_ CHAPTER XII. THE WILL IN PNEUMONIA
"Who shall stay you?--My will, not all the world."
Hamlet.
What is true of tuberculosis and the influence of the will has proved to be still more true, if possible, of pneumonia. Clinical experience with the disease in recent years has not brought to us any remedy that is of special value, nor least of all of specific significance, but it has enabled us to understand how individual must be the treatment of patients suffering from pneumonia. We have recognized above all that mentally disturbing factors which lessen the patient's courage and will to live may prove extremely serious. We hesitate about letting an older person suffering from pneumonia learn any bad news and particularly any announcement of the death of a near relative, above all, a husband or wife. The shock and depression consequent upon any such announcement may prove serious or even fatal. The heart needs all its power to accomplish its difficult task of forcing blood through the limited space left free in the unaffected lung tissue, and anything which lessens that, that is anything which
disheartens the patient, to use our expressive English phrase, must be avoided as far as possible.
When a man of fifty or beyond, one or more of whose friends has died of pneumonia about his age, comes down with the disease and learns, as he often will in spite of the best directed effort to the contrary, that he is suffering from the affection, if he is seriously disturbed by the knowledge, we realize that it bodes ill for the course of the disease. If a pneumonia patient, especially beyond middle life, early in the case expresses the thought that perhaps this may be the end and clings at all insistently to that idea, the physician is almost sure to feel little confidence of pulling him through the illness. In probably no disease is it more important that the patient's courage should be kept up and that his will should help rather than hamper.
Courage is above all necessary in pneumonia because the organs that are most affected and have most to do with his recovery are so much under the control of the emotions. Any emotional disturbance will cause the heart to be affected to some extent and the respiration to be altered in some way. When a pneumonia patient has to lie for days watching his respirations at forty to the minute, though probably he has never noticed them before, and feels how his heart is laboring, no wonder that he gets scared, and yet his scare is the very worst thing that can happen to him. It will further disturb both his heart and his respiration and leave him with less energy to overcome the affection. He may be tempted to make conscious efforts to help his lungs in their work, though any such attempt will almost surely do more harm than good. He must just face the inevitable for some five to nine days, hope for the best all the time and keep up his courage so as not to disturb his heart. After middle life only the patients who are capable of doing that will survive the trial that pneumonia gives. The super-abounding energy of the young man will carry him through it much better; and besides, the young man usually has much less solicitude as to the future and much less depending on his recovery.
A generation ago or even less, whiskey or brandy or some form of strong, alcoholic stimulant, as it was called, was looked upon as the sheet anchor in pneumonia. For a generation or more at that time, the same remedy had been looked upon by a great many physicians as an extremely precious resource in the treatment of tuberculosis. The therapeutic theory behind the practice was that in affections of the lungs a particular strain was placed upon the heart and therefore this organ needed to be stimulated just as far as could be done with safety. As alcohol increases the rapidity of the heart beat, it was considered to be surely a stimulant and came to be looked upon as the safest of heart stimulants, because, except when used over very long periods, direct bad effects had not been noticed. In pneumonia, above all, the heart needed to be stimulated because it had to pump blood through the portion of the lungs unaffected by the pneumonia, usually congested and offering special hindrances to the circulation; besides, a much larger amount of blood than usual had to be pumped through these portions of the lungs in order to compensate for the solidified portions.
A number of very experienced physicians came to be quite sure that alcoholic stimulants were the most valuable remedy that we had for this special purpose of cardiac stimulation; some of them went so far as to say, with a well known New York clinician, that if they were to be offered all the drugs of the pharmacopeia without alcoholic stimulant for the treatment of pneumonia on the one hand, or whiskey or brandy on the other without all the pharmacals, they would prefer to take the alcohol, confident that it would save more patients for them. They were quite sure that they had made observations which justified them in this conclusion.
We know at the present time that alcohol is not a stimulant but always a narcotic. It increases the rapidity of the heart beat, though not by direct stimulation, but by disturbing the inhibitory nerve apparatus of the heart and thus permitting the heart to beat faster. Just as there is a governor on a steam engine, to keep it from going too fast and regulate its speed to a definite range, so there is a similar governing apparatus or mechanism in connection with the heart. It is by affecting this that alcohol makes the heart go faster. Blood pressure is not raised, but on the contrary lowered, and the effect of alcohol is depression and not stimulation. In spite of this, good observers seemed to note favorable effects from the use of alcohol in both pneumonia and tuberculosis. This appears to be a paradox until one analyzes the psychic effects of alcohol and places them alongside the physical, in order to determine the ultimate equation of the influence of the substance.
Alcohol has a very definite tendency to produce a state of euphoria, that is, of well-being. The patient's mind is brought to where it dismisses solicitude with regard to himself. This neutralizes directly the anxiety which so often acts as a definite brake upon resistive vitality. The alcoholic stimulant, in so far as it has any physical effect, probably does a little harm, but its influence on the mind of the patient not only serves to neutralize this, but adds distinctly to the patient's prospects of recovery. Without it, the dread which comes over him paralyzes to some extent at least his heart activity and interferes with lung action. Under the influence of alcohol, he gains courage--artificial, it is true--but still enough to put
heart in him, and this is the stimulation that the older clinical observers noted. The patient can, with the scare lifted, use his will to be well ever so much more effectively and psychic factors are neutralized that were hampering his resistive vitality.
This illustrates very well indeed the place of dilute alcohol in some of the usual forms in therapeutics about the middle of the nineteenth century. Practically all the textbooks of medicine at that time recommended alcohol for many of the continued fevers. In sepsis, in child-bed fever, in typhoid, in typhus, as well as in tuberculosis and pneumonia and other less common affections, whiskey or brandy was recommended highly and usually given in considerable quantities. All of these affections are likely to be accompanied by considerable anxiety and solicitude with a series of recurring dreads that sadly interfere with nature's efforts toward recovery. Under certain circumstances, the scare, to use the plain, simple word, was sufficient to turn the scale against the patient. The giving of whiskey at least lifted the scare [Footnote 5] and enabled the patient to use his vital resources to best advantage.
[Footnote 5: The use of whiskey for snake-bite probably has no other significance than this lifting of the scare. It used to be said that the alcoholic stimulation neutralized the depressant effect of snake poisoning on the heart. Now we know that this is not true, and in addition, we know of no effect that alcohol in the system might have in neutralizing the presence of the toxic albumin which constitutes the danger in snake poisoning. It is only rarely that the bite of a rattlesnake will be fatal. Experts declare that the snake must be a large one, its sting must be inflicted on the bare skin, it must not have stung any one so as to empty its poison glands for more than twenty-four hours, and the full dose of the poison must be injected beneath the skin for the bite to be fatal. Very rarely are all these conditions fulfilled. When a person is bitten by a snake, however, the terror which ensues is quite sufficient of itself to hurt the patient seriously and he may scare himself to death, though the snake poison would not have killed him. The whiskey lifts the scare and gives nature a chance to neutralize the poison which she can usually do successfully.]
It is extremely important, then, first to be sure that the patient's will to be well is not hampered by unfortunate psychic factors and secondly, that his courage shall be stimulated to the greatest possible degree. Fresh air is the most important adjuvant for this that we have. The outdoor air gives a man the courage to dissipate dreads and makes him feel that he can accomplish what seemed impossible before. Undoubtedly this is one of the favorable effects of the fresh-air treatment of pneumonia, for it makes people mentally ever so much less morbid. The patient's surroundings must be made as encouraging as possible and there must be no signs of anxious solicitude, no long faces, no weeping, and as far as possible, no disturbance about business affairs that might make him think that a fatal termination was feared. His will to get well must be fostered in every possible way and obstacles removed. This is why it has been so well said in recent years that good nursing is the most important part of the treatment of pneumonia. This does not mean that a good nurse can replace a physician, but that both must coordinate their efforts to making the patient just as comfortable as possible, so that he will feel assured that everything that should be, is being done for him, and that it is only a question of being somewhat uncomfortable for a few days and he will surely get well.
Sunny rooms, smiling faces, flowers at his bedside, cheerful greetings, all these, by adding to the patient's euphoria, bolster up his will and make him feel that after all, thousands of people have suffered from pneumonia and recovered from it, and there is no reason why he should not, provided that he will not interfere with his own recovery. _