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.





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