Psychotherapy

Whenever there is difficulty of expectoration, especially when expectoration is abundant as in certain of the chronic bronchitises, and above all in dilatation of the bronchi, the advantage of position should be taken to aid in the expectoration. Patients who have to cough up large amounts in dilatation of the bronchi and who have long severe fits of coughing in the early morning, will often obtain a great measure of relief by leaning out of bed with one hand on the floor, doing their coughing in that position. Gravity helps in the emptying of the pockets of the bronchi and in five minutes they succeed in getting up satisfactorily as much material as would come up, only after severe convulsive efforts for an hour, when gravity was in opposition to their efforts. Children in whooping cough naturally bend over in order to cough. They will cough easiest if placed on a bed with a pillow beneath their chest so as to lift the face from the mattress, or in the case of older children, with the head projecting beyond the edge of the bed. This is only a trifle, but it will often save children severe convulsive efforts. Tuberculous patients who have to cough much, should be encouraged to find for themselves by trial whether certain positions, leaning out of bed, may not be of great service to them. There is often in advanced cases an accumulation of material during the night that must be expectorated, and the patients are severely shaken up by their efforts to bring it up. I have known cases where a considerable measure of relief was afforded by leaning out of bed with the elbow on a pillow, a chair or foot-stool somewhat lower than the level of the bed. The mechanical help of gravity is particularly important where cavities exist and a considerable amount of material has to be emptied out of them.

In modern surgical times one does not often see the emptying of a purulent pleurisy through the bronchi, but I once had an opportunity to see the termination of one of these cases in a very favorable way. When I saw her the patient had already coughed up a cup full of purulent fluid and, altogether, about a quart of pus was thus evacuated. The patient had been so ill that the effort was considerable, but the evacuation was greatly helped by having her lean out of bed whenever material was to be expectorated. The patient is still alive and in good health—fifteen years after the event.

Heart Cases.—Position is also often of very great importance for the relief of the symptoms of patients suffering from heart affections. For organic heart affections, rest in bed is often advised. It must not be forgotten that this does not necessarily mean in a recumbent position. Whenever there is difficulty of breathing in connection with an affection of the heart, the recumbent position is extremely uncomfortable. This is nature's safeguard against the accumulation of fluid in the dependent parts of the lungs at the terminal capillaries of the pulmonary circulation. Most of the natural demands have a definite reason and are prophylactic rather than merely a symptom of aimless discomfort. Patients with heart disease often want to sit up in a chair. Their wish should, as a rule, be yielded to. There is no need of their sitting in a narrow uncomfortable armchair, nor of being incommoded by the position they have to assume. The end of a large lounge, especially one that curves over towards the floor on which pillows can be piled so as to make the patient comfortable, and yet afford many changes of position, is the best.

In general, the arrangements should be such that changes of position can be secured without much difficulty. These prevent hypostatic pneumonia and guard the patient against serious accumulations in the lung tissue because of sluggish circulation. Changes of position can be used as valuable suggestions. Often the main portion of the patient's symptoms consists of the intense fatigue due to one position. This can be relieved and the patient made to feel that, after all, the ailment to which he is suffering must not be so serious since relief can be afforded so simply. Besides, when patients complain, something must be done for them. Medicine cannot be given for every symptom and yet some remedial measure there must be to satisfy them. This satisfaction will often be secured by changes of position, by slight local treatment, by the adjustment of pillows so as to relieve fatigue of particular muscles and parts of the body, and by the movements of the limbs and the head into other positions than those in which they have become fatigued. The experienced nurse is of the greatest possible value in these cases.

Restlessness.—Usually restlessness is considered to be an unfavorable symptom of disease, just as are pain and tenderness. Like these, however, it is really conservative rather than in any sense destructive. Pain prevents serious changes from taking place without our attention being effectively called to them. Restlessness induces the patient to change position frequently and often leads to the discovery of some position in which there is much more comfort than the one that had been assumed. Restlessness, in the recumbent position, is usually nature's protest against the maintenance of a posture in which, owing to failure of circulation, there may be leakage of serum into the lung tissues with dangerous results. Restlessness, in abdominal pain, often leads to such a change of position as affords the best condition for the relief of the discomfort as far as that may be brought about by position of muscles. The man with colic very soon discovers that lying on his stomach may relieve his pain. The drawing up of the knees in peritoneal conditions is the result of a similar reaction. The physician must learn to imitate nature, and recognize what mechanical conditions are likely to be of help. As soon as these afford relief, they act as a strong favorable suggestion, on the patient, and relieve dreads with regard to his affection.

Joint Affections.—In painful joint conditions, position may help much to bring relief or at least considerable mitigation of symptoms. In rheumatism, for instance, of the acute articular type, a number of small pillows can be disposed in various ways, underneath the patient's limbs, between them and in other positions, so as to give as much comfort as possible and will often be of great value. There should be at least half a dozen pillows at the disposal of the patient, besides three or four for the head. In certain relaxed positions of the joints, there is more room within the capsule than others and, almost unconsciously, the patients assume such positions when there is pain from effusion. Occasionally, however, in the midst of fever, or because of apathy, patients may not do this, and then care should be taken to bring them some measure of relief. Generally patients suffering from fever, with delirium of typhoid condition, that is, when there is considerable apathy, should have their positions changed gently from time to time to prevent discomfort developing, and as a prophylactic against skin disturbances from pressure. In children, this is particularly important.

Bladder Evacuation.—In emptying the bladder position may mean much. After childbirth, especially the first, many women are quite unable to empty their bladders while lying down, though if they are allowed to assume the usual position there is little or no difficulty. In certain sensitive men whose power over their bladder is disturbed by self-consciousness, the presence of anyone in the room or near them, makes it impossible for them to urinate, and this is particularly true if they are lying down. In the milder forms of prostatism position occasionally seems to have some influence in helping to empty the bladder. When there is a prostatic bladder pouch behind the prostate, it is quite impossible to empty this in the standing position. It may be emptied in the prone position, that is, lying face downwards, particularly if the pelvis is elevated above the rest of the trunk. Undoubtedly some of the cures reported after operation, when the operation itself effected no reduction in the size of the prostate (as the removal of the testicles or vasectomy), the improvement was brought about partly by the more favorable position in which, for weeks after the operation, the patient emptied his bladder, and also by the greater control gained over it, by the persuasion that the operation would do him good. The same suggestion can be made in connection with the new position for urination with just as good effect.

Intra-abdominal Conditions.—There are many intra-abdominal conditions in which position is of great importance for the relief of pain. Appendicitis cases are found with the right knee drawn up because this relieves the tension of the abdominal muscles, and probably also of the large muscles that go to the thigh and lie behind the peritoneal cavity. In most cases of intra-abdominal pain flexing of the knees on the abdomen means much in affording relief, and patients usually discover this for themselves. There are certain apathetic patients, however, who need to be helped by suggestions. In certain of the painful conditions, due to intra-pelvic conditions, relaxation of muscles by flexion lessens the pain. Pressure upon the abdomen, as by lying on a pillow, often does this also. Apparently one reason why children with flatulent colic stop crying almost at once, when laid on their stomachs, is because the pressure thus produced tends to bring about a movement of the gas that, collected at one or two places, was causing painful distention.

Importance to the Physician.—There are many other suggestions with regard to position that will occur to thoughtful physicians in particular cases. The one idea is to secure such an alteration of the posture as is likely to bring about mechanically relief of pain. If relief is afforded in this way, as has already been emphasized, a very favorable influence is produced on the patient's mind. Above all, he realizes that his physician not only understands his general condition, but his experience with many patients suffering from the same ailment has given him the power to direct even such slight changes of position as will give comfort. Nothing that I know adds more to the confidence that a patient has in his physician than the realization of this sort of knowledge. Therefore, the necessity for such consideration of each individual case as will enable the physician to recommend such modifications of position to patients. At the same time the patient's mind can be influenced very favorably by attaching definite significance to these alterations, and having them, as it were, repeat their favorable suggestions every time that he thinks about them, and be pleased as to the relief they have afforded. This is the sort of psychotherapy that is particularly likely to be successful, and it needs careful cultivation and development.

CHAPTER IV

TRAINING

One of the most important factors for therapeusis in the sense of the amelioration of defective motor conditions, the relief of disturbing sensory affections and the restoration of or compensation for defective functions of various kinds is training. By this is meant the training of the power of attention and its concentration in such a way that defects are overcome. There are many examples of almost marvelous improvement of function brought about in this way that are familiar, but it is well to recall some of them here in order to illustrate the uses to which this therapeutic mode may be applied. A blind man is able to read by means of his finger tips, and to recognize raised letters that seem quite beyond the possibility of tactile recognition by ordinary individuals gifted with all their senses. The peculiar skill is simply due to the individual being able by concentration of attention upon slight variations in touch sensation to recognize even minute differences readily and so read raised letters with comparative ease and rapidity.

Over and over again it has been shown that neither the congenitally blind nor those whose vision has become defective have any better sense of touch than the average person. With an esthesiometer, their power to recognize the distance between the points of a calipers is shown to be no better than that of an ordinarily sensitive individual. This is illustrated in other ways. Certain blind persons, even those born blind, are known to be able to distinguish colors more or less accurately, that is, at least the three primary colors. Their power to do this is consequent upon a faculty of recognizing differences in heat absorption. The ordinary seeing person going into a room in the dark recognizes at once the difference between a pencil and a piece of metal of the same shape and size by its weight and the greater tendency of the metal to feel colder. When we are not sure whether a pillar in a structure is of stone or an imitation, we determine this by touch, and the fact that stone absorbs heat rapidly while wood and other imitations of stone do not. It is the same faculty for distinguishing specific heat that enables certain blind people to recognize colors. If pieces of cloth of different colors are put over snow when the sun is shining on them, it will be found that black absorbs much more heat than the colored cloths, or white, and consequently that the snow melts faster beneath the black. After black comes red, then green, then blue. It is this difference in the power to absorb heat that the blind recognize and thus distinguish colors after long patient training of themselves.

Obstacle Sense.—An example of the value of training is the so-called obstacle sense which has been rather carefully studied in recent years. By means of it blind people are able to avoid larger obstacles and to know when they are passing an open door or window on a corridor or a building alongside a street. Blind children have been known to play in a garden where there were trees and other obstacles and carefully avoid them even while moving rather rapidly. This sense is disturbed whenever there is loud noise in the vicinity. It is not very active and yet it is of considerable value to the blind. Its disturbance by noise would seem to indicate that it is due to some sense faculty in the tympanum, or ear drum. It exists in everybody, but remains quite undeveloped except in those who need it and therefore learn to make use of it.

Touch and Sight.—The triumph of training is to be seen in the cases of those who are born blind and deaf and who yet are taught to understand through lip and throat reading by the tips of the fingers and taught to talk by being shown patiently the method by which others accomplish it, though the only avenue to their brain is the dull sense of touch which means so little for the ordinary individual. The cases of Laura Bridgeman and of Helen Keller illustrate how a sense that is usually quite neglected can be made to supply the place of both the eyes and the ears by patient, persistent training. Lip reading by sight is, of course, a very interesting example of the same principle that can be learned by anyone who has good sight in a comparatively short time. There are compensations of this kind and powers of development latent in every sense and function of the body that can be employed to make life interesting and to restore usefulness after nearly every form of lesion or defect. Practically all of this compensatory power is mental, hence its place in psychotherapy. We do not increase the power of the sense but by concentration of attention the mind is rendered capable of obtaining definite information from sensory stimuli that are present in every person but that are ordinarily neglected.

Hearing.—One of the most surprising instances of the value of training for cases in which favorable results seemed quite out of the question, is Urbantschitsch's method of training the deaf to hear. After investigating it personally I reported it in the International Clinics.23 Patients who could hear but very little, indeed, only the loudest noises, were trained by means of loud shouting and the hearing of loud notes gradually to catch sounds more and more easily until not infrequently they could hear rather well. Sometimes even those who were thought to be absolutely deaf to sound were found to be able to hear very loud sounds and then it was invariably discovered that by practice they could be made to hear much more. The secret of the success consisted not in any increase in the power to hear, but entirely in training the attention to recognize and differentiate sounds so that what seemed at first a confused murmur gradually became intelligible. It is exactly the same process as that by which a man learns to read with his fingers. He is not able to differentiate the letters but after a time it is possible to do so without difficulty.

Equilibrium.—There are typical examples of almost as striking increase of muscle sensation, or rather of ability to distinguish minute differences in muscular sensation, noted in those who train this faculty carefully. Acrobats succeed in developing wonderful control over muscles and marvelous response to slight disturbance of equilibrium. The ordinary individual has comparatively small balancing powers, but the slack-rope performer seems almost to defy the laws of gravity, because he has learned so to coordinate all muscular action as to enable him to maintain his balance. He has trained himself to distinguish every variety of message from his semicircular canals. Of itself neither of these senses gives us very much information, indeed, only as much as we ask for from it, but when we pay careful attention to the minute details of the information that it imparts, we are able to use it to great advantage.

Muscle Training.—It is this power of training to enable us to appreciate minute sensations that forms the basis of the Frenkel treatment of tabes. For the proper guidance of the muscles the muscular sense is all-important, though ordinarily we are quite unconscious of the information it conveys. This is seriously disturbed by the degeneration in tabes. The patient can, however, be taught to use even the slight amount of it that remains to great advantage or else to avail himself of some other compensatory sensations which will enable him to guide his muscles in various motions much better than before.

This same faculty can probably be employed in many other conditions. Frenkel has shown that it is applicable in paralysis agitans and markedly relieves the rigidity that is so annoying a symptom. It gives these patients something to occupy their minds, too, which means a great deal for their general condition, for occupation of attention saves them from neurotic disturbance of themselves.

Sufferers from infantile paralysis can be taught to do many things with their weakened muscles that seem to be quite impossible to them. It requires patience to get results, but they mean so much that the efforts are well worth while. After cerebral incidents, sometimes actual apoplexies, sometimes injuries, occasionally serious effusions due to kidney diseases, there may be disturbance of motor functions. It is surprising how often training will enable the sufferer to use his muscles much better in these cases than at first seemed possible. I have seen a man who had lost most of his power for writing after a cerebral incident regain it as a consequence of being taught to write from his shoulder, instead of from the forearm as had been his custom.

Heart Training.—In recent years we have learned that training is not only good for the external muscles and enables them to do more work without discomfort, but that it is particularly beneficial to the heart muscle whenever that organ can respond to it favorably. At all of the heart cures in recent years, exercise of some kind or another is one of the important features and the failure of physicians generally to secure as good results while pursuing all the other methods followed at these cures, seems to show that exercise was probably the most important factor. Nauheim is the typical heart cure and there, besides the resisted movements in the bath, there is the graduated exercise of the walks around the town, all of which, owing to the situation, lead up hill. Walking up hill, even though it be a gradual ascent, might seem to be the worst possible exercise for heart patients, yet it proves eminently beneficial.

Respiratory Training.—Shortness of breath is often a bothersome symptom, especially for stout people, and prevents them from taking necessary exercise. When it cannot be traced directly to some affection of the heart or of the circulatory apparatus, it is usually due to lack of exercise. Much can be done for it by deliberate training. In the modern time, with elevators so common, people seldom have to walk up-stairs, and consequently one of the modes of exercise that was particularly likely to furnish some training in deep breathing is absent. Any one who has seen the shallow breathing of many of the patients who come to Nauheim and how much it has improved by the gradually increased walks up the hills around the valley, will appreciate how much training in deep breathing means. This exercise of the diaphragm will often give benefit besides in making the bowels more regular, and in getting rid of the accumulation of fat in the abdomen, which is one of the mechanical causes of the interference with the diaphragm and consequent shortness of breath.

Training the Appetite.—Just as training may be used for the sensory and motor systems that are external, so it may also be used for many internal functions analogous to these. There are a great many people who eat too little. They are the nervous, irritable persons with no fund of reserve energy to draw on when anything happens, and who are in their years before middle life likely to be the victims of infectious disease. They suffer much from lack of proper covering in the winter time and from a certain protection that is afforded to the nervous system generally by being up to weight. Often their under-weight is a life-story, and occasionally it is a family matter. When they suffer from neurotic symptoms a gain in weight nearly always does them good. They complain that when they increase their diet they have uncomfortable feelings. This is only what is to be expected, since the muscularis of their stomach—much more important than its secretory function—has not been accustomed to as much exercise as is now being demanded of it.

On the other hand, for those who are over-weight, training in eating less is the one important therapeutic factor. If their diet is cut down suddenly, they soon become discouraged. If there is a gradual reduction of food quantities, variety being allowed, so that they may eat practically everything they have been eating before, the system gradually accommodates itself to less and less food. This is the only sensible way of bringing about reduction in weight. It requires constant attention over a long period, but it can be done with excellent success.

In the same way the bowels may be trained to perform their work regularly. Habit means probably more with them than any other factor. Our digestive tract, however, is largely dependent on habit. We get hungry three times a day or twice a day, according to the custom that we have established. Countries differ radically in the matter, and nearly always, when a man goes from one country to another in early years, he changes to the habits of the new country, though if he comes after middle age he usually clings to those that he is used to.

Training to Stand Pain.—There are many painful conditions, especially involving the muscles in the neighborhood of joints, that are worse on rainy days and are spoken of as rheumatism, that can be very much improved by training in the use of muscles. As men grow older and gain in weight, the lack of exercise in their sedentary lives incapacitates their muscles for activities of many kinds. The consequence is that where most strain is put upon them, in the neighborhood of joints, they readily become tender and painful. It is this class of cases particularly that is benefited by irregular practitioners of all kinds. Mental healing, osteopathy, Eddyism, the many liniments, rubbings and manipulations prove beneficial. What is needed is training in the use of muscles so as to enable them to do the work that is required of them without discomforting reaction. This is particularly true for the leg and foot muscles. Exercises that strengthen the muscles of the calf and of the thigh, and particularly such as require free movement of the foot, are almost sure to relieve these patients of many annoying symptoms. Pains around the ankles and in the knee and hip, worse in rainy weather, disappear as a consequence of such gradually increased use of these muscles as gives them increased nutrition and power. This subject is discussed more fully under Foot Troubles and Painful Conditions of the Knee.