in nosology of this
possibility of some habit predisposing to or favoring the development
of disease.

After measles and whooping cough tuberculosis is especially likely to
develop. In both of these diseases, but especially in the latter,
coughing is an element of the affection that probably predisposes to
the implantation of the tubercle bacillus so commonly present in the
air of our cities. The lesions produced in the extreme expulsive
efforts of the paroxysm form favorable niduses for the micro-organism.
Children particularly, if at all encouraged, are likely to cough
more than is good for them. On the slightest irritation they cough. It
is almost impossible to restrain them from scratching when they are
suffering from eczema, yet we take rather elaborate means to do so,
and quite as much must be done to prevent them from coughing when
there is no special reason for it. This does not refer to cases in
which material is being abundantly expectorated. Elimination can only
be secured by a proper expulsive effort. Very often, however, children
notice how much solicitude their little dry cough arouses. They like
to be the objects of attention. They are dosed with various cough
remedies, more or less pleasant, whenever they cough. Instead of being
told that they should restrain their cough except when it is
necessary, they are rather encouraged to cough whenever there seems to
be the slightest occasion.


Reflex Coughs.--There are a number of coughs that are said to be
reflex because they are not induced by any lesion of the lungs or of
the larynx, or, indeed, of any of the air passages. In these cases
some pathological condition is often found in another organ or set of
organs, usually one of those connected with the vagus nerves. The wide
distribution of these pharyngo-laryngo-esophago-pulmano-cardio-gastric
nerves gives ample opportunity for reflexes. We hear much of reflex
cough. There is a stomach cough and an intestinal cough, a uterine
cough, an ear cough, etc. These coughs are always dry, though often
very irritating to patients, and especially may be a source of dread
and disturbance of mind and health because they seem to signify some
serious pathological condition. As a rule, these coughs can be
restrained to a great degree and frequently suppressed entirely by
suggestion and discipline. In many cases there is some temptation to
cough consequent upon irritation of nerve endings communicated through
some devious paths to the nerve supply of the respiratory tract, but
this tendency is not very strong and can be easily overcome. It may be
said that this is asking too much of human nature, and that, just as
sneezing carries with it a certain satisfaction and so is apparently
worth the trouble of indulging in, coughing should be permitted, at
least, if not encouraged, but the reasoning is fallacious.


Habit Coughs.--An interesting cough that comes to the physician is
that in which there is absolutely no pathological reason to account
for it. There is an irritation of the mucous membrane somewhere along
the respiratory tract but it is very slight and somehow the habit has
been acquired of yielding to the reflex that it occasions. I have seen
these coughs in children in cases where I was sure that they were
nothing but tics. I have seen so-called hacking coughs in girls of
twelve to sixteen that were explained as ovarian, or sometimes as
puberty coughs, that were really nothing more than habits. A slight
hyperemia of the mucous membrane in the upper respiratory tract due to
an ordinary cold began in a very slight degree the irritation, and
then the habit of coughing was not given up. Of course, I know the
danger of treating such cough as habit coughs. Tuberculosis in its
initial stage may exist for a prolonged period before it produces any
increase of secretion and at a time when none of the ordinary physical
diagnostic signs are present, except possibly a little prolongation of
expiration over the affected area. At this stage tuberculosis will
sometimes produce gastric disturbance, and, as I have already said,
these are spoken of as stomach coughs when there really is something
much more serious than them at work. When there has been no running
down in weight, and, above all, no special opportunity for
contagion, then, if there are no physical signs in the lungs, these
coughs will be best treated as habits and gradually be made to stop by
suggestion. The limitation of coughing will do good in any case.


Coughs as Tics.--Some coughs are not really due to any difficulty in
the respiratory tract, but are caused by nervous irritability. There
are certain habits in the matter of clearing the throat that sometimes
become pronounced and apparently impossible to stop. As I have said,
these are tics rather than true coughs. Many of these neurotic coughs
very seriously alarm patients and also their friends. They are dry, as
a rule, rather harsh and inclined to be brassy. Occasionally they are
only what is known as "hacks," as if the patient were trying to clear
the throat of some offending material. Of course, at no time must the
significance of cough be made light of unless a careful investigation
of the patient's condition has been made.


Diagnosis.--Names for these coughs should not be too readily accepted
which, by satisfying legitimate curiosity and lessening proper
apprehension with regard to them, will stop further investigations.
Besides stomach coughs, one often hears of intestinal and even uterine
or ovarian coughs. In many cases the real condition is one of an
incipient tuberculous condition and there may be no sign of this
except a disturbance of the pulse and perhaps a slight variation of
the temperature range for the day (two degrees or more Fahrenheit in
the twenty-four hours). Such coughs should always be carefully
investigated for the possibility of incipient tuberculosis. At once
the patient should be warned about coughing without necessity, since
this only tends to disseminate the tuberculous process and may help to
break down nature's wall of protective lymph.

Where there is no disturbance of pulse or temperature and the patient
is not under weight and there are no signs in the lungs, then the
cough is merely a habit and partakes of the nature of a tic. Sometimes
these habits are rather difficult to break; always, however, much can
be done by suggestion, by a habit of self-control, by self-discipline,
and by thorough persuasion of the patient. Drugs are likely to
inveterate the condition if not allied with suggestion.


Removing Unfavorable Suggestions.--For the ordinary coughs and colds
of the winter time there are many unfavorable suggestions that deserve
to be eliminated. For instance, most people are sure that exposure to
the air will inevitably make their cold and cough worse. This is a
relic of the olden time when the confinement of patients to their
rooms was supposed to be the best remedial measure for all respiratory
diseases. Tuberculosis patients were kept in and died without any
chance. Now these patients, even while running a temperature, or
suffering from pleurisy, or the intercostal painful conditions that
are often serious complications because of the irritability and
discomfort produced, and which are so often supposed to be due to
drafts, are put out on the porch, or on the roof of a hospital, or
allowed calmly to lie in bed between two open windows, without the
slightest hesitation. They begin to improve under such treatment much
sooner than if they were confined, and indeed the whole prognosis of
tuberculosis has been completely changed by the modification of the
old-time habit of confinement to that of perfectly free access of
outer air and even cold air that has taken its place.

This principle of treatment must be applied for coughs and colds.
While patients are running a temperature they must not take
exercise, they must not be allowed to work, above all they must not be
allowed to get in crowds nor tire themselves in any way. The room in
which they are, however, must be thoroughly aired, the window must be
open all night and, if possible, they must sit in the sun for several
hours a day. This will cure a cough or a cold quicker than anything
else. Many coughs that hang on when treated by remedies of various
kinds, yield at once if the patient is given an abundance of fluid
diet and gets freely into the air. There is no danger of catching
another cold, because a cold is not due to a low outdoor temperature,
but to dust and microbes, and is a real infection.


Irrational Remedies.--There are an innumerable number of supposed
remedies for colds. Scarcely any one who has reached the age of forty
apparently feels that he or she is doing the whole duty to humanity
unless they have some remedy for colds to recommend. Most of the
popular remedies that are employed probably do as much harm as good
and many of those that are very popular and are sometimes recommended
even by physicians have no rational standing in present-day
therapeutics. Perhaps the most popular is a combination of quinin and
whisky. The effect of this is to give patients, who are unaccustomed
to whisky and who are susceptible to quinin, about as uncomfortable a
twenty-four hours the day after they take the remedies as can be
imagined. Quinin now has no possible specific therapeutic significance
in the cure of the series of infections called colds. In the days when
we did not understand malaria and considered it in some way as an
essential fever due to the absorption of miasmatic material, quinin
seemed to have a specific influence upon several conditions.
Accordingly it was employed in all sorts of fevers and, because it is
comparatively harmless, also in that short infectious fever which we
call a common cold. No physician now employs it (except in small doses
as a general tonic) for febrile conditions, unless in malaria. There
we know that it acts by killing the plasmodium and is a real specific.
We do not think of it any more, however, as a general febrifuge and
there is no justification for its use in the slight infective
conditions we know as colds.

As for the whisky, if taken in stiff doses as it often is, the
reaction is likely to make the patient quite miserable the next day.
It seems to be the rule for him to think that if, notwithstanding the
taking of the quinin and whisky, he feels thus ill, he would have been
ever so much worse without it. Colds, however, when left untreated so
far as drugs go but managed by natural means often run a mild course.
Some of the reputation of quinin and whisky is due to the fact that
not infrequently persons suffer from chilly feelings that seem to
portend a cold and take quinin and whisky and the cold does not
develop. The remedies are then supposed to have aborted or to have
inhibited the development of the cold. Anyone who has seen a number of
these cases treated expectantly, however, knows how often it happens
that the chilly feelings that seem to announce the cold pass off
without incident after a good night's rest.


Rational Treatment.--The old rule of getting the emunctories at work
must be the basis of any rational therapy of colds. A mild opening of
the bowels, especially if there is some constipation, a hot drink on
going to bed so that there is some sweating and perhaps the use of a
mild diuretic will almost surely affect these cases favorably.
Patients have to be careful, however, next morning to stimulate
the circulation in their skin to activity so that the cutaneous
muscles shall react upon the capillaries and the capillaries
themselves tonically contract in order that there may not be too much
blood near the surface of the body, or the patient may easily be
chilled in cold weather. This chilling of the blood when much of it is
near the surface seems to lower its vitality and the patient easily
reinfects himself or, if he goes into dusty or crowded places, catches
a fresh dose of infectious material. This is the process which is
called catching a fresh cold.

The removing of the unfavorable suggestions of remedies that do harm
rather than good and the giving of favorable suggestions founded on
our present-day knowledge of what a cold is and just what we need to
do in order to benefit it, is the most important element in the
treatment. Above all, however, the patient must sleep in an airy room
and must be sure that he is neither breathing his own expired air nor
that of anyone else. With thorough ventilation, however, and the
stimulating effect of the cold air and the confidence due to proper
directions, colds rapidly get better.

There can be only one reason for keeping patients indoors who are
suffering from cold. That is, if they are suffering from fever, the
being out involves exertion. In that case, of course, patients must
rest and must avoid exertion, but there is no reason why they should
not have all possible fresh air. The unfavorable state of mind towards
fresh air and especially night air in these patients was cultivated by
the profession up to a generation or two ago, but is quite unjustified
by our present knowledge. Night air is probably a little better than
day air because it is freer from dust. It is because of malaria that
night air was supposed to be detrimental, but we have found that the
only good reason for this was that the mosquito travels at night.
There are no other constituents of night air that produce any serious
effect.

As a rule, patients suffering from colds need more sleep than other
people and above all need more sleep than they ordinarily take, for
this will increase their resistive vitality and enable them to throw
off the infection. A good rule is to add two hours of sleep to the
usual quota. The unfortunate habit of keeping people indoors and of
keeping fresh outdoor air away from them, because it is feared they
will catch a fresh cold, often seriously disturbs sleep and delays
recovery. In a word, many a cold that hangs on does so mainly because
of unfortunate suggestions of one kind or another that have come to
occupy a place in the supposed therapeutics of the condition. The
removal of these and the insistence on just as much recourse as
possible to the therapeutic means at nature's command constitute the
basis of successful therapy of these very common infections, which
probably are the source of more morbidity in the community because of
their wide diffusion and frequent recurrence than all the other
infectious diseases put together.





Next: Tuberculosis

Previous: Bradycardia



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