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.

Removing Unfavorable Suggestions.—For the ordinary coughs and colds of the winter time there are many unfavorable suggestions that deserve to be eliminated. For instance, most people are sure that exposure to the air will inevitably make their cold and cough worse. This is a relic of the olden time when the confinement of patients to their rooms was supposed to be the best remedial measure for all respiratory diseases. Tuberculosis patients were kept in and died without any chance. Now these patients, even while running a temperature, or suffering from pleurisy, or the intercostal painful conditions that are often serious complications because of the irritability and discomfort produced, and which are so often supposed to be due to drafts, are put out on the porch, or on the roof of a hospital, or allowed calmly to lie in bed between two open windows, without the slightest hesitation. They begin to improve under such treatment much sooner than if they were confined, and indeed the whole prognosis of tuberculosis has been completely changed by the modification of the old-time habit of confinement to that of perfectly free access of outer air and even cold air that has taken its place.

This principle of treatment must be applied for coughs and colds. While {349} patients are running a temperature they must not take exercise, they must not be allowed to work, above all they must not be allowed to get in crowds nor tire themselves in any way. The room in which they are, however, must be thoroughly aired, the window must be open all night and, if possible, they must sit in the sun for several hours a day. This will cure a cough or a cold quicker than anything else. Many coughs that hang on when treated by remedies of various kinds, yield at once if the patient is given an abundance of fluid diet and gets freely into the air. There is no danger of catching another cold, because a cold is not due to a low outdoor temperature, but to dust and microbes, and is a real infection.

Irrational Remedies.—There are an innumerable number of supposed remedies for colds. Scarcely any one who has reached the age of forty apparently feels that he or she is doing the whole duty to humanity unless they have some remedy for colds to recommend. Most of the popular remedies that are employed probably do as much harm as good and many of those that are very popular and are sometimes recommended even by physicians have no rational standing in present-day therapeutics. Perhaps the most popular is a combination of quinin and whisky. The effect of this is to give patients, who are unaccustomed to whisky and who are susceptible to quinin, about as uncomfortable a twenty-four hours the day after they take the remedies as can be imagined. Quinin now has no possible specific therapeutic significance in the cure of the series of infections called colds. In the days when we did not understand malaria and considered it in some way as an essential fever due to the absorption of miasmatic material, quinin seemed to have a specific influence upon several conditions. Accordingly it was employed in all sorts of fevers and, because it is comparatively harmless, also in that short infectious fever which we call a common cold. No physician now employs it (except in small doses as a general tonic) for febrile conditions, unless in malaria. There we know that it acts by killing the plasmodium and is a real specific. We do not think of it any more, however, as a general febrifuge and there is no justification for its use in the slight infective conditions we know as colds.

As for the whisky, if taken in stiff doses as it often is, the reaction is likely to make the patient quite miserable the next day. It seems to be the rule for him to think that if, notwithstanding the taking of the quinin and whisky, he feels thus ill, he would have been ever so much worse without it. Colds, however, when left untreated so far as drugs go but managed by natural means often run a mild course. Some of the reputation of quinin and whisky is due to the fact that not infrequently persons suffer from chilly feelings that seem to portend a cold and take quinin and whisky and the cold does not develop. The remedies are then supposed to have aborted or to have inhibited the development of the cold. Anyone who has seen a number of these cases treated expectantly, however, knows how often it happens that the chilly feelings that seem to announce the cold pass off without incident after a good night's rest.

Rational Treatment.—The old rule of getting the emunctories at work must be the basis of any rational therapy of colds. A mild opening of the bowels, especially if there is some constipation, a hot drink on going to bed so that there is some sweating and perhaps the use of a mild diuretic will almost surely affect these cases favorably. Patients have to be careful, {350} however, next morning to stimulate the circulation in their skin to activity so that the cutaneous muscles shall react upon the capillaries and the capillaries themselves tonically contract in order that there may not be too much blood near the surface of the body, or the patient may easily be chilled in cold weather. This chilling of the blood when much of it is near the surface seems to lower its vitality and the patient easily reinfects himself or, if he goes into dusty or crowded places, catches a fresh dose of infectious material. This is the process which is called catching a fresh cold.

The removing of the unfavorable suggestions of remedies that do harm rather than good and the giving of favorable suggestions founded on our present-day knowledge of what a cold is and just what we need to do in order to benefit it, is the most important element in the treatment. Above all, however, the patient must sleep in an airy room and must be sure that he is neither breathing his own expired air nor that of anyone else. With thorough ventilation, however, and the stimulating effect of the cold air and the confidence due to proper directions, colds rapidly get better.

There can be only one reason for keeping patients indoors who are suffering from cold. That is, if they are suffering from fever, the being out involves exertion. In that case, of course, patients must rest and must avoid exertion, but there is no reason why they should not have all possible fresh air. The unfavorable state of mind towards fresh air and especially night air in these patients was cultivated by the profession up to a generation or two ago, but is quite unjustified by our present knowledge. Night air is probably a little better than day air because it is freer from dust. It is because of malaria that night air was supposed to be detrimental, but we have found that the only good reason for this was that the mosquito travels at night. There are no other constituents of night air that produce any serious effect.

As a rule, patients suffering from colds need more sleep than other people and above all need more sleep than they ordinarily take, for this will increase their resistive vitality and enable them to throw off the infection. A good rule is to add two hours of sleep to the usual quota. The unfortunate habit of keeping people indoors and of keeping fresh outdoor air away from them, because it is feared they will catch a fresh cold, often seriously disturbs sleep and delays recovery. In a word, many a cold that hangs on does so mainly because of unfortunate suggestions of one kind or another that have come to occupy a place in the supposed therapeutics of the condition. The removal of these and the insistence on just as much recourse as possible to the therapeutic means at nature's command constitute the basis of successful therapy of these very common infections, which probably are the source of more morbidity in the community because of their wide diffusion and frequent recurrence than all the other infectious diseases put together.