Psychotherapy

I had followed the case carefully during many years, seeing him at times, and I was always opposed to the idea of operation and fully confident that none of the operations were really needed. He could not be persuaded that what his case needed most was occupation of mind with something besides his condition. Whenever I could persuade him of this I had seen him gain in weight, get into much better spirits and be almost able to take up his work again. Then he would become discouraged, and before long I would hear of another operation that was planned, or was about to be performed. During the course of one of his many progressive losses in weight as a consequence of depression of mind, he developed tuberculosis. He resisted this very well, but eventually died rather suddenly of an empyema. A careful autopsy showed nothing but the traces of former operations, and no reason why they should have been done.

Another case: A friend, also a clergyman, had three operations done, one of them circumcision, the second an appendectomy and the third on a supposed floating kidney. None were indicated, so far as I could see, by any definite symptoms, or justified by his condition. He had vague abdominal discomfort, and this continued to bother him in spite of treatment by various specialists, and his mind became so much occupied with it that he was ready to submit to anything in order to be rid of his burden of discomfort. At no time was it an ache, nor did he ever speak of it as a pain. He had some tendency to dilatation of the stomach and at times, when much occupied with indoor work and neglecting muscular exercise, there was probably some delay of digestion. His appetite was good whenever he would let it be; his bowels were regular whenever he was eating sufficient to stimulate them to normal function; he slept well, except when unnerved by something, but the presence of this abdominal discomfort disturbed most of his waking hours. He could stand it so far as it had gone, but he was sure that it would become so much worse in the future that it would be unbearable. He dreaded that cancer or some other awful development would come after a time.

As a matter of fact, the main portion of the discomfort in these cases is the dread of what may happen. It is a dread, just as misophobia or claustrophobia or acrophobia or any of the other dreads that we discuss in the chapter on that subject. The constant occupation with this dread apparently inhibits to some degree the flow of nerve impulses to the abdominal organs, and digestion, already disturbed, is still more impaired. Indeed, the whole of the discomfort seems to be a consciousness of stomach and intestinal function rather than anything more serious. The stomach will take two or three pounds or even more of mingled liquids and solids at a meal and pass them on to the intestines without forcing itself into the field of our consciousness. Anyone who is aware what a thin-walled membranous bag the human stomach is—what it most nearly resembles is perhaps the familiar bladder of the cow—may well be surprised that, though it is supplied with many sensitive nerves, it gives so little sign of the load that is often placed in it. It may, however, be brought rather poignantly into the sphere of consciousness by concentration of attention on it.

The intestines function usually with the same lack of reflex. They proceed to pass on this quantity of food, store up two or three days' rations, digest what is nutritious and eliminate what must be rejected, without rising into consciousness. If either stomach or intestines once begin to attract attention, then it will be difficult, unless care is exercised to distract the mind from them, to replace and keep them back in the sphere of the unconscious once more. Peristaltic movements are constantly taking place in the digestive tract. Various things may interfere with peristalsis, and the disturbance of it will almost surely cause some sensation. It may not be serious, and digestive processes may continue, yet there may be discomfort. If there is delay in the passage of food, gas accumulates in the stomach, presses up against the diaphragm and interferes with the heart action. This will give rise to many bothersome sensations, some of which are felt in the heart region itself; others much lower down on the left side, where it is rather hard to recognize just what the real seat of them may be. A good deal of the abdominal discomfort of which people complain, is due to such functional disturbances, emphasized by the fact that digestive action has come into the sphere of consciousness and now attention is being concentrated on it, to the detriment of digestion itself, as well as to the increase of the annoyance which the discomfort may occasion.

Operations for abdominal discomfort are quite contra-indicated, unless there are very definite localizing symptoms of some pathological lesion that can surely be relieved by operative intervention. To operate on general principles is sure to emphasize the patient's concentration of attention on his abdominal discomfort, if it does not relieve it, and in most of these cases it utterly fails. The strong suggestion of an operation will relieve for the time being, just as operations for epilepsy seemed to relieve when that procedure was first introduced, though now, unless there are definite localizing signs, there is no question of such an operation.

Toxic Factors.—Tea.—A very interesting phase of abdominal discomfort seems to be associated with the taking of nerve stimulants. I have frequently found that patients who complained of vague abdominal uneasiness, sometimes rising particularly at night to the height of colicky feelings but always on the left side, were indulging to excess in tea or coffee. In one case, a woman was taking, she thought, about a dozen cups of tea a day. Just how much more than this she actually was taking I do not know, for it is almost incredible the amount of tea that middle-aged women who are alone may take. I once found by actual count made for me, that a woman was taking almost a score of cups of tea in each twenty-four hours.

Just as soon as there is a reduction in the amount of tea taken in these cases, relief is afforded the patient. This relief will not, however, be absolutely satisfactory because the craving for the tea stimulation makes the patients irritable, and it takes but very little to cause them to complain that they still have their old discomfort. In the course of three or four days they realize that the root of the trouble has been reached. If the discomfort has continued for a good while, a sort of habit seems to be formed, and the attention of the mind gives a sense of uneasiness, if not discomfort, in the left abdominal region. Usually it is in the upper left quadrant and seems to be stomachic in origin. The discomfort is apparently due to the presence of air, or gas, which is not properly expelled because of some lack of co-ordination of muscles, and then the warmth of a room or of the bed at night, or the presence of some slightly irritant substance makes the discomfort more noticeable. In the patient's over-stimulated condition, there is inability to withstand it patiently. In none of these cases is there a fever, though in all there is some disturbance of the pulse as if the heart's action were interfered with and the organ resented it.

Coffee .—In some cases the same vague abdominal discomfort occurs as a consequence of taking too much coffee. This is seen in men more than in women. The tea topers are nearly all women, though my attention was first called to this vague discomfort, that made life miserable for a tea tester, who spent most of his day tasting tea, though drinking very little of it. With regard to coffee, individual idiosyncrasy is an extremely important matter. Some men seem to be able to take five, six or even more cups of coffee in the day without inconvenience; some cannot take even a small cup of coffee after six o'clock at night without being kept awake for several hours; others cannot take a large cup of coffee in the morning without having considerable discomfort, which is usually attributed to indigestion. I have known large, strong men, who were much better for not taking any coffee, or at the most a tablespoonful of it in a cup of milk in the morning to satisfy the taste.

Loose Kidney.—Movable kidney is responsible for many of these cases of abdominal discomfort. Where it exists to a marked degree it may be relieved by operation. It occurs much more frequently in women than in men because, for physiological reasons, the kidneys are normally more movable in women and this is particularly true of the right kidney, which would otherwise perhaps be injured by pressure between the pregnant uterus and the liver. It is probable that many of the cases of the kidney of pregnancy are really due to an abnormal fixity of the kidney to a particular place, so that the growing uterus interferes by pressure with its circulation and its function. Slight movability of the kidney, then, should not be considered pathological.

I have seen a number of these cases. They seem to occur particularly in women who have lost weight. The fat around the kidney is somewhat absorbed during the course of loss in weight, and this leaves this organ more movable and also less protected and consequently more liable to irritation. One sees it rather frequently in many unmarried women who have some strenuous occupation. Many of these young women come back from their vacation at the end of the summer having gained fifteen or twenty pounds in weight. If there has been any kidney sensitiveness or movability before, both have usually disappeared. The kidney is well held in place because there is much more fat within the abdomen, all the organs are better cushioned, yet without any interference with their function.

During the course of the year these patients, school-teachers, stenographers, and daily workers of various kinds, lose in weight. When they have lost ten pounds the kidney begins to be sensitive again and somewhat movable. By the time they have lost fifteen to twenty pounds there is serious complaint in the right upper quadrant of their abdomen extending at times over toward the navel, and the kidney becomes quite movable. At this time the treatment must consist in holding the kidney as firmly in place as possible, for dragging downward will be followed by reflex symptoms in the stomach and intestines. Disinclination to food, loss of appetite, and even the occurrence of some nausea, as well as some constipation, are easily traced to kidney reflexes. During the night there is no trouble, because while the patient is lying down the kidney falls into its proper position. On arising in the morning the kidney drops down out of place. If a corset is put on at this time the kidney may be forced still further out of place, giving rise, after a couple of hours, to considerable discomfort. New shoes can be borne at first, but after a time the pressure they produce shuts off circulation and causes intolerable discomfort. To a less degree this happens to the kidney if thus compressed and this explains the course of symptoms in many cases.

Mechanical Treatment .—If the corset is adjusted before the patient rises, and fits reasonably snugly, but not too tight, the contents of the abdomen will all be kept in place, and the kidney will maintain its normal position. When the corset is not sufficient to retain the kidney in place, a simple pad, a towel or a napkin or, if there is much sensitiveness, something more elaborate, especially adapted to conditions, can be placed over the kidney, and when held firmly by the corset will keep the kidney in its place. At first the kidney is usually sensitive to this on account of having been pressed upon during the preceding weeks or months. The patient must bear some little inconvenience at first, must get accustomed to the new conditions in which the kidney is kept in place, and must not expect complete relief at once. Any improvement must be considered a step forward, and further amelioration can be confidently promised. As in all other cases of the use of apparatus or mechanical aids—spectacles, false teeth or crutches—the patient must be content to grow used to the new order of things, before expecting satisfying relief.

This is the palliative treatment. The natural treatment of many of these cases is to have the patient maintain such weight as will hold the kidney in place, because of the fat within the abdomen, without any necessity for external aids. This can be done more readily than is often thought to be possible. These patients insist that they lose their appetite when they settle down to work, but what they really lose is the habit of eating a definite amount at stated intervals. Very often it will be found that breakfast, which they took abundant time to eat during vacation, is rushed. The luncheon suffers in the same way and is small in quantity. They take only one good meal, and one good meal is not sufficient to maintain normal weight.

Question of Operation .—When a kidney is so movable as to deserve the adjective "floating," so that it moves considerably from its place and, perhaps, even sags and may be felt in the subumbilical region, it should be fastened up by surgical means. There is a choice between two evils. The fastening of the kidney in the loin does not restore the normal condition, but puts it in an artificial condition. The kidney supports are of such a kind that it was evidently meant to be slightly movable. When it is fastened firmly in the loin, it is likely to feel every jar, and certain post-operative cases that I have seen, in which firm adhesions had supposedly taken place, complained considerably of the discomfort occasioned by this. In a certain number of cases, even after the operation, the kidney is still somewhat movable, because the adhesions yield and some of the old distress returns. All this must be realized before there is any question of an operation. There must be not merely a little discomfort, but enough of actual ache and of reflex disturbance that can be traced directly to the kidney to warrant the operation.

No floating kidney should be operated upon in a patient who has lost much in weight and has developed a sensitiveness of the kidney since the reduction of weight. Definite efforts should first be made to bring about increase in weight, so as to see whether this will not restore the previous condition of reasonable comfort. At times it is said that the disturbance of the stomach, that is reflex to such a floating kidney, prevents the patient from taking and assimilating enough food to restore normal weight. This will be true if attention has been called to the condition very seriously, and if the patient is persuaded that this is the reason why there is no appetite and poor digestion. Ordinary palliative measures, such as a binder, or a specially made corset, will be sufficient to prevent the kidney from producing reflex disturbance of the stomach, and will exert a strong suggestion to this effect under the influence of which the patient will usually gain in weight.

Intermittent Discomfort .—The discomfort that comes with a loose kidney may be quite intermittent. I have known patients to be bothered by it for months, and then quite free from it for several years, only to have their discomfort renewed so that they become quite worried. Some definite local or mechanical condition can generally be found for these variations in feeling.

In thin people a jolting ride over a rough road or stepping off a car will occasionally be the beginning of the trouble, and as this also is likely to cause a stone in the kidney to give its first manifestations, there may be serious suspicion of a more grave pathological condition than is really present. If this discomfort continues only the X-ray can absolutely decide the question.

Once the mechanical conditions which cause the discomfort are understood by the patient, the actual ache becomes much more easy to bear. Apprehension makes it almost intolerable. Attention exaggerates it, and makes diversion of mind difficult. Understanding helps all the conditions and lessens the pain, not actually but mentally, until after a time very little attention is paid to it.

SECTION VII

CARDIOTHERAPY

CHAPTER I

THE HEART AND MENTAL INFLUENCE

The heart is an organ so vitally important that we might expect it to be carefully protected by nature from any interference with its action through mental influence, emotional conditions, or voluntary or involuntary feelings. As a matter of fact, it is extremely susceptible to mental influence, stimulant or depressive, and to emotions of all kinds. Psychotherapy, that is, the removal of inhibiting influences originating in the mind, and the suggestion of favorable mental influences, is probably more important for the heart than for any other organ in the body. The law of reserve energy has its most noteworthy applications with regard to it. When we are apparently so completely fatigued that we cannot do anything more, a purely mental stimulus may so enliven the heart as to give the body a new supply of strength and energy. A man wandering through a desert, or swimming for his life at sea, may be so exhausted as to be quite ready to give up entirely, and be brought to the conviction that he has absolutely no strength left for further effort, when a flash in the distance, or a sound that indicates that help is near, or some other mental incitement, will give renewed energy. It is probably through the heart that there comes to us most of our power to accomplish things when we are already so tired as to seem exhausted. On the other hand, it is the failure of circulation in muscles, because of a slacking heart, that produces the sense of exhaustion. Muscular work is easy or even pleasant when we are in good spirits, while, whenever exertion is undertaken in the midst of discouragement, we cannot accomplish nearly so much as when conditions are so framed as to give stimulus and encouragement.

If a perfectly normal heart can be so affected by mental conditions and emotions as to be seriously disturbed in its work on the one hand, or greatly stimulated into new activity on the other, it is to be expected that a heart affected by disease will be similarly affected and probably even to a greater degree. It is clear, then, that our cardiac patients have to be guarded against unfavorable mental conditions, and have to have all their reserve energy called out for them by encouragement and by the best possible prognosis for their reflection. This is especially true as regards the removal of the many unfavorable suggestions which, because of ignorance, have in the past gathered round most forms of heart disease.

Emotion and the Heart.—The mental and emotional influence over the heart's action was the truth that lay at the basis of the old fallacy with regard to the physiology of the heart. The literature of all countries testifies that the heart was long supposed to be the seat and origin of the emotions. Every one has experienced how the heart jumps when something unexpected happens. People have fainted from excess of joy as well as of grief. The physical side of emotion is so generally associated with some modification of the heart beat that it is no wonder that emotions were directly connected with the organ. When people are in depressed states the heart is apt to beat more slowly than usual, while when in states of exhilaration, even those dependent merely on mental factors, the pulse is more rapid. Melancholic states have occasionally been attributed to the slowness of the pulse, but the slow pulse seems to be a symptom connected with the mental condition rather than a causative factor. In the maniacal conditions, the rapidity of the pulse, which is sometimes quite marked, must probably be explained in the same way, as due to the mental excitement under which the patient is laboring.

The Heart and the Nervous System.—Prof. Von Leyden ten years ago recalled attention to the fact that the heart is literally the primum movens in man, and that before the central nervous system is laid down, or there is any possible question of impulses flowing from center to periphery, the heart, or at least its embryonic representative, is beating as constantly, regularly, rhythmically, as it is to do during all the subsequent life of the individual. Oliver Wendell Holmes has expressed it poetically by stating that the angel of life sets this heart pendulum going and only the angel of death can break into the case and stop it.

Primitive Heart Action .—The original beating of the heart is entirely automatic, and quite apart from any nervous initiative or stimulus. The original bend in the primal blood vessel, which is to represent the heart in the course of development, begins to pulsate very early in the chick and evidently does the same thing in all other living things. Notwithstanding this fact that the heart is thus easily demonstrated to be the primum movens, the first exhibitor of vitality, and might thus seem to be one of the organs or indeed the one which should be safe from any nervous interference, later on powerful connections with the nervous system are made, and heart acceleration and inhibition become familiar phenomena. Every emotion, as we have said, has its influence on the heart and even a certain amount of voluntary control may be acquired. Indian fakirs are said to be able to cause the heart to slow and almost to stop. The curious phenomenon of suspended animation which they sometimes exhibit is said to be due to this. Certain of the well-developed muscular subjects who exhibit themselves at medical clinics are able to cause their hearts to miss a beat, but this is said to be rather a result of will-power over other muscles compressing the thorax, and interfering with the heart, than direct influence upon the heart itself.

Mental Influence over Diseased Hearts.—Worry produces much more serious symptoms in heart patients than in others. Anxiety about the heart itself is often a source of serious detriment to a heart patient. Most people have such a terror of having anything the matter with their hearts that the haunting thought of such calamity is likely to have a definite influence in preventing the development of such compensation as will enable the heart to do its work to the best advantage. It used to be the custom to refrain from telling patients suffering from tuberculosis that they had the disease. On the other hand, people with heart disease were usually informed of that fact. The reason given for the latter course was that heart disease may in many cases be the forerunner of sudden death, and the warning knowledge was supposed to enable a man to get his affairs in order. No worse policy for either disease could well have been imagined. The pulmonary patient should be told at once, the heart patient should, as far as possible, be saved the depressing knowledge of his condition.

Dr. MacKenzie, whose practically illuminating studies of heart disease give him a right to express opinions with regard to it (and when those opinions concern the influence of the mind they are doubly valuable because of the absolute objectivity of his studies), has some rather strong expressions with regard to the importance of modifying the mental state in heart cases. He says:

The consciousness of heart trouble has often a depressing effect on people, whether the trouble be slight or serious. When such people become convinced that the trouble is curable or not serious, their condition at once becomes greatly improved. Cures by faith, whether in drugs, baths, elaborate methods or religion, act by playing upon the mental condition. But our employment of this element in treatment should not be the outcome of blind unreasoning faith in some rite or ceremony, bath or drug, but in the intelligent perception of the nature of the symptoms. The reassurance of the patient of the harmless nature of the complaint goes a great way in curing him. The reassurance that with reasonable care no danger need be feared is extremely helpful. Even in serious cases when there is reasonable hope of recovery or a certain degree of recovery, the encouragement of the patient may and does help forward his improvement.