Treatment.—The rôle of psychotherapy in this form of cardiac disturbance associated with gastro-intestinal affections is, after the differentiation of neurotic from serious organic conditions, to give the patient such reassurance as is justified by his condition. It is surprising how many people are worrying about their hearts because their stomachic and intestinal conditions give rise to heart palpitation, that is to such action of the heart as brings it into the sphere of their consciousness, sometimes with the complication of intermittency or even more marked irregularity. The less the experience of the physician the more serious is he likely to consider these conditions and the more likely he is to disturb the patient by his diagnosis and prognosis. Until there is some sign of failing circulation, or of beginning disturbance of compensation, the attachment of a serious significance to these conditions always makes patients worse and removes one of the most helpful forms of therapeusis, that of the favorable influence of the mind on the heart. On the other hand, unless the patients' own unfavorable auto-suggestions as regards the significance of their heart symptoms are corrected, these people not only suffer subjectively, but bring about such disturbance of their physical condition as makes many symptoms objective.

While there are serious affections in which heart and stomach are closely associated, these are quite rare and usually manifest themselves in acute conditions and in old people. In the chapter on Angina Pectoris attention is called to the fact that there are may forms of pseudo-angina due to cardiac neuroses consequent upon gastric disturbance and without heart lesion. Broadbent has not hesitated to say that these forms of angina cause more suffering or at least produce more reaction on the part of the patient and are always the source of more complaint than the paroxysms due to serious cardiac conditions which present the constant possibility of a fatal termination.

Where the stomach is the cause of the cardiac neuroses psychotherapy is an extremely important element in the treatment. The continuance and exaggeration of their symptoms is often due to a disturbance of mind consequent upon the feeling that they have some serious form of heart disease. Without {335} definite reassurance in this matter all the experts in heart disease insist that it is extremely difficult to bring about relief of symptoms in these patients. Whenever the general health of the individual has not suffered from his heart affection, it is quite safe to assume that no organic disease of the heart is present, no matter what the symptoms, for, as Broadbent and many other authorities emphasize, gastric cardiac neuroses can simulate every form of heart disturbance. The older physicians insisted that what they called sympathy with the hypochondriac organs might produce all sorts of heart symptoms. The patient must be told this confidently. The slightest exaggeration of the significance of his symptoms can do no possible good and will always do positive harm.

After reassurance, the most important thing is, of course, regulation of the diet and of the digestive functions generally. Unfortunately, regulation of the diet to many patients and even to many physicians seems to mean the limitation of diet. I have seen sufferers from cardiac symptoms have these increased by excessive limitation of diet. If they are lower than they ought to be in weight they must be made to regain it. Above all, there must be no limitation of meat-eating except in the robust. Very often the heart seems to crave particularly that form of nutrition that comes through meat. It is especially important that the bowels should be regular. Fast eating is very harmful. Occupation with serious business immediately after eating is almost the rule in these cases.

All of these elements of the case need special study in each individual patient. The needed suggestions can then be made. Above all, the patient is made to realize that his case is understood and that it is only the question of a gradual acquirement of certain habits, including proper exercise, that is needed for the restoration of his heart to normal.

CHAPTER V

ANGINA PECTORIS

The two forms of this affection, known commonly as true and false angina, are characterized by pain or anguish in the precordial region with reflected pains in other portions of the body. It used to be said that whenever the precordial pain was accompanied by reflected pains in the neck, or down the arm, or, as they may be occasionally, in the jaw, in the ovary, in the testicle, sometimes apparently in the left loin, this was true angina and the patient was in serious danger of death. We know now that false angina may be accompanied by various reflex pains and that, indeed, a detailed description of the anguish and its many points of manifestation is more likely to be given by a neurotic patient suffering from pseudo-angina than by one suffering from true angina. True angina occurs in most cases as a consequence of hardening of the arteries of the heart or of some valvular lesion that interferes in some way with cardiac nutrition. The definite sign of differentiation is that in practically all cases of true angina, there are signs of arterial degeneration in various parts of the body. Without these, the "breast pang," as the English {336} call it, is likely to be neurotic and is of little significance as regards future health or its effect upon the individual's length of life.

Besides the physical pain that accompanies this affection there is, as was pointed out by Latham, a profound sense of impending death. It used to be said that this was characteristic of the organic lesions causing true angina pectoris. It is now well known, however, that the same feeling or such a good imitation of it that it is practically impossible to recognize the true from the false, occurs in pseudo-angina. It is this special element in these cases that needs most to be treated by psychotherapy and which, indeed, can only be reached in this way. Where there are no signs of arterial degeneration and no significant murmurs in the heart, it should be made clear to these patients that they are not suffering from a fatal disease, but only from a bothersome nervous manifestation. Especially can this reassurance be given if the angina occurs in connection with distention of the stomach or in association with gastric symptoms of any kind. In young patients who are run down in health and above all in young women, the subjective symptoms of angina—the physical anguish and the sense of impending death—are all without serious significance.

Differential Diagnosis of True and False Angina.—In the diagnosis of angina pectoris the main difficulty, of course, lies in the differentiation between the true and false forms, that is, those dependent on an organic affection of the heart muscle or blood vessels and those resulting from a neurosis. The neurotic form is not uncommon in young people and is often due to a toxic condition. Coffee is probably one of the most frequent causes of spurious angina, though the discomfort it produces is likely to be mild compared with the genuine heart pang. It must not be forgotten, however, that neurotic patients exaggerate their pains and describe their distress in the heart region as extremely severe and as producing a sense of impending death, when all they mean is that, because the pain is near their heart it produces an extreme solicitude and that a dread of death comes over them because of this anxiety. Coffee and tea, especially when taken strong and in the quantities in which they are sometimes indulged in, may be sources of similar distress. Tobacco will do the same thing in susceptible individuals, or where there is a family idiosyncrasy, and especially in young persons.

For the differentiation of true and spurious angina Huchard's table as given by Osler is valuable:

True Angina and Psychotherapy.—One of the most frequent occasions for the development of true angina is vehement emotion. The place of psychotherapy then in the affection will at once be recognized. A classical example of the influence of the mind and the emotions in the production of attacks of angina pectoris in those who are predisposed to them by a pre-existing pathological condition, is the case of the famous John Hunter. He was attacked by a fatal paroxysm of the affection in the board room of St. Thomas' Hospital, London, when he was about to begin an angry reply with regard to some matter concerning the medical regulation of the hospital. He had previously recognized how amenable he was to attacks of the disease as a consequence of emotion or excitement, and had even stated to friends that he was at the mercy of any scoundrel who threw him into an attack of anger. Some of the deaths from fright or sorrow at a sudden announcement of the death of a relative, or even the deaths from joy are due to angina pectoris precipitated by the serious strain put upon the heart by the flood of terror or emotion.

Men who are sufferers from what seems to be true angina pectoris must be made to understand without disturbing them any more than is absolutely necessary that strong emotions of any kind—worry, anger, exhibitions of temper, and, above all, family quarrels, must be avoided. Not a few of the serious attacks of angina pectoris which physicians see come as a consequence of family jars, owing to the persistence of a son or daughter in a course offensive to the parent. A part of the prophylaxis, then, consists in impressing this fact on members of the family and making them understand the danger. The disposition that causes the family friction is, however, often hereditary and will, therefore, prove difficult of control. It is one of the typical cases of inheritance of defeats.

Solicitude and Prognosis.—The distinguished French neurologist, Charcot, had several attacks of what seemed to be true angina pectoris. His friends were much disturbed by it. Physicians who saw him during the attack feared that he was suffering from an incurable heart lesion. He himself, as his son, Dr. Charcot, told me, refused to accept this diagnosis, and preferred to believe that what he was suffering from was a cardiac neurosis—and, of course, he had seen many of them. He was unwilling to have a heart specialist examine him very carefully for he did not wish to be persuaded of the worst aspects of his condition.

What he said in effect was, "This is either a neurotic condition, as I think it is, or it is an organic condition. If it is organic, my physicians would be apt to tell me that I must stop working so hard, and I am sure that if I should do that I would do myself more harm than good by having unoccupied {338} time on my hands. I want to go on doing my work. If I am wrong some time I shall be carried off in one of these attacks. That will not be such a serious thing, for after all I must die some time and my expectancy of life cannot normally be very long. I prefer, then, to go on with my work and think the best, for it does not seem that I could do anything that would put off the inevitably fatal issue if I am to die a cardiac death." He was found dead one morning, but he had passed into the valley of death without being seriously disturbed and without any of the neurotic symptoms that so often develop in discouraged patients. Curiously enough, one of our most distinguished heart specialists in this country went through almost the same experience and preferred to live "the brief active life of the salmon rather than the long slow life of the tortoise."

The best possible factor in therapy is secured if patients can be brought to the state of mind of these distinguished physicians who calmly faced the future, refusing to disturb themselves or their work, because they feared that the worry that would come down upon them in inactivity would aggravate their disease. Where men are occupied with some not too exacting occupation, that takes most of their attention and at which they have been for years, it is best to leave them at it, though the harder demands of it must be modified. If they can be brought to persuade themselves, as did the two physicians—though probably only half-heartedly—that their affections may possibly be merely neurotic and not true angina, it will always be better for them. Death may come, and commonly will, suddenly, but, after one has lived a reasonably full life, that is rather a blessing (and not in disguise) than the terror which it is sometimes supposed to be.

Pseudo-Angina.—The neurotic form of angina is quite compatible, not only with continued good health but with long life, and even after a long series of attacks, some of them very disturbing in their apparent severity, there may be complete relief for years, or for the rest of life. Exaggeration of feeling due to concentration of attention plays a large role in these cases, and it is evident that the dread of something the matter with the heart connected with even a slight sense of discomfort may readily become so emphasized as to seem severe pain, though many people have similar feelings without making any complaint.

In spite of reassurances attacks of pseudo-angina are likely to worry both patient and physician. The only working rule is that in younger people discomfort in the heart region, even though it may be accompanied by some sympathetic pain in the arm or in the left side of the neck, is usually spurious angina. Broadbent goes so far as to say that this is true also in many older persons. His method of making the differentiation is interesting because so easy and practical that it deserves to be condensed here. The earlier attacks of true angina are practically always provoked by exertion, while spurious angina is especially liable to come on during repose. Any cardiac symptom or pain that can be walked off may be set down as functional and due to some outside disturbing influence, or to nervous irritability. When palpitation or irregular action of the heart, or intermission of the pulse, or pain in the cardiac region, or a sense of oppression follows certain meals at a given interval, or comes on at a certain hour during the night, there need be little hesitation in attributing the disturbance, whatever it may be, to indigestion in {339} some of its forms. Nightmare from indigestion, Broadbent thought, is not a bad imitation of true angina.

In Broadbent's mind acute consciousness of any heart disturbance lays it in general under the suspicion of being neurotic in origin. He was talking to some of the best clinical practitioners in the world and some of the most careful observers of our generation, when, before the London Medical Society, he said: "The intermission of the pulse of which the patient is conscious and the irregularity of the heart's action—though this can be said with less confidence—which the patient feels very much, is usually temporary and not the effect of organic heart disease." This is particularly true, of course, in people of a neurotic character, and Broadbent went on to say that "speaking generally, angina pectoris in a woman is always spurious, and the more minute and protracted and eloquent the description of the pain, the more certain may one be of the conclusion."

I had the opportunity to follow the case of a young woman who had a series of attacks of angina pectoris some twenty years ago, so severe that a bad prognosis seemed surely justified, and though at times the attacks were rather alarming to herself and friends, nothing serious developed and for the past ten years, since she has gained considerably in weight, they have not bothered her at all. She used to be rather thin and delicate, trying to do a large amount of work and living largely on her nervous energy. At times of stress she was likely to suffer from pain in the precordia running down the left arm and accompanied by an intense sense of the possibility of fatal termination. With reasonably large doses of nux vomica, an increase in appetite came and a steadying of her heart that soon did away with these recurrent attacks. These came back later several times when she neglected her general condition, but there never were any objective symptoms that pointed to an organic lesion. After twenty years she is in excellent health, except for occasional attacks of a curious neurotic indigestion that sometimes produces cardiac disturbances. Of course, such cases are not uncommon in the experience of those who see many cardiac and nervous patients.

For the treatment of pseudo-angina, mental influence is all important. Of course, the conditions which predispose to the mechanical interference with heart action that occasions the discomfort, must be relieved as far as possible. The severity of the symptoms, however, are much more dependent on the patient's solicitude with regard to them, they are much more emphasized by worry about them, than by the physical factors which occasion them. Reassurance is the first step towards cure. After relief has been afforded from the severer attacks, the patient's solicitude as to the future must be allayed and the fact emphasized that there are many cases in which a number of attacks of cardiac discomfort simulating angina pectoris have been followed by complete relief and then by many years of undisturbed life. It is important to make patients understand that, in spite of the fact that their attacks occur during the course of digestion, as is not infrequently the case, this constitutes no reason for lessening the amount of food taken. Nearly always these attacks occur with special frequency among those who are under weight, and disappear rather promptly when there is a gain in weight. Solicitude with regard to the heart must be relieved wherever possible and then with the regaining of general health the heart attacks will disappear.

CHAPTER VI

TACHYCARDIA

Etymologically tachycardia means rapid heart. There are two forms of rapid heart, that which is constant and that which occurs in periodical attacks. It is for this latter that the term tachycardia has been more particularly used, though occasionally the adjective paroxysmal is attached to it to indicate the intermittent character of the affection. With regard to the persistent type of rapid heart something deserves to be said, however, because patients' minds are often seriously disturbed by them. Often it has existed for years, sometimes is known to be a family trait and probably has existed from childhood, yet the discovery of it may be delayed until some pathological condition develops, calling for the attendance of a physician who may be needlessly alarmed and in turn alarm his patient by his recognition of it. The cause for this persistent rapid pulse is not well known and is difficult to determine. Heredity, as has been suggested, sometimes plays an important role in it. Certain families have one or more members in each generation with rapid hearts. Whenever persistent rapid heart is a family trait the patient can be assured, as a rule, without hesitation, that the general prognosis of the case is that of the lives of the rest of the family. Usually the symptom seems to mean nothing as regards early mortality or any special tendency to morbidity.

Favorable Prognosis.—While a rapid pulse often and indeed usually has some serious significance, it must not be forgotten that it may be an individual peculiarity and be quite compatible with long life and hard work. One of the first patients that I saw as a physician had a pulse between ninety-six and one hundred. As there was a slight tendency to irregular heart action also, I was inclined to think that there must be some cardiac muscle trouble. There was apparently no valve lesion. He told me that a physician ten years before had noted his rapid pulse and had made many inquiries about it which rather seriously disturbed him. He had been an extremely healthy man during his fifty-five years of life and there seemed no reason to conclude, since his rapid pulse had been in existence for ten years, that it meant anything serious. He has now lived well beyond the age of seventy and still has a pulse always above ninety. Contrary to what might be thought, he is an extremely placid, unexcitable individual, who, under ordinary circumstances, will probably live for many years to come. He has no family history of tachycardia, though there is a history of rather nervous irritable hearts in other members for two generations.

An interesting case of this kind came under my observation about fifteen years ago in a clergyman whose pulse was never below ninety, and who on slight excitement, or after a rapid walk, or after a heavy meal, would have a pulse of 120. He knew that it was a family trait, his father having had it yet living to be past seventy. He gave a history of its having been recognized in his own person more than twenty years before. His general health, however, was excellent. He took long walks and, indeed, pedestrian excursions {341} were his favorite exercise. He was able to go up flights of stairs rather rapidly without discomfort. He was the pastor in a tenement house district so he had plenty of opportunity for such exertion. Infections of any kind, colds and the like, disturbed his pulse very much, if the ordinary standard was taken, but it was not irregular and the increase in rapidity was probably only proportionate to the original height of the pulse in his case. After all, as the normal pulse of sixty to seventy rises to between ninety and one hundred even in a slight fever, it is not surprising if a pulse normally above ninety should rise fifty per cent. to one hundred and thirty-five under similar conditions. He is now well past sixty, after over thirty-five known years—and probably longer—of a pulse above ninety, yet he is in excellent general health and promises, barring accident, to live beyond seventy.

Some ten years ago I first saw another of these cases of fast heart, with a family history of the affection in a preceding generation. He was a man who had not taken good care of himself and had been especially over-indulgent in alcohol. This indulgence consisted not in rare sprees but in the persistent daily taking of large quantities of straight whiskey. In spite of warnings, he has not given up this habit; yet at the age of sixty-five he is apparently in good health and is able to fulfill the duties of a rather exacting occupation.

Persistent rapid pulse often occurs in connection with some disturbance of the thyroid gland. The larval forms of Graves' disease occur particularly in young persons, though they are sometimes seen in those beyond middle life. They seem to be due to a lack of development of the thyroid in consonance with the rest of the tissues, though occasionally, especially after the menopause, they seem to be connected with some degenerative process out of harmony for the moment with other forms of degeneration. When they occur in young persons they may, of course, represent the beginning of incipient Graves' disease, but they are often only functional and the symptoms may pass away entirely. The rapid heart action may come and go, though usually the attacks last for some days and oftener for a week or more at a time.

Paroxysmal Tachycardia.—A rapid heart may not only exist continuously in an individual for many years without any impairment of general health or shortening of life, but there may be spasmodic attacks of this condition with the pulse running up so high as to deserve the name of paroxysmal tachycardia; yet the patient may live for many years and die from some affection not connected with his heart. Perhaps the most remarkable case of this kind on record is that reported by Prof. H. C. Wood of Philadelphia. The patient was a physician in his later eighties when he came under Dr. Wood's observation. His first attack of paroxysmal tachycardia came in his thirty-seventh year. These attacks had apparently always been similar to those he then suffered and were abrupt in onset and the pulse would rise rapidly to 200 a minute. The original prognosis had been, of course, very unfavorable. The physician had outlived all the prophets of evil in his case, however. When large numbers of these cases were studied, it was found that they always last more than ten years, and, while heart failure in such cases is reported, it is doubtful if this occurs with more frequency in these patients as the result of strong reflexes than in the general run of patients, for it must not be forgotten that there is a certain average number of deaths from so-called heart failure in people supposed to be in good health.

In connection with these attacks of paroxysmal tachycardia, there often come intense feelings of depression and even local disturbances of circulation. It is probable that in many cases there is a serious factor at work. MacKenzie has suggested that they are due to nodal rhythm of the heart in which the heart beat does not start at the root of the sinus as is usual, but in some other portion of the musculature and as a consequence there is serious interference with the regular rhythmic action. In a number of cases of heart failure, tachycardia becomes a prominent feature and it is probably due to some such disturbance as this. Such cases often look very serious for a time, yet frequently recover completely after a brief interval. This must not disguise the fact, however, that many of these cases, especially where acute dilatation of the heart can be demonstrated, are extremely dangerous and may end in a sudden fatal termination. The patient seems so much prostrated that occasionally the physician may doubt whether it is worth while to put him to the bother necessary in order to diagnose the acute dilatation of the heart. It always is, however. If it were nothing else but the occupation of the patient's attention with the doctor's manipulations, as far as that is possible, the effect would be good, besides whatever irritation may be caused to the heart muscle itself by percussion of the heart area will probably do mechanical good.

The most important element evidently is that the patient shall not be allowed to lose courage or to think that nothing can be done for him. Something must be done, and a combination of swallowing movements and deep breathing, as far as that is possible, with counter-irritation through the chest wall should be carried out. Drugs also should be employed and the aroma of strong coffee with the irritating effect of ammonia upon the nostrils should be employed. These act upon the vagus so as to stimulate the heart, but above all they act upon the mind, and nothing so stimulates the heart as reawakened hope.

CHAPTER VII

BRADYCARDIA

Bradycardia, or persistent slow pulse, is much rarer than the persistent rapid pulse discussed at the beginning of the chapter on tachycardia. Cases are, indeed, sufficiently rare to be medical curiosities. Prof. Clifford Allbutt has called attention to the fact that the status of bradycardia or brachycardia, as Osler (following Riegel because of the analogue tachycardia) prefers to call it, is very different from that of tachycardia. In the latter, especially, in the specific sense of the term, the symptoms occur paroxysmically, endure for a definite length of time and then there is a return to the normal pulse rate. For this, or at least for the condition known as essential tachycardia, there is no well-defined cause and no definite pathological lesion. Bradycardia or brachycardia, however, is usually present as the result of some known physiologic or pathologic condition; it endures as long as the cause continues to act and then ceases, usually not to return unless the same cause gives rise to it again.

There are some cases, however, of slow pulse that cannot be traced to any definite lesion and in which the pulse is much slower at certain times than at others, though without its being possible to trace any definite immediate cause. These cases seem to be physiological analogues of tachycardia. In tachycardia there is an irritation of the accelerator nerves to the heart, in brachycardia of the inhibitory nerves.

Depressed Mental States.—Occasionally the reason for this can be found, though it is rather vague. In depressed mental states, for instance, a pulse between fifty and sixty is common. In people who suffer from periodic fits of depression it is not unusual to find that in the early morning the pulse is not more than fifty-five. I have seen patients who were worrying about their hearts present records of early morning pulse before they got up that were always below sixty. This is probably in a certain number of people quite normal. I remember a series of observations made on the attendants in the Charite Hospital in Berlin in which it was clear that the normal German morning temperature at seven a.m. was below 97 F., while the pulses were always below sixty. A reassurance of this kind is helpful to patients who have acquired the bad habit of taking their own pulse and have been disturbed by finding it so much below what they consider normal.

Illustrative Case.—A number of cases of persistent slow pulse seem to be congenital or produced by some definite pathological lesion, yet do not prove serious for the patient. Some years ago I described one of these cases in a paper read before the Section on Medicine of the New York Academy of Medicine [Footnote 29] and I have had the opportunity to follow it for about fifteen years. Though the patient's pulse is usually below forty and even after a rapid walk does not rise above fifty, she is in reasonably good health and during those years has buried two husbands. When I saw her she was compelled to go up and down stairs frequently and yet did not experience much difficulty. While patients suffering from palpitation would find it impossible, because of the discomfort produced, to make the journeys up and down stairs that she did, she felt only about as much respiratory discomfort as would come to a woman of her size. Her respirations were somewhat hurried—22 to 24 to the minute—but her general health was very good. Her urine was normal, her liver not enlarged, her ordinary organic functions were not disturbed and there was no sign of arterial degeneration.

[Footnote 29: The Medical News, November 10, 1900.]

With the pulse rate as low as this one might expect to find the patient phlegmatic, slow of movement and not readily moved to emotion. On the contrary, she has always been rather nervous and high-strung and inclined to be excitable. Her cardiac condition was first noted just after the first grip epidemic in this country, though her attention was not called to it during the course of the grip. It seems probable that the heart condition was acquired as a consequence of some irritative lesion affecting the inhibitory nerves to the heart that developed at that time. After her heart condition had been discovered she was for a time a skirt dancer and frequently danced for the amusement of her friends. She was always lively and active and after her first husband's death, when it became necessary for her to earn her own living, she was on the stage for a time and danced without any embarrassment of either {344} heart or respiration. As a consequence of running down in weight and general health, owing to conditions since her husband's death, she noticed that dancing proved exhausting to her and she gave it up.

In general, she considered herself quite as capable as any of her friends for the ordinary duties and amusements of life. When I first saw her her digestion had been somewhat disturbed by worries and unsuitable nutrition taken at irregular intervals and this, I think, accounted much more than her heart for her complaint of tiredness on exertion. Later, after her second marriage, when she was in better circumstances, all her symptoms disappeared and even her heart rate rose so that it was seldom below forty, and after exertion always went to fifty. What was needed in her case more than anything was a change of environment, the satisfaction of mind that comes with freedom from worries and the cares of making her own living, and the improvement in digestion due to regular meals of good, simple, nutritious food.

Compatibility with Health and Activity.—The above case is interesting as illustrating mental influence upon such a serious condition as bradycardia. Most people who suffer from it are likely to be over-depressed and this reacts to disturb digestion and also further to disturb the heart itself. What these patients need above all, then, is reassurance with regard to their condition. There are some striking examples in history and in medical literature of bradycardia or persistent slow pulse in persons who are able to accomplish a large amount of work and whose general health and capacity for accomplishment were not at all disturbed by this physical condition. Above all, they were not depressed and did not lack initiative. Napoleon I, whose pulse is said normally to have been about forty, rising during the excitement of battle to fifty, is a typical example. Medical literature records a number of patients with congenital slow pulse without any discernible heart lesion who lived long and successful lives. One of these was a very successful English athlete. The prognosis of these cases is not as bad as it might seem to be and the mental state of the patient is more important than anything else in the treatment.

SECTION VIII

RESPIRATORY DISEASES


CHAPTER I

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 {346} 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 {347} 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 {348} 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.