Psychotherapy

Dr. Saleeby, in "Health, Strength and Happiness," has expressed very forcibly what has come to be the feeling of many physicians with regard to gymnastics, especially indoor gymnastics:

The natural spontaneous exercise having been forbidden, and the bad consequences of no exercise having become conspicuous, there has been adopted a system of factitious exercise—gymnastics. That this is better than nothing, we admit; but that it is an adequate substitute for play we deny. . . . The common assumption that, so long as the amount of bodily action is the same, it matters not whether it be pleasurable or otherwise, is a grave mistake. . . . The truth is that happiness is the most powerful of tonics. . . Hence the intrinsic superiority of play to gymnastics. The extreme interest felt by children in their games and the riotous glee with which they carry on their rougher frolics, are of as much importance as the accompanying exertion. And as not supplying these mental stimuli, gymnastics must be radically defective.

Granting, then, as we do, that formal exercises of the limbs are better than nothing—granting further that they may be used with advantage as supplementary aids, we yet contend that they can never serve in place of the exercises prompted by nature. For girls, as well as boys, the sportive activities to which the instincts impel, are essential to bodily welfare. Whoever forbids them, forbids the divinely appointed means to physical development.

Play and Exercise.—There has been a distinct tendency in modern times to think that gymnastic exercise can be a substitute for play for growing young folks. When certain of the instruments and methods of the modern systems of gymnastics which have been introduced into schools, and are supposed to be so wonderfully beneficial, are put to the test of the psychology of exercise, the conclusions are likely to be very different from the theories under which they were introduced. Dr. Saleeby has expressed these differences rather strikingly:

Anyone who will consider for a moment the natural constitution of man and the principles of natural education, must agree that the deplorable thing called a dumb-bell offers an exquisite parody of what exercise should really be. The cat, as she exercises her kittens along the lines of their natural proclivities and needs, never telling them that this is exercise for the sake of exercise, and certainly prepared, if she could, to turn up her nose at any artificial implement we might offer her—should be our model in this respect. It may be imagined that some unfortunate girl, brought up on early Victorian lines, having never been permitted to wear comfortable garments, or to stretch her arms, would welcome and enjoy the dumb-bells when first introduced to them. But any one who has had a natural childhood and who has been taught to play, and who has taken his or her exercise naturally, or incidentally in the course of pursuing some mental interest—any such person may be excused for saying that a pair of dumb-bells should be deposited in our museums as indications of what was understood by exercise even as late as the earlier years of the twentieth century. All exercise for the sake of exercise is a mistake—or, at any rate, a second best. You may do your mind—and body, too—more harm by sheer boredom than you may gain good from the exercise you go through. The dumb-bell symbolizes the fact that the most elementary and obvious truths of psychology are still unrecognized, though the play and games of every natural child—if you object to be instructed by kittens—should be perfectly sufficient to teach us what indeed nature taught us ages ago, if only we would listen to her.

Indoor Sport.—Indoor sport is another thing. In wintry weather it is impossible to play outside conveniently, and indoor games have their place. Unfortunately they are usually associated with dust, and when played before crowds of spectators, the participants suffer also from the disadvantage of rebreathed air containing, too, the emanations of those who are looking on. It must not be forgotten that these two factors are the most prominent predisposing causes of tuberculosis. Those who have any tendency to tuberculosis, by which is meant specifically all those who are associating with tuberculosis patients, whether those patients are related to them or not, or who are more than 20 per cent. under the weight that they should have for their height, should not be allowed to take part in indoor sports where these drawbacks are sure to be encountered.

Sport, because of the diversion of mind involved, is an ideal form of exercise. An exercise that becomes a mere routine and that can be eventually gone through with so mechanically as to leave abundant room for thoughts of business or study or worries of other kinds, loses sight of one of the principal purposes of exercise as nature demands it.

Horseback Biding.—It is because of the complete diversion of mind that is necessarily involved in it, that horseback riding makes such a magnificent exercise for the busy man. The old expression "the outside of a horse is the best thing for the inside of a man" is founded even more on the mental influence of horseback riding than its physical quality. The same amount of exercise in the open air, taken otherwise, often does not accomplish so much good, because a man's thoughts may continue to run on his business or be occupied with his worries, or he may not be able to divert his thoughts from himself and his digestion or his ills. A horseback rider must pay attention to the other animal, rather than himself, and that represents the complete diversion of mind so necessary for the health of most people. Just as soon as man rides an old favorite animal on whose back he can throw down the reins, allowing it to saunter on as it will, while he occupies himself with other things, then horseback riding loses its efficacy and falls back into the class of bicycle riding or carriage riding or walking in the open air unless there is diversion of mind in the scenes, or the necessity for care at street crossings, to banish preoccupation of mind. Unless business troubles and worries are necessarily excluded by its conditions, or are deliberately eliminated from the mind during the course of any exercise, it may even become a renewed source of worrisome thoughts, rather than a renewal of energy, mental and physical.

It is doubtful whether horseback riding should ever be recommended for those who have not been accustomed to it from their youth. To ask a man past forty to learn to ride horseback for the sake of exercise is nearly always a mistake. It becomes a trial rather than a recreation, and may thus do harm rather than good. On the other hand, horseback riding is one of the things that may be, and indeed often is, much abused. The old English fox-hunting squire would never have lived out his life even as long as he did, consuming the amount of proteid material that was his custom, and drinking his three or more quarts of port at dinner every day, but that the excessive drain upon his system by long days of hard riding in the hunting field made calls upon his nutrition which kept even this amount of food and stimulant from doing immediate harm. Just as soon, however, as long spells of severe exercise become excuses for the consumption of big dinners, and exercise is used as a factor to enable one to overeat with more comfort than would otherwise be the case, a vicious circle is formed, and one serious abuse is counterbalanced by another. What many well-to-do people of leisure need is not so much more exercise as less eating.

Walking.—Perhaps the best and most readily available form of exercise for most people is walking. It has one disadvantage. As soon as the walk becomes too much of a routine, and the ground gone over has lost its interest, or is even of such a nature as to permit or, indeed, tempt introspection and occupation with other things, rather than with the surroundings, then walking loses most of its efficacy as a form of exercise. Walking in the country, for instance, becomes monotonous, though at first it is a great source of pleasure. Walking in a large city, however, has little of this objection and as large city life has grown more and more strenuous in recent years, the good effect of walking to and from the office or walking in the busy parts of the city has been increased. Between the trolley and the automobile, and the hustling commercial traffic of the streets, it is impossible for a man to walk through the busier portions of any large American city without keeping his wits thoroughly intent on what he is doing, nor without requiring all of his attention for his transportation. An abstracted man will in the course of a half hour have so many narrow escapes from being run down in a busy quarter that he will either eschew walking in that particular neighborhood, or give up his habits of mental abstraction, or else he will come to himself some day in a hospital.

Besides, the passing show in city life is itself of surpassing interest. It is not things but men that interest us most. There are so many phases of human life to be seen on busy city streets, so many things happen in the course of even a short walk to bring out prominently traits of human nature that, if a man is at all sympathetic, he finds much to occupy his attention, to distract him from his own worries and take him away from his business cares. The long walk to and from the office may thus become an efficacious source of thoughts that are different and of profound pleasure. All depends on the man and his mood. Men who try it whole-heartedly soon find a renewed interest in life. An hour of daily walking in the open air with the distractions of city life all around, provided the walking is done briskly and faithfully, is of infinitely more hygienic value than an hour of gymnasium work. There is only one thing that hampers this form of exercise—there are so many excuses to tempt one not to keep it up. If one gets to a gymnasium there is an instructor or director who keeps tabs on one's hours and so helps a weak human will, and excuses are easier made to one's self than to others.

Massage as Exercise.—This curious tendency of men to take their exercise far more regularly, provided some other is concerned in their taking it so that it cannot be neglected without explanation, is illustrated in many of the experiences of the doctor in modern life. A number of forms of massage have come into vogue as wonderful cure-alls. It is comparatively easy for some men, and above all for many women, to take their exercise by means of massage rather than in some more vigorous way that requires their own initiative. A man who is working hard, and who feels the need of exercise, will not take the easy natural way of getting up half an hour earlier, having his breakfast half an hour sooner and then walking down to his office four or five miles, but he hears of someone who gives vigorous massage and he engages him to come every morning and exercise him for half an hour or an hour. In order to do so, he has to get up an hour earlier, but the fact that he has the engagement with someone else, rather than with himself, makes it more difficult for him to make excuses, and so morning after morning, in spite of the fact that he may have been up late the night before, perhaps to a big dinner, he gets up to be given his exercise. If he is a heavy eater he will, of course, at the end of a week or ten days feel ever so much better for he has been using up material that was clogging his circulation and irritating his nervous system.

At the end of a month he will probably feel so much better that he will conclude that he has found the root of all evil in life, or of all disease, in a failure of circulation that can be removed by means of massage, manipulation and passive movements. When he gets well enough to give it up, he drops straight back into his old troubles, because what he needs is a radical change of life that will adapt his eating to the amount of exercise that he takes, and his exercise to the amount that he eats. If this fails to come, he has had only a temporary benefit that has probably tempted him rather to increase the amount that he eats normally than otherwise and will probably do him harm in the end. This massage brings about a distinct reduction in the weight of women, and as most of them are very desirous of this, the remedy becomes even more precious to them than to men. Here, too, however, it is only a temporary expedient. They are tempted to eat more than before, or at least not to reduce their diet, and the good that is accomplished is only for the moment, while no habits, either of restraint of eating, or of more exercise in the open air which so many of them need, have been formed.

Passive Movements.—The success of osteopathy has been largely founded on this curious peculiarity of human nature. People are not satisfied to regulate their eating and exercise in a sensible way. They prefer to submit to various methods of exercise, manipulations and passive movements which make up for the muscular exertion that should help the circulation within the body, but do not accomplish the purpose nearly so well as the voluntary exercise of muscles. It requires little exercise of will to submit to this treatment, while for many people it requires considerable exertion of will power to exercise their muscles for themselves. The old particularly, who are likely to suffer from achy conditions around joints, always worse on rainy days, which would be expelled by enough exercise to stimulate the circulation in these structures, find the new remedial measures of vicarious exercise of great service to them and consequently osteopathy has gained many votaries. Old members of many a state legislature who have been accustomed to ride for so long that exercise is almost an unknown quantity in their lives, are treated by the osteopath and lose so many vague pains and aches and discomforts of various kinds that it has not been difficult to persuade them that it is a great new discovery in medicine, and so in many of the states the osteopaths have secured legal recognition.

Summary.—Exercise, as exercise, often does harm rather than good. Thin people seldom need exercise, stout people seldom take enough of it. No one should be encouraged to exercise merely that he may be able to use up material that he has eaten, when it is evident that he is eating more than is required for his ordinary occupation. The question can never be settled without taking into consideration all these individual peculiarities of each case. Properly used, exercise is one of the most important therapeutic aids. But it is liable to as many abuses as are drugs, and the patient's attitude of mind toward any particular exercise is always an extremely important factor. If the exercise produces fatigue and disgust, then it will do no good, in spite of all that is hoped from it. If it creates true diversion of mind, it will surely be precious, even though it may, for other reasons, seem unsuitable.

CHAPTER III

POSITION

There are many changes of position that relieve pain, lessen discomfort, aid in excretion, and in the evacuation of material from the body, yet it is often found that very little advantage is taken of this natural method of therapeutic aid. Traditions and habit often rule to such an extent that certain quite unfavorable positions are assumed, modifications of which frequently bring about distinct amelioration of symptoms. Very often patients learn this alone. There are many mechanical principles that can be applied in the treatment of pathological conditions which patients will not use unless definite suggestions are made. Often the physician has to suggest that they should try first one position and then another, in order to determine whether a certain amount of relief may not be afforded by position alterations, and perhaps function encouraged, or at least certain inhibiting factors modified for the better.

Favoring Return Circulation.—For people who have to stand much during the day, position in their resting hours is often extremely important. The caricature of the old-time American exhibited him with his feet on the mantlepiece, or somewhere as high as his head. For thin individuals there is no doubt that the placing the feet about as high as the head often makes a very comfortable position for a time. To those who have been standing much it is particularly restful. This may be easily accomplished lying down, though it must not be forgotten that the tendency to place the feet on a neighboring chair, or over the arm of the chair, so often seen in young folks, is in response to a physiological stimulus that brings relief to the heart by encouraging by means of gravity the return circulation in the veins from dependent portions of the body distant from the heart. For people who have not much exercise, and who have to stand all day, a brisk walk or leg exercises that thoroughly empty their muscles of blood by bringing about active contraction of them is important as a factor in their hours of rest. It makes all the difference in the world between the feeling of intense tiredness due to the sluggish circulation, and a return of vigor in the muscles.

Varicose Veins.—For patients suffering from varicose veins, position is particularly important. When they have to stand much, their limbs get painfully tired. The ache in the sense of fatigue is reflected over the body with the resultant depression. Active exercise, for a time, is not so good for them, and yet it is helpful. The ideal relief from their achy condition is afforded by gentle massage upwards of the limbs. That empties the dilated veins of blood and restores vigor to the circulation. It must not be forgotten, that when the circulation in the lower limbs is rendered sluggish by varicosity, the heart is also affected because it is so much more difficult to secure the return of blood through the tortuous dilated veins. This accounts for the intense general sense of fatigue that many of these patients have. Varicosities have a definite tendency to develop in those who are occupied in standing occupations, waiters, footmen, clerks, and the like, and often they have to continue at these occupations in spite of the varicose condition. It is particularly important for them to have an hour of lying down during the middle of the day so as to break their day's work in two. With a little insistence it can be secured in a great many cases and will afford more relief to the patient than anything else that can be done, even the wearing of rubber stockings, bandages and the like. I have known waiters massage each other at the time they had their period of rest with excellent results.

For the rupture of a varicose vein, position may be one of the most important auxiliaries to prevent serious hemorrhage. I remember as an ambulance surgeon once being called to see a case in which a great deal of blood had been lost because efforts had been used to stop the bleeding by the application of a tourniquet. This shut off the superficial arteries, but not the deep ones and effectually prevented the return of any venous blood into the trunk, while all the time the ruptured varicose veins continued to bleed profusely. Local applications of styptics failed, of course, because the varicose vein itself had nearly the diameter of the little finger. Pressure over the wound did good for the time, but the bleeding was renewed whenever it was let up, and the two physicians in charge, alarmed at the loss of blood, were beginning to lose their heads. The ambulance was summoned to take the patient to the hospital and when it was suggested that if the tourniquet were removed and her foot was elevated the bleeding would probably stop without more ado, the suggestion seemed too simple to be true, but the event showed that that was all that was necessary.

Relief for Flat Foot.—For the achy discomfort of flat-foot, which is usually felt much more in the calf and the knee than in the ankle, some vigorous exercise for the foot, and especially for the calf muscles, at times during the day is likely to give great relief. Ten minutes of vigorous movement of the calf muscles followed by half an hour lying down will save most of them from the intense tiredness that is very discouraging in the late afternoon in many of the standing occupations. This relief removes from patients' minds the common idea that there must be something serious the matter with them. A good many of those who are cured of rheumatism by osteopathy, and of kidney trouble by the advertising specialists, and of various nervous diseases by new thought and irregular mental healing, are only sufferers from conditions such as can be relieved in this way. When flat-footed people sit down they should be advised to cross their feet (not their legs), because this emphasizes the arch of the foot somewhat and helps to strengthen and preserve it.

Abdominal Relaxation.—Many of the discomforts within the abdomen of which patients complain, especially whenever their attention is concentrated on them, can be benefited by suggestions as to position. Many a man who feels very uncomfortable after a hearty meal when sitting curled up beneath a lamp to read the evening paper, does not notice it at all when he stretches out on an easy Morris chair and with head back talks to friends. Many a man who thinks that his discomfort after dinner must mean serious dyspepsia, finds that a game of billiards after dinner will often dissipate almost completely his ill-feeling, unless, of course, it is due to overeating. After meals generally, positions that crowd the abdominal organs should be avoided. It must not be forgotten either that when lying down a full stomach may very well interfere with the heart action and produce marked palpitation. There are many men who cannot lie down within two hours of having eaten a hearty meal without decided heart irregularity, though while they are sitting up or standing quietly, or even moving, there will be no sign of this. Many of the vague discomforts within the abdomen, those due to movable kidney, or even chronic conditions in the biliary or urinary tracts, are only manifest when there is crowding of the organs within the abdomen.

How much the mechanical element may mean in kidney and biliary conditions is well illustrated by the relief often afforded by changes of position when calculi in these organs are giving trouble. Both renal and biliary calculi, which perhaps have been lying quite harmlessly in their positions for years, are especially likely to become productive of discomfort by a jolting ride, or the jar of a fall, or by the influence of changes of position produced by gymnastic efforts of an acrobatic kind, or by a loop-the-loop experience, or something of the kind. In spite of this, only rarely does the physician try to use changes of position for their relief. I have seen a man suffering from excruciating biliary colic get almost immediate relief when put standing on his head alongside of a lounge. He looked upon it as magic. It was only that the stone, in the midst of the relaxation of all abdominal muscles produced by the unusual position, was able to drop back into the gall bladder, where it had been for months perhaps years before without giving any trouble. Similar relief is often afforded from the pain of kidney stones before they become definitely engaged in the ureter.

Raising the Head.—Patients suffering from respiratory difficulties usually learn to accommodate themselves to such changes of position as will afford them the greatest relief. The difficulty of breathing leads to such tossing about that the position easiest for the patient is almost inevitably found. When respiratory difficulties first declare themselves patients may not realize how much relief will be afforded by raising the head, or by the assumption of a sitting position. Often such patients prefer to sit in a chair. It should be borne in mind that, wherever this is compulsory, dispositions can be made so that the chair shall be as comfortable as possible, that its seat edge shall not press upon the underportion of the legs so as to impede blood circulation, nor press upon nerves, and that comfortable arrangements shall be made for the arms. When the patient's head has to be raised in the bed, it is much better to raise the mattress by placing some large properly-shaped object underneath it, so as to secure a gradual slant rather than have the patient's head and upper portion of the thorax bent by pillows. In default of something better, a chair placed so that the mattress lies along its back will be a handy aid. This is a matter of nursing rather than strictly of medical attendance, but unless the physician pays attention to it, it will be neglected, or at least in many cases not used to the best advantage.