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 {208} certain quite unfavorable positions are a.s.sumed, 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 ma.s.sage 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 ma.s.sage 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 {209} 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 ill.u.s.trated 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 {210} 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 a.s.sumption 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.

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 acc.u.mulation of material during {211} 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 rec.u.mbent position. Whenever there is difficulty of breathing in connection with an affection of the heart, the rec.u.mbent position is extremely uncomfortable. This is nature's safeguard against the acc.u.mulation 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 a.s.sume. 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 acc.u.mulations 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 {212} 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 a.s.sumed. Restlessness, in the rec.u.mbent 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 a.s.sume 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 a.s.sume 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 p.r.o.ne 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 t.e.s.t.i.c.l.es 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.

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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 ill.u.s.trate 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 {214} 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 ill.u.s.trated 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 pa.s.sing 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 ill.u.s.trate 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 {215} 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_. [Footnote 24] 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.

[Footnote 24: Lippincott & Co., Phila., Vol. IV, 8th series, 1899.]

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 ca.n.a.ls. 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 {216} 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.