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.