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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 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.





Next: Neurotic Asthma And Cognate Conditions

Previous: Character As A Therapeutic Asset



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