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When the practical homespun psychology of the family physician yielded to the pressure of the newly developing scientific approach to medicine, the community suffered a great loss. While prescientific medicine had many weaknesses it had always been a real staff on which suffering humanity could lean in times of need.
The change from giving most attention to relieving the patient’s symptoms and assuring him and the family that he would soon be more comfortable, be relieved of pain, or be out of danger, to that of making a diagnosis; was a shift from making the patient the object of greatest concern to that of substituting interest in the disease for interest in the patient. This was an instance in which, while training the backward horse of the team we neglected the other and let him become incompetent in comparison.
In order to understand the psychology of the tuberculous patient we must conceive of man in his dual relationship of a physical machine housing a psychical being. While all human bodies have essentially the same parts, and while the psychical or emotional side of man, as well as his physical being, shows similar characteristics in all human beings, yet our study of both the physical and psychical must be directed to the individual. While certain characteristics are found in common, those which are of greatest importance to man in health or disease are those which are peculiar to the individual in review.
We wholly miss the essence of the disease, tuberculosis, unless we proceed from the standpoint that the physical mechanism only houses the individual who is ill. If the tuberculous patient were not a thinking, wishing, hoping individual, subject to the effects of joy, happiness, sorrow, disappointment, discouragement and despair; and if these states did not react favorably or unfavorably upon his progress toward recovery, the problems of the physician who guides the patient would be comparatively easy.
In the first place, let us inquire what are we trying to accomplish in the treatment of tuberculosis? Are we trying to heal a lung or joint or bone just that they may be restored in their integrity? Far from it, we are attempting to restore these members to a state of integrity so that the being housed in the injured body may take his place in life capable of enjoying and accomplishing; otherwise our efforts are misdirected. This is what gives us the greatest problems in the therapy of the tuberculous. It is better to say the treatment of the tuberculous patient rather than the treatment of tuberculosis, for this emphasizes the patient rather than the disease.
The reaction toward disease is both physical and psychical. These two aspects of man are so closely bound and their reactions are so nicely integrated that reaction in one affects the other, the nature of the individual and the amount of the reaction depending primarily on that basic condition which may be taken as his usual or predominant status, and secondarily, upon modifying factors.
For our purpose it is fruitless to discuss whether disturbances in the physical machine or in the psychical being are primary in the makeup of a given individual, but we do know that the composite physical and psychical being shows many variants and that reaction to disease or to any other stimulus is individual.
Just as we know man’s personality may be altered according to the state of his physical body, so can the functions and likewise the structure of his body be changed by varying psychological states.
The general effect of tuberculous disease on the body and likewise upon the psychical aspects of the individual will vary according to its extent and severity. In general, its primary effect is that of injuring and destroying structures locally and of altering function throughout the body; but a disturbed function causes worry, fear, anxiety, and depression; causes the patient to be cognizant of body functions, which should be carried on unnoticed, and has a tendency to cause a centering of his attention upon himself. This may lead to self-pity, fear, pessimism, and defeat, all of which again react through the nervous and endocrine systems of the patient to further stimulate changes in function which may already be disturbed or to create new departures from normal.
The effect of a wrong diagnosis of tuberculosis, or of the patient suspecting it, is often apparent in an increase in nervousness, insomnia, feelings of tiredness, lack of vigor, loss of appetite, disturbed digestion, loss of weight, increased heart action and shortness of breath. When, after an adequate examination, the patient is told that active tuberculosis does not exist these symptoms will often disappear like magic. They are psychical in origin and are relieved by changing the psychology of fear and despondency to one of confidence and happiness.
When a definite diagnosis is made, however, then there is a mixed psychologic condition brought about based on the necessity of facing the fact of a serious illness which removes one from his accustomed work, separates him from his domestic, social, and business activities and carries with it a certain amount of uncertainty for the future. This is mitigated somewhat by the physician’s statement of the hopefulness connected with the proper treatment and the immediate institution of the same. At best, however, there is always some doubt, unhappiness, disappointment, worry, and depression connected with the illness and the sacrifices that must be made. These gradually may be displaced by proper suggestion. To appreciate the tuberculous patient’s problem one must think of the number of ways in which one facing the fact of having active tuberculosis must reorganize his life and activities as he plans to face the future.
A physician, to meet such situations, must be more than a physician. Above all, he must be a humanitarian. He must be able to appreciate others’ problems and be sympathetic toward them and their solution. He must not only be a counselor but a wise counselor. He must understand that he has not a tuberculous lesion alone to heal but a human being to restore to healthful thinking and living, so that he may take his place in enjoying life and producing to the extent of his ability; adding his part to the sum total of the world’s accomplishment.
There is a tendency for a chronic illness like tuberculosis which is attended by toxic absorption, and which requires much rest and often divorcement from business activity and social responsibility for months and sometimes many months, to make patients dependent and childlike in their psychology, to produce in them such a psychic trauma that they lose confidence and shrink from facing life’s problems which await them on recovering. They fear the future at times more than they fear the disease. The prevention of this state of dependence can be best accomplished by early diagnosis and immediate application of adequate treatment. Such a program should restore ninety per cent of patients to health and usefulness before they become chronic invalids. But we are far from this desired goal. We are still treating most of our cases when the disease is advanced and far advanced, at a time when the psychical problems are real and serious. In early cases from nine months to a year and a half of active treatment will return most patients to lives of usefulness; in advanced cases the time is two or three times as long, and the result is less certain and less satisfactory. So it is evident that the psychic problems of the tuberculous patient vary much with the extent of the disease. Then, too, early cases as a rule have a minimum of ill feeling, while advanced cases often suffer greatly.
Tuberculous patients should always give attention to those things which will prevent their minds from degenerating during the time required for treatment. Reading, studying, sewing, knitting, drawing, painting, making light mechanical toys, and other such diversions suited to the particular patient according to his condition will help him pass the time and at the same time bring him through his illness with a minimum loss of his powers of concentration and correlation. As soon as the patient is in a condition to exert himself, suitable exercise may be prescribed. I find walking the safest of all exercises for tuberculous patients. I try to have patients walk from one to five miles a day by the time they are through with their treatment. Thus they regain confidence while they have their physician to guide them. Patients who follow out programs such as this are in a condition to assume light work soon after their active treatment is finished. Their morale is good. They know they can withstand exertion. They have not lost their powers of concentration. They may face return to home and business with a degree of security and confidence.
Not only does such a program bring the patient through his treatment but it relieves him of that awful defeatism which pervades the one who has not had the proper psychical aid and the proper physical rehabilitation. It too makes the treatment as pleasant as is possible for a regime which requires confinement and isolation from one’s interests for long periods of time. That it shortens the time of treatment, too, is self-evident, for it relieves the patient of depressive and harmful emotions which hamper physiologic function; but best of all it preserves independence, self-respect, ambition, and fitness. Unfortunately, no matter how adequate the treatment, at times, patients are unable to assume their usual working obligations. They must either take a part-time job or wait longer and risk the danger of further deterioration while doing so. So attention should be given to rehabilitation and finding work such as these patients can do. It is important that they should become self-supporting as soon as possible after a successful result has been attained.
Our object is not alone to heal tuberculosis but to heal the patient who has it; to repair his psychologic injuries as well as those which have a physical basis; to restore him to the place where he can meet the problems of life without being hampered by a defeatism such as often follows chronic devastating disease. We should encourage him to gain proper control of himself and acquire a sane outlook on life so as to be able to approach his problems optimistically, in the easy way, with a confidence of being able to fill his position in life to the fullest capacity.