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.





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